S2192 Peroral Endoscopic Myotomy Versus Pneumatic Dilation for Achalasia: An Updated Systematic Review and Meta-Analysis

Introduction: Peroral endoscopic myotomy (POEM) and pneumatic dilation (PD) are established treatment modalities for achalasia. However, the optimal therapeutic approach remains debated. We aimed to perform an updated meta-analysis comparing clinical outcomes of POEM compared to PD in patients with achalasia. Methods: We systematically searched PubMed, Embase, and the Cochrane Library databases for studies comparing POEM with PD for the treatment of achalasia. The primary outcome was treatment success, defined as an Eckardt score ≤3 without the need of retreatment. Secondary outcomes included adverse events, need of retreatment, post-treatment Eckart score, symptoms recurrence, gastroesophageal reflux disease (GERD), lower esophageal sphincter (LES) pressure, proton pump inhibitor (PPI) use, integrated relaxation pressure (IRP), esophageal diameter, bleeding, and treatment failure - defined as an Eckardt score >3 or requirement for retreatment. A random-effects meta-analysis was conducted to generate pooled risk ratios (RRs) and mean differences (MDs) and their related 95% confidence intervals (CIs). Results: Thirteen studies with a total of 5,669 patients were included, of whom 2,341 (41.3%) underwent POEM. Pooled analysis showed that POEM was associated with higher treatment success (RR = 1.55; 95% CI: 1.33–1.80; P < 0.001), reduced need for retreatment (RR = 0.29; 95% CI: 0.18–0.47; P < 0.001), lower Eckardt scores (MD = -0.63; 95% CI: -1.03 to -0.23; P < 0.01), lower symptom recurrence (RR = 0.25; 95% CI: 0.13–0.48; P < 0.001), reduced LES pressure (MD = -1.78 mmHg; 95% CI: -3.38 to -0.18; P = 0.03), and lower treatment failure rates (RR = 0.35; 95% CI: 0.21–0.58; P < 0.001). Conversely, POEM was associated with a higher incidence of GERD (RR = 3.41; 95% CI: 1.70–6.82; P < 0.001) and a greater rate of overall adverse events (RR = 1.92; 95% CI: 1.11–3.32; P = 0.020). No significant differences were observed between the groups regarding PPI use, IRP, bleeding, or esophageal diameter. Conclusion: This meta-analysis suggests that POEM offers superior efficacy compared to PD in terms of treatment success, symptom control, and reduction in retreatment and treatment failure rates. However, POEM is associated with a higher risk of GERD and adverse events, indicating that PD may be a better option in patients where procedural safety is prioritized, such as those with significant comorbidities.