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ECKARDT SCORES WITH PERORAL ENDOSCOPIC MYOTOMY (POEM) IN SPASTIC ESOPHAGEAL DISORDERS (EXCLUDING ACHALASIA) WITH FAILED MEDICAL THERAPY: A META-ANALYSIS AND SYSTEMATIC REVIEW
Harsha V. Moole*1,5, Anwesh Poosala2, Sowjanya Kapaganti3, Vu Nguyen4, Achuta Uppu5, Raghuveer R. Boddireddy6, Vishnu Moole2, Abhiram Duvvuri7, Anthony Baldoni1, Ayesha Waqar1, Vamsi Emani1, Sowmya Dharmapuri6, Srinivas R. Puli1
1University of Illinois College of Medicine Peoria, Peoria, IL; 2Medicine, Mamatha medical college, NTR University of Health Sciences, Khammam, India; 3Medicine, Pondicherry Institute of Medical Sciences, Pondicherry, India; 4Ho Chi Minh City medicine and pharmacy university, Ho Chi Minh City , Viet Nam; 5Genesis Medical Center, Davenport, IA; 6Medicine, NTR University of Health Sciences, Vijayawada, India; 7Kansas City VA Medical Center, Kansas City, KS
Background: Peroral endoscopic myotomy (POEM) is primarily being studied in achalasia patients. There is limited experience with POEM in other spastic esophageal disorders - nutcracker esophagus, jack hammer esophagus and diffuse esophageal spasms. Based on the current guidelines, the primary treatment options for these spastic esophageal disorders are medications like calcium channel blockers, nitrites, botulinum toxin; esophageal dilation, surgical myotomy. Eckardt score is a clinical scoring system for spastic esophageal disorders (maximum score, 12), based on symptoms scores for dysphagia, regurgitation, chest pain and weight loss.
Aims: This is a meta-analysis to evaluate the effect of POEM on Eckardt scores of patients with spastic esophageal disorders. Primary outcomes are the Eckardt scores of patients that underwent POEM - preoperative, post-operative (<30days since procedure) and at follow up period (median 12 months).
Methods:
Study selection criterion: Studies that evaluated POEM in either nutcracker esophagus, jack hammer esophagus or diffuse esophageal spasms, with failed medical therapy were included in this analysis. Studies evaluating only achalasia patients were excluded from this analysis. Studies must have mentioned regarding Eckardt scores in this patient population.
Data collection & extraction: Articles were searched in Medline, Pubmed, and Ovid journals. Two reviewers independently searched and extracted data. Any differences were resolved by mutual agreement.
Statistical Method: Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects) and DerSimonian Laird method (random effects). The heterogeneity among studies was tested using I2 statistic.
Results: Initial search identified 127 reference articles, of which 42 articles were selected and reviewed. Data was extracted from 8 studies (N=567) which met the inclusion criteria. Median age of the patients was 52 years, with 54% males. Median follow up period was 12 months. The p for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. In the pooled patient population, effect size of preoperative Eckardt scores in patients that underwent POEM was 6.47 (95% CI = 6.18 to 6.77). Post-operative Eckardt scores and Eckardt scores at median follow up period were 1.13 (95% CI = 0.99 to 1.26) and 1.20 (95% CI = 0.96 to 1.43) respectively. I2 heterogeneity calculated for the POEM group Eckardt scores preoperative, post-operative and at follow up are 87.4%, 0%, 73.7% respectively.
Conclusions: In patients with nutcracker esophagus, jack hammer esophagus or diffuse esophageal spasms, that failed medical therapy, POEM procedure resulted in exceptionally improved Eckardt scores. POEM seems to be a viable endoscopic alternative to surgical myotomy if appropriate technical and operator expertise are available.
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