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IS PERORAL ENDOSCOPIC MYOTOMY (POEM) FEASIBLE IN PEDIATRIC PATIENTS WITH ACHALASIA? A META-ANALYSIS AND SYSTEMATIC REVIEW
Harsha V. Moole1,2, Ayesha Waqar*1, Anthony Baldoni1, Sowmya Dharmapuri5, Vu Nguyen7, Vishnu Moole5, Anwesh Poosala5, Raghuveer R. Boddireddy5, Achuta Uppu2, Abhiram Duvvuri4, Vamsi Emani1, Sowjanya Kapaganti6, Srinivas R. Puli3
1University of Illinois College of Medicine at Peoria (UICOMP), Peoria, IL; 2Genesis Medical Center, Davenport Iowa, Davenport, IA; 3Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria (UICOMP). , Peoria, IL; 4Kansas City VA medical center, Kansas City, MO; 5NTR University of Health Sciences , Hyderabad, India; 6Pondicherry Institute of Medical Sciences, Pondicherry, India; 7Ho Chi Minh City medicine and pharmacy University, Ho Chi Minh, Viet Nam
Background:
Achalasia is a primary esophageal motility disorder characterized by failure of lower esophageal sphincter to relax in response to swallowing, along with loss of peristalsis of esophagus. Although surgical myotomy has been the mainstay treatment modality, peroral endoscopic myotomy (POEM) has emerged as an endoscopic alternative, and there is limited experience in pediatric population.
Aims:
This is a meta-analysis to pool the evidence for the success of POEM in treating achalasia in pediatric population. Primary outcomes are to evaluate the technical success rate and clinical success rate of POEM in treating pediatric patients with achalasia.
Methods:
Study selection criterion: Studies that evaluated POEM in achalasia patients were included in this analysis. Only pediatric patient (age <18years) studies were included in this analysis. Studies must have mentioned regarding either technical success rate and / or clinical success rate of POEM in this patient population. Technical success was defined as adequate and successful completion of the peroral endoscopic myotomy. Clinical success was defined as an improvement in Eckardt score to <3.
Data collection & extraction: Articles were searched in Medline, Pubmed, Ovid journals, CINAH, International pharmaceutical abstracts, old Medline, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials & Database of Systematic Reviews. 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 168 reference articles, of which 31 articles were selected and reviewed. Data was extracted from 9 studies (N=587) which met the inclusion criteria. Median age of the patients was 15 years, with 52% 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 that underwent POEM, technical success was achieved in 94.69% (95% CI= 92.36 to 96.62). Clinical success was achieved in 93.89% (95%CI = 91.82 to 95.67) of the pooled POEM patients. I2 heterogeneity calculated for the technical and clinical success was 77.8% and 57.2% respectively. Bias indicator for technical success variable, Begg-Mazumdar: Kendall's tau b = 0.04; P >0.99. Bias indicator for clinical success variable, Begg-Mazumdar: Kendall's tau b = -0.17; P = 0.48.
Conclusions:
In pediatric patients with achalasia, POEM procedure seems to have excellent technical and clinical success rates. It is a viable alternative to surgical management when appropriate technical and operator expertise are available.
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