Gastroesophageal reflux disease after per-oral endoscopic myotomy as compared with Heller's myotomy with fundoplication: a systematic review with meta-analysis

BACKGROUND AND AIMS: Per-oral endoscopic myotomy (POEM) represents a less invasive alternative, as compared with conventional laparoscopic Heller's myotomy (LHM), for achalasia patients. It cannot be excluded, however, that the lack of fundoplication after POEM may result in a higher incidence of reflux disease, as compared with LHM. The aim was to conduct a systematic review of prospective studies reporting the incidence of reflux disease developed after POEM and LHM.

METHODS: Literature search with electronic databases was performed (up to February 2017) to identify full articles on the incidence of gastro-esophageal reflux symptoms, endoscopic- and pH-monitoring-findings after POEM and LHM (with fundoplication). Proportions and rates were pooled by means of a random or fixed effects models, according to the level of heterogeneity between studies.

RESULTS: After applying the selection criteria, 17 and 28 studies, including 1,542 and 2,581 subjects who underwent POEM and LHM, respectively, were included. Pooled rate of postprocedure symptoms was 19.0% (95% CI, 15.7%-22.8%) after POEM, and 8.8% (95% CI, 5.3%-14.1%) after LHM, respectively. Pooled rate estimate of abnormal acid exposure at pH-monitoring was 39.0% (95% CI, 24.5%-55.8%) after POEM, and 16.8% (95% CI, 10.2%-26.4%) after LHM, respectively. Rate of post-POEM esophagitis was 29.4% (95% CI, 18.5%-43.3%) after POEM, and 7.6% (95% CI, 4.1%-13.7%) after LHM. At meta-regression, heterogeneity was partly explained by POEM approach and study population.

CONCLUSIONS: Incidence of reflux-disease appears to be significantly more frequent after POEM than after LHM with fundoplication. pH-monitoring and appropriate treatment after POEM should be considered in order to prevent long-term reflux-related adverse events.