Meta-Analysis Confirms Long-Term Safety, Efficacy of POEM

LONG BEACH, Calif.—A new systematic review and meta-analysis has shed light on the long-term viability of peroral endoscopic myotomy (POEM) in the treatment of achalasia. The study, presented at the 2025 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, found that POEM is a safe and effective alternative to laparoscopic Heller myotomy over 24 months, with the advantage of shorter operative times.

“There are concerns regarding long-term outcomes of POEM, particularly the risk of increased gastroesophageal reflux disease after the procedure, because it lacks an antireflux component,” began Odelle Ma, MD, a general surgery resident at the University of Alberta, in Edmonton. “Although several prior review studies have shown comparable short-term clinical efficacy and safety between POEM and lap Heller, the length of follow up for these studies are all less than 12 months.” As such, she and her colleagues sought to compare two-year outcomes between the procedures.

The investigators searched a variety of databases through January 2024. Of 121 studies that underwent full-text review, nine were included (eight cohort studies and one randomized controlled trial); each compared the two procedures for treatment of achalasia with a minimum 24-month follow-up. The study’s primary end point was treatment success, which was defined as an Eckardt score of less than 3.

The meta-analysis included 1,099 patients, 583 in the POEM group and 516 in the laparoscopic Heller myotomy group. Mean follow-up was 34.5 months for POEM patients and 35.2 months for Heller myotomy patients.

Treatment success was 85% in POEM and 80% for Heller myotomy (odds ratio [OR], 1.43; 95% CI, 0.96-2.13; P=0.08). The researchers also found no significant difference in the incidence of perioperative complications between groups (OR, 0.85; 95% CI, 0.40-1.82; P=0.68).

On the other hand, operative time was 35.69 minutes shorter (95% CI, –50.24 to –20.83 minutes; P<0.00001) and hospital length of stay was 0.7 days shorter (95% CI, –1.03 to –0.36 days; P<0.0001) in POEM patients.

GERD was reported using different measures across investigations. Initially, the meta-analysis showed no difference between the two procedures in terms of esophagitis incidence. However, when the researchers conducted a sensitivity analysis and removed one outlier trial from the analysis, POEM was found to result in statistically greater rates of esophagitis (OR, 2.57; 95% CI, 1.45-4.53; P=0.001). Similarly, POEM patients were more likely to use proton pump inhibitors after surgery (OR, 1.72; 95% CI, 1.03-2.89; P=0.04). Complication rates were low, with no significant differences found between the groups.

As Dr. Ma explained, the meta-analysis was limited by its small sample size and the inclusion of only one randomized controlled trial. In addition, heterogeneity in outcome reporting between included studies led to a decrease in the analyzable population for certain variables, such as postoperative GERD.

“This is the first systematic review and meta-analysis to study long-term outcomes, and we showed that safety and efficacy of POEM remain comparable to lap Heller at two years post-procedure. More randomized studies are needed to examine outcomes beyond two years and determine the clinical significance of GERD post-POEM.”