Download PDF
Endoscopy 2020; 52(04): 251-258
DOI: 10.1055/a-1090-0788
Systematic Review

Anterior versus posterior approach in peroral endoscopic myotomy (POEM): a systematic review and meta-analysis

Babu P. Mohan
1   Internal Medicine, University of Arizona, Banner University Medical Center, Tucson, Arizona, USA
,
Andrew Ofosu
2   Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Brooklyn, New York, USA
,
Saurabh Chandan
3   Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, USA
,
Daryl Ramai
4   Internal Medicine, The Brooklyn Hospital Center, Brooklyn, New York, USA
,
Shahab R. Khan
1   Internal Medicine, University of Arizona, Banner University Medical Center, Tucson, Arizona, USA
,
Suresh Ponnada
5   Internal Medicine, Carilion Roanoke Memorial Hospital, Roanoke, Virginia, USA
,
Douglas G. Adler
6   Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Referred to by:

Author commentary on Babu P. Mohan et al.Endoscopy 2020; 52(04): v14-v14
DOI: 10.1055/a-1089-6852

Abstract

Background Peroral endoscopic myotomy (POEM) is increasingly being used as the endoscopic treatment option for achalasia. Data are limited as to the comparative efficacy of anterior vs. posterior myotomy.

Methods We searched multiple databases from inception to August 2019 to identify studies reporting on POEM. We selected studies that reported on the outcomes of POEM, along with information on myotomy approach. We performed a comparative analysis of clinical success, gastroesophageal reflux disease (GERD), and adverse events with anterior and posterior myotomy in POEM by meta-analysis.

Results 1247 patients from 18 studies were analyzed: 623 patients (11 cohorts) were treated via anterior myotomy and 624 patients (12 cohorts) via posterior myotomy. The pooled rate for clinical success gave an odds ratio (OR) of 1.02 (95 % confidence interval [CI] 0.52 – 2.0; I 2 0; P = 0.9); for GERD by esophagogastroduodenoscopy (EGD) was OR 1.02 (95 %CI 0.62 – 1.68; I 2 0; P = 0.9), and for GERD by pH was OR 0.98 (95 %CI 0.59 – 1.63; I 2 34; P = 0.9). The individual pooled rates of clinical success at 12 months and > 12 months, GERD (by symptoms, EGD, pH), and adverse events (mild, moderate, severe) were comparable. The pooled total procedure time with anterior myotomy was 82.7 minutes (95 %CI 69.0 – 96.4; I 2 98) and with posterior myotomy was 62.1 minutes (95 %CI 48.5 – 75.7; I 2 90).

Conclusion Anterior and posterior myotomy in POEM seem comparable to each other in terms of clinical success, GERD, and adverse events. The total procedure time with posterior myotomy seems to be shorter than with anterior myotomy.

Tables 1s – 2s, Figs. 1s – 10s, Appendix 1s – 3s



Publication History

Received: 05 September 2019

Accepted: 09 December 2019

Article published online:
20 January 2020

© Georg Thieme Verlag KG
Stuttgart · New York

 

  • References

  • 1 Boeckxstaens GE, Annese V, Varannes SBd. et al. Pneumatic dilation versus laparoscopic Heller's myotomy for idiopathic achalasia. NEJM 2011; 364: 1807-1816
    CrossrefPubMedGoogle Scholar
  • 2 Sonnenberg A. Time trends of US hospitalization for esophageal disease. J Clin Gastroenterol 2014; 48: e71-e75
    CrossrefPubMedGoogle Scholar
  • 3 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Ren Z, Zhong Y, Zhou P. et al. Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). Surg Endosc 2012; 26: 3267-3272
    CrossrefPubMedGoogle Scholar
  • 5 Moher D, Liberati A, Tetzlaff J. et al. Preferred reporting items for systematic reviews and meta-analyses: The prisma statement. Ann Int Med 2009; 151: 264-269
    CrossrefPubMedGoogle Scholar
  • 6 Stroup DF, Berlin JA, Morton SC. et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000; 283: 2008-2012
    CrossrefPubMedGoogle Scholar
  • 7 Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 2010; 25: 603-605
    CrossrefPubMedGoogle Scholar
  • 8 Glenny A, Altman D, Song F. et al. Indirect comparisons of competing interventions. Health Technol Assess 2005; 9: 1-134, III-IV
    PubMedGoogle Scholar
  • 9 Mohan BP, Chandan S, Garg R. et al. Lumen-apposing metal stents, fully covered self-expanding metal stents, and biodegradable stents in the management of benign of GI Strictures: A systematic review and meta-analysis. J Clin Gastroenterol 2019; 53: 560-573
    CrossrefPubMedGoogle Scholar
  • 10 Mohan BP, Jayaraj M, Asokkumar R. et al. Lumen apposing metal stents in drainage of pancreatic walled-off necrosis, are they any better than plastic stents? A systematic review and meta-analysis of studies published since the revised Atlanta classification of pancreatic fluid collections. Endosc Ultrasound 2019; 8: 82-90
    CrossrefPubMedGoogle Scholar
  • 11 Mohan BP, Shakhatreh M, Dugyala S. et al. EUS versus percutaneous management of postoperative pancreatic fluid collection: A systematic review and meta-analysis. Endosc Ultrasound 2019; 8: 298-309
    CrossrefPubMedGoogle Scholar
  • 12 Mohan BP, Shakhatreh M, Garg R. et al. Comparison of Franseen and fork-tip needles for EUS-guided fine-needle biopsy of solid mass lesions: A systematic review and meta-analysis. Endosc Ultrasound 2019; DOI: 10.4103/eus.eus_27_19.
    CrossrefPubMedGoogle Scholar
  • 13 Eckardt VF, Aignherr C, Bernhard G. Predictors of outcome in patients with achalasia treated by pneumatic dilation. Gastroenterology 1992; 103: 1732-1738
    CrossrefPubMedGoogle Scholar
  • 14 Kusano M, Hosaka H, Kawada A. et al. Development and evaluation of a modified Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease to distinguish functional dyspepsia from non-erosive reflux disease. J Gastroenterol Hepatol 2012; 27: 1187-1191
    CrossrefPubMedGoogle Scholar
  • 15 Kusano M, Shimoyama Y, Sugimoto S. et al. Development and evaluation of FSSG: frequency scale for the symptoms of GERD. J Gastroenterol 2004; 39: 888-891
    CrossrefPubMedGoogle Scholar
  • 16 Jonasson C, Wernersson B, Hoff DA. et al. Validation of the GerdQ questionnaire for the diagnosis of gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2013; 37: 564-572
    CrossrefPubMedGoogle Scholar
  • 17 Jones R, Junghard O, Dent J. et al. Development of the GerdQ, a tool for the diagnosis and management of gastro-oesophageal reflux disease in primary care. Aliment Pharmacol Ther 2009; 30: 1030-1038
    CrossrefPubMedGoogle Scholar
  • 18 Armstrong D, Bennett JR, Blum AL. et al. The endoscopic assessment of esophagitis: a progress report on observer agreement. Gastroenterology 1996; 111: 85-92
    CrossrefPubMedGoogle Scholar
  • 19 Dent J. Endoscopic grading of reflux oesophagitis: the past, present and future. Best Pract Res Clin Gastroenterol 2008; 22: 585-599
    CrossrefPubMedGoogle Scholar
  • 20 Johnson LF, Demeester TR. Twenty-four-hour pH monitoring of the distal esophagus. A quantitative measure of gastroesophageal reflux. Am J Gastroenterol 1974; 62: 325-332
    PubMedGoogle Scholar
  • 21 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointestinal Endoscopy 2010; 71: 446-454
    CrossrefPubMedGoogle Scholar
  • 22 DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986; 7: 177-188
    CrossrefPubMedGoogle Scholar
  • 23 Sutton AJ, Abrams KR, Jones DR. et al. Methods for meta-analysis in medical research. New York: John Wiley & Sons Ltd; 2000: 205-228
    Google Scholar
  • 24 Higgins J, Thompson SG, Spiegelhalter DJ. A re‐evaluation of random‐effects meta‐analysis. J R Stat Soc Ser A Stat Soc 2009; 172: 137-159
    CrossrefPubMedGoogle Scholar
  • 25 Riley RD, Higgins JP, Deeks JJ. Interpretation of random effects meta-analyses. BMJ 2011; 342: d549
    CrossrefPubMedGoogle Scholar
  • 26 Mohan BP, Adler DG. Heterogeneity in systematic review and meta-analysis: how to read between the numbers. Gastrointest Endosc 2019; 89: 902-903
    CrossrefPubMedGoogle Scholar
  • 27 Kanwal F, White D. “Systematic reviews and meta-analyses” in Clinical Gastroenterology and Hepatology. Clin Gastroenterol Hepatol 2012; 10: 1184-1186
    CrossrefPubMedGoogle Scholar
  • 28 Higgins JP, Thompson SG, Deeks JJ. et al. Measuring inconsistency in meta-analyses. BMJ 2003; 327: 557
    CrossrefPubMedGoogle Scholar
  • 29 Guyatt GH, Oxman AD, Kunz R. et al. GRADE guidelines: rating the quality of evidence 2014; inconsistency. J Clin Epidemiol 2011; 64: 1294-1302
    CrossrefPubMedGoogle Scholar
  • 30 Easterbrook PJ, Gopalan R, Berlin JA. et al. Publication bias in clinical research. Lancet 1991; 337: 867-872
    CrossrefPubMedGoogle Scholar
  • 31 Duval S, Tweedie R. Trim and Fill: A simple funnel-plot–based method of testing and adjusting for publication bias in meta-analysis. Biometrics 2000; 56: 455-463
    CrossrefPubMedGoogle Scholar
  • 32 Rothstein HR, Sutton AJ, Borenstein M. Publication bias in meta-analysis: Prevention, assessment and adjustments. NewYork: John Wiley & Sons; 2006
    Google Scholar
  • 33 Khashab MA, Sanaei O, Rivory J. et al. Peroral endoscopic myotomy: anterior versus posterior approach: a randomized single-blinded clinical trial. Gastrointest Endosc 2019; DOI: 10.1016/j.gie.2019.07.034.
    CrossrefPubMedGoogle Scholar
  • 34 Ramchandani M, Nabi Z, Reddy DN. et al. Outcomes of anterior myotomy versus posterior myotomy during POEM: a randomized pilot study. Endosc Int Open 2018; 6: e190-e198
    Article in Thieme ConnectPubMedGoogle Scholar
  • 35 Tan Y, Lv L, Wang X. et al. Efficacy of anterior versus posterior per-oral endoscopic myotomy for treating achalasia: a randomized, prospective study. Gastrointest Endosc 2018; 88: 46-54
    CrossrefPubMedGoogle Scholar
  • 36 Stavropoulos SN, Modayil RJ, Zhang X. et al. Is there a difference in outcomes between anterior and posterior peroral endoscopic myotomy (POEM)? A randomized study from an experienced high-volume operator. Gastrointestinal Endoscopy 2018; 87: AB121
    PubMedGoogle Scholar
  • 37 Hungness ES, Sternbach JM, Teitelbaum EN. et al. Per-oral endoscopic myotomy (POEM) after the learning curve: durable long-term results with a low complication rate. Ann Surg 2016; 264: 508-517
    CrossrefPubMedGoogle Scholar
  • 38 Shiwaku H, Inoue H, Sasaki T. et al. A prospective analysis of GERD after POEM on anterior myotomy. Surg Endosc 2016; 30: 2496-2504
    CrossrefPubMedGoogle Scholar
  • 39 Tang X, Gong W, Deng Z. et al. Feasibility and safety of peroral endoscopic myotomy for achalasia after failed endoscopic interventions. Dis Esophagus 2017; 30: 1-6
    PubMedGoogle Scholar
  • 40 Ward MA, Gitelis M, Patel L. et al. Outcomes in patients with over 1-year follow-up after peroral endoscopic myotomy (POEM). Surg Endosc 2017; 31: 1550-1557
    CrossrefPubMedGoogle Scholar
  • 41 Werner YB, Costamagna G, Swanstrom LL. et al. Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years. Gut 2016; 65: 899-906
    CrossrefPubMedGoogle Scholar
  • 42 Zheng Z, Zhao C, Su S. et al. Peroral endoscopic myotomy versus pneumatic dilation - result from a retrospective study with 1-year follow-up. Z Gastroenterol 2019; 57: 304-311
    Article in Thieme ConnectPubMedGoogle Scholar
  • 43 de Pascale S, Repici A, Puccetti F. et al. Peroral endoscopic myotomy versus surgical myotomy for primary achalasia: single-center, retrospective analysis of 74 patients. Dis Esophagus 2017; 30: 1-7
    PubMedGoogle Scholar
  • 44 Duan T, Tan Y, Zhou J. et al. A retrospective study of peroral endoscopic full-thickness myotomy in patients with severe achalasia. J Laparoendosc Adv Surg Tech A 2017; 27: 770-776
    CrossrefPubMedGoogle Scholar
  • 45 Guo H, Yang H, Zhang X. et al. Long-term outcomes of peroral endoscopic myotomy for patients with achalasia: a retrospective single-center study. Dis Esophagus 2017; 30: 1-6
    PubMedGoogle Scholar
  • 46 Meng F, Li P, Wang Y. et al. Peroral endoscopic myotomy compared with pneumatic dilation for newly diagnosed achalasia. Surg Endosc 2017; 31: 4665-4672
    CrossrefPubMedGoogle Scholar
  • 47 Peng L, Tian S, Du C. et al. Outcome of peroral endoscopic myotomy (POEM) for treating achalasia compared with laparoscopic heller myotomy (LHM). Surg Laparosc Endosc Percutan Tech 2017; 27: 60-64
    CrossrefPubMedGoogle Scholar
  • 48 Tyberg A, Sharaiha RZ, Familiari P. et al. Peroral endoscopic myotomy as salvation technique post-Heller: International experience. Dig Endosc 2018; 30: 52-56
    PubMedGoogle Scholar
  • 49 Wang X, Tan Y, Lv L. et al. Peroral endoscopic myotomy versus pneumatic dilation for achalasia in patients aged ≥ 65 years. Rev Esp Enferm Dig 2016; 108: 637-641
    PubMedGoogle Scholar
  • 50 Zhang W, Linghu EQ. Peroral endoscopic myotomy for type III achalasia of Chicago classification: outcomes with a minimum follow-up of 24 months. J Gastrointest Surg 2017; 21: 785-791
    CrossrefPubMedGoogle Scholar
  • 51 Inoue H, Sato H, Ikeda H. et al. Per-oral endoscopic myotomy: A series of 500 patients. J Am Coll Surg 2015; 221: 256-264
    CrossrefPubMedGoogle Scholar
  • 52 Kumbhari V, Tieu AH, Onimaru M. et al. Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of Type III achalasia in 75 patients: a multicenter comparative study. Endosc Int Open 2015; 3: e195-e201
    Article in Thieme ConnectPubMedGoogle Scholar
  • 53 Louie BE, Schneider AM, Schembre DB. et al. Impact of prior interventions on outcomes during per oral endoscopic myotomy. Surg Endosc 2017; 31: 1841-1848
    CrossrefPubMedGoogle Scholar
  • 54 Lu B, Li M, Hu Y. et al. Effect of peroral esophageal myotomy for achalasia treatment: A Chinese study. World J Gastroenterol 2015; 21: 5622-5629
    CrossrefPubMedGoogle Scholar
  • 55 Lv L, Liu J, Tan Y. et al. Peroral endoscopic full-thickness myotomy for the treatment of sigmoid-type Achalasia: Outcomes with a minimum follow-up of 12 months. Eur J Gastroenterol Hepatol 2016; 28: 30-36
    CrossrefPubMedGoogle Scholar
  • 56 Ramchandani M, Nageshwar Reddy D, Darisetty S. et al. Peroral endoscopic myotomy for achalasia cardia: Treatment analysis and follow up of over 200 consecutive patients at a single center. Dig Endosc 2016; 28: 19-26
    CrossrefPubMedGoogle Scholar
  • 57 Puhan MA, Schunemann HJ, Murad MH. et al. A GRADE Working Group approach for rating the quality of treatment effect estimates from network meta-analysis. BMJ 2014; 349: g5630
    Google Scholar
  • 58 Rodriguez de Santiago E, Mohammed N, Manolakis A. et al. Anterior versus posterior myotomy during poem for the treatment of achalasia: systematic review and meta-analysis of randomized clinical trials. J Gastrointestin Liver Dis 2019; 28: 107-115
    PubMedGoogle Scholar