Comparative efficacy of first-line therapeutic interventions for achalasia: a systematic review and network meta-analysis

Antonio Facciorusso, Siddharth Singh, Syed M Abbas Fehmi, Vito Annese, John Lipham, Rena Yadlapati, Antonio Facciorusso, Siddharth Singh, Syed M Abbas Fehmi, Vito Annese, John Lipham, Rena Yadlapati

Abstract

Background: Several interventions with variable efficacy are available as first-line therapy for patients with achalasia. We assessed the comparative efficacy of different strategies for management of achalasia, through a network meta-analysis combining direct and indirect treatment comparisons.

Methods: We identified six randomized controlled trials in adults with achalasia that compared the efficacy of pneumatic dilation (PD; n = 260), laparoscopic Heller myotomy (LHM; n = 309), and peroral endoscopic myotomy (POEM; n = 176). Primary efficacy outcome was 1-year treatment success (patient-reported improvement in symptoms based on validated scores); secondary efficacy outcomes were 2-year treatment success and physiologic improvement; safety outcomes were risk of gastroesophageal reflux disease (GERD), severe erosive esophagitis, and procedure-related serious adverse events. We performed pairwise and network meta-analysis for all treatments, and used GRADE criteria to appraise quality of evidence.

Results: Low-quality evidence, based primarily on direct evidence, supports the use of POEM (RR [risk ratio], 1.29; 95% confidence intervals [CI], 0.99-1.69), and LHM (RR, 1.18 [0.96-1.44]) over PD for treatment success at 1 year; no significant difference was observed between LHM and POEM (RR 1.09 [0.86-1.39]). The incidence of severe esophagitis after POEM, LHM, and PD was 5.3%, 3.7%, and 1.5%, respectively. Procedure-related serious adverse event rate after POEM, LHM, and PD was 1.4%, 6.7%, and 4.2%, respectively.

Conclusions: POEM and LHM have comparable efficacy, and may increase treatment success as compared to PD with low confidence in estimates. POEM may have lower rate of serious adverse events compared to LHM and PD, but higher rate of GERD.

Keywords: Endoscopy; Myotomy; POEM; Pneumatic dilation.

Conflict of interest statement

Drs Antonio Facciorusso, Siddharth Singh, Syed M Abbas Fehmi, Vito Annese, John Lipham, and Rena Yadlapati have no conflicts of interest or financial ties to disclose.

Figures

Fig. 1
Fig. 1
Flow chart of the included trials
Fig. 2
Fig. 2
Network geometry of trials. Network of included studies with the available direct comparisons between interventions for management of achalasia. The size of the nodes and the thickness of the edges are weighted according to the number of studies evaluating each treatment and direct comparison, respectively. PD pneumatic dilation, LHM laparoscopic Heller myotomy, POEM peroral endoscopic myotomy
Fig. 3
Fig. 3
Direct meta-analysis comparing different treatment strategies for achalasia. Primary outcome was treatment success assessed at 1 year. PD pneumatic dilation, LHM laparoscopic Heller myotomy, POEM peroral endoscopic myotomy

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