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A META-ANALYSIS AND SYSTEMATIC REVIEW OF PROSPECTIVE TRIALS: ECKARDT SCORE WITH PERORAL ENDOSCOPIC MYOTOMY (POEM) VERSUS SURGICAL MYOTOMY IN MANAGING ADULT ACHALASIA PATIENTS
Abhiram Duvvuri*1, Vishnu Moole2, Anwesh Poosala2, Raghuveer R. Boddireddy2, Achuta Uppu3, Vamsi Emani4, Sowmya Dharmapuri2, Srinivas R. Puli4, Harsha V. Moole4,3
1Gastroenterology, Kansas City Veteran Affairs Medical Center, Overland Park, KS; 2NTR University of Health Sciences, Vijayawada, India; 3Genesis Medical Center, Davenport, IA; 4University of Illinois College of Medicine at Peoria, Peoria, IL
Background:
Achalasia is a primary esophageal motility disorder characterized by loss of peristalsis of esophagus and failure of lower esophageal sphincter to relax in response to swallowing. Surgical myotomy has been the mainstay treatment modality. Peroral endoscopic myotomy (POEM) has recently been described as an endoscopic alternative. Eckardt score is a clinical scoring system for achalasia (maximum score, 12), based on symptoms scores for dysphagia, regurgitation, chest pain and weight loss.
Aims:
This is a meta-analysis of prospective trials, to compare the effect of POEM versus surgical myotomy on Eckardt scores while treating adult patients with achalasia. Primary outcomes are the Eckardt scores in POEM and surgery group - preoperative, post-operative (<30days of intervention) and at follow up period.
Methods:
Study selection criterion: Only prospective studies that evaluated POEM only and POEM versus surgical myotomy, in achalasia patients were included in this analysis. Only adult patient studies were included in this analysis. Studies must have mentioned regarding Eckardt scores in this patient population.
Data collection & extraction: Articles were searched in Medline, Pubmed, Ovid journals, CINAH, and International pharmaceutical abstracts. 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 model) and DerSimonian Laird method (random effects model). The heterogeneity among studies was tested using I2 statistic.
Results:
Initial search identified 368 reference articles, of which 74 articles were selected and reviewed. Data was extracted from 34 studies (N=1784) which met the inclusion criteria. Median age of the patients was 47 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, preoperative Eckardt scores in POEM and surgery group are 6.48 (95% CI = 6.32 to 6.65) and 5.90 (95% CI = 5.36 to 6.44) respectively. Post-operative Eckardt scores in POEM group was 1.02 (95% CI = 0.92 to 1.12). Eckardt scores at median follow up period (in POEM and surgery group) were 1.15 (95% CI = 1.07 to 1.23) and 1.21 (95% CI = 0.90 to 1.52) respectively. I2 heterogeneity calculated for the POEM group Eckardt scores preoperative, post-operative and at follow up are 62%, 92.7%, 84.2% respectively. I2 heterogeneity calculated for the surgery group Eckardt scores preoperative and at follow up are 21%, 32.9% respectively.
Conclusions:
In adult patients with achalasia, POEM procedure was as effective as or even slightly better than surgical myotomy, in reducing the Eckardt scores.
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