VP33 Peroral Endoscopic Myotomy For Treating Achalasia: A Rapid Review

Abstract

Introduction:

The best available research and funding policy evidence regarding the regulatory status, patient selection criteria, safety, clinical effectiveness, and financial impact of peroral endoscopic myotomy (POEM) for the treatment of achalasia was synthesized for statewide decision making for a South Australian local health network.

Methods:

A comprehensive systematic search of twenty-three gray literature sources and three published literature databases for international evidence was conducted, based on a priori inclusion criteria. The methodological quality of the included studies was critically appraised. Data extraction and synthesis were conducted in narrative form.

Results:

Short-term safety and clinical data from very low-level studies showed that POEM appears to be a relatively safe and clinically effective endoscopic treatment for esophageal achalasia, compared with laparoscopic Heller myotomy (LHM). One primary safety concern consistently highlighted by the literature was gastroesophageal reflux (GER) after POEM, since no anti-reflux procedure is involved. Operative time and length of hospital stay for POEM were comparable with LHM and potentially favor POEM. The comparative long-term outcomes for the POEM procedure are not known. No studies have investigated the cost-effectiveness of POEM. Conflicting findings were reported on whether POEM is cheaper or more expensive than LHM. POEM is a technically challenging procedure with a substantial learning curve. Patients who undergo POEM may require postoperative surveillance and testing to evaluate procedural success and to identify potential complications. Current literature showed limited analysis and systematic elucidation of an optimal patient group that may best benefit from POEM.

Conclusions:

The POEM procedure should be carried out at an experimental or trial level only, with strict auditing of results. POEM procedures should ideally be performed at institutions where an adequate level of surgical and critical care backup is available to provide expert care should complications arise. Monitoring of patient outcomes, including symptom improvement, is recommended for clinical assessment and reporting to determine future adoption in the South Australian public health sector.