Endoscopic versus surgical myotomy for achalasia and its impact of future esophageal cancer incidence: a Markov analysis based on a systematic review and meta-analysis of literature

Introduction: Achalasia increases the risk of esophageal cancer due to chronic food stasis and inflammation. Laparoscopic Heller’s myotomy (LHM) with partial fundoplication and peroral endoscopic myotomy (POEM) have shown similar outcomes in resolving dysphagia, but POEM had higher postoperative gastroesophageal reflux disease (GERD). GERD, however, increases the risk of esophageal adenocarcinoma. We aim to determine, via a probabilistic approach, the likelihood of esophageal cancer in patients who underwent either LHM or POEM as the initial myotomy of choice for achalasia. Methods: Systematic reviews and meta-analyses of studies published from 2015 to 2024 reporting outcomes of LHM or POEM, including revisional procedures and cancer incidence, were performed. A Markov decision tree model was developed, with input probabilities based on the systematic review. Primary outcome was probability of esophageal cancer. Results: Twenty-six studies were included into a five-step Markov decision tree. Meta-analyses revealed that POEM did not differ from LHM in dysphagia resolution (RR 1.00, 95% CI: 0.91–1.11) and did not significantly increase post-operative esophagitis (RR 2.51, 95% CI: 0.68–9.26). Re-operative POEM was superior to LHM (OR 3.39, 95% 1.04–11.05) in patients with refractory or recurrent dysphagia patients. Achalasia significantly increases the risk of esophageal squamous cell carcinoma. Based on 10 000 simulations over a 10-year period, primary LHM or POEM did not significantly impact esophageal cancer development (1.9% vs 1.5%, P = 0.089), though POEM consistently resulted in more esophagitis (42.3% vs 16.0%, P < 0.001). Refractory or recurrent achalasia had the highest input probability of esophageal cancer. Conclusion: The overall likelihood of esophageal cancer after LHM or POEM was similar, likely due to the low, albeit elevated, risk of esophageal cancer in achalasia. However, the significantly higher post-procedural esophagitis with POEM, which may necessitate long-term management and surveillance, must also be considered when considering the initial myotomy of choice. Re-operative POEM should be considered in patients with refractory or recurrent dysphagia after treatment.