Is POEM the Answer for Management of Spastic Esophageal Disorders? A Systematic Review and Meta-Analysis
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Background and Aims
Spastic esophageal disorders (SEDs) include spastic achalasia (type III), diffuse esophageal spasm (DES), and nutcracker/jackhammer esophagus (JH). Per-oral endoscopic myotomy (POEM) has demonstrated efficacy and safety in the treatment of achalasia. Recently, POEM has been indicated for the treatment of SEDs. We conducted a systematic review and meta-analysis to determine the clinical success and safety of POEM in SEDs.
We searched several databases from 01/01/2007 to 01/10/2016 to identify studies (with five or more patients) on POEM for the treatment of SEDs. Weighted pooled rates (WPRs) for clinical success and adverse events (AEs) were calculated for all SEDs. Clinical success was defined as Eckardt scores of ≤3 and/or improvement in severity of dysphagia based on achalasia disease-specific health-related quality of life questionnaire. The WPRs for clinical success and AEs were analyzed using fixed- or random-effects model based on heterogeneity. The proportionate difference in clinical success and post-procedure adverse event rates among individual types of SEDs was also calculated.
A total of eight observational studies with 179 patients were included in the final analysis. Two studies were of good quality and six were of fair quality based on the National Institutes of Health quality assessment tool. The WPR with 95% confidence interval (CI) for cumulative clinical success of POEM in all SEDs was 87% (78, 93%), I 2 = 37%. The total number of patients for individual disorders, i.e., type III achalasia, JH, and DES, was 116, 37, and 18, respectively. The WPRs for clinical success of POEM for type III achalasia, DES, and JH were 92, 88, and 72%, respectively. Proportion difference of WPR for clinical success was significantly higher for type III achalasia in comparison with JH (20%, P = 0.01). The WPR with 95% CI for AEs of POEM in all SEDs was 14% (9, 20%), I 2 = 0%. The WPRs for post-procedure adverse events for type III achalasia, DES, and JH were 11, 14, and 16%, respectively. There was no difference in safety of POEM among individual SEDs.
POEM is an effective and safe therapeutic modality for the treatment of spastic esophageal disorders.
KeywordsPOEM Spastic esophageal disorders Achalasia Jackhammer esophagus Diffuse esophageal spasm Spastic achalasia
MAK was involved in conception and design; analysis and interpretation of data; drafting of article; and final approval of article. VK was involved in conception and design; drafting of article; critical revision; and final approval of article. SN was involved in drafting of article; critical revision; and final approval of article. AI, Y-IC, YHC, and MB were involved in data collection and final approval of article. RN was involved in search strategy and final approval of article. MKI was involved in analysis and interpretation of data; drafting of article; and final approval of article. MO and AS were involved in data collection; critical revision; and final approval of article. VB was involved in critical revision and final approval of article. LS, HI, and AR were involved in critical revision and final approval of article. MAK was involved in conception and design; analysis and interpretation of data; drafting of article; critical revision; and final approval of article.
Compliance with ethical standards
Conflict of interest
Dr. Khashab is a consultant for Boston Scientific. Drs. Muhammad Ali Khan, Vivek Kumbhari, Saowanee Ngamruengphong, Amr Ismail, Yen-I Chen, Yamile Haito Chavez, Majidah Bukhari, Richard Nollan, Mohammad Kashif Ismail, Manabu Onimaru, Valerio Balassone, Ahmed Sharata, Lee Swanstrom, Haruhiro Inoue, and Alessandro Repici have no conflicts of interest or financial relationships relevant to this article.
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