S2239 PerOral Endoscopic Plication of the Esophagus (POPE) for the Management of End-Stage Achalasia: A Systematic Review and Meta-Analysis

Introduction: Achalasia is a progressive neurodegenerative motility disorder characterized by degeneration of the myenteric plexus and impaired relaxation of the lower esophageal sphincter (LES). In end-stage disease, the esophagus becomes severely dilated and refractory to conventional therapies. Esophagectomy remains the last resort despite its significant morbidity and mortality. In this context, Peroral Endoscopic Plication of the Esophagus (POPE) has recently emerged as a minimally invasive alternative for these patients. Methods: A systematic review and meta-analysis was conducted in accordance with PRISMA and Cochrane guidelines. We performed a comprehensive literature search in PubMed, Scopus, and the Cochrane Library on May 15, 2025. Studies reporting technical and clinical outcomes of POPE in patients with end-stage achalasia were included. Reviews, editorials, and commentaries were excluded. Primary outcomes were technical and clinical success. Secondary outcomes included adverse events, length of hospital stay (LOS), Eckardt score reduction, rate of rePOPE (POPE retreatment), need for esophagectomy, and mortality. The quality of the included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Case Series. The study was registered with PROSPERO. Results: A total of 4 case series and 45 patients (mean age 65.4 years; 46.7% man) were analyzed. Technical success was achieved in all cases, with an average of 3.8 sutures placed and a mean procedure time of 59.9 minutes. The clinical success rate was 94.9% (95% CI, 85.0-100), with a mean Eckardt score reduction of 4.81 from baseline. Four minor intraprocedural adverse events occurred: Three mucosal perforations and one bleeding event, all successfully managed endoscopically. One post-procedural bleeding event resolved spontaneously without intervention. Mean LOS was 0.33 days (range, 0–1). Follow-up ranged from 0.75 to 48 months. No major adverse events were observed. No patients required esophagectomy, and no deaths were reported. Ten patients (22.2%) required rePOPE at a mean of 23 months, primarily due to suture dehiscence. Conclusion: POPE appears to be a safe, effective, and reproducible minimally invasive alternative to esophagectomy for patients with end-stage achalasia. Despite promising outcomes, current evidence is limited to a small retrospective case series. If validated in large prospective multicenter studies, POPE may redefine the therapeutic algorithm for end-stage achalasia.