The Efficacy and safety of full-thickness versus circular peroral endoscopic myotomy for treatment of achalasia: a systematic review and meta-analysis

Sudheer Dhoop; Mohammed Abu-Rumaileh; Wasef Sayeh; Sami Ghazaleh; Conner Lombardi; Manthanbhai Patel; Bisher Sawaf; Wade Lee-Smith; Adrian Zhou; Ali Nawras; Yaseen Alastal

Authors Sudheer Dhoop, Mohammed Abu-Rumaileh, Wasef Sayeh, Sami Ghazaleh, Conner Lombardi, Manthanbhai Patel, Bisher Sawaf, Wade Lee-Smith, Adrian Zhou, Ali Nawras, Yaseen Alastal.

Abstract

Background Peroral endoscopic myotomy (POEM) is a treatment for esophageal achalasia with 2 variations in myotomy depth: full-thickness myotomy (FTM) and circular myotomy (CM). This systematic review and meta-analysis compares the efficacy and safety of these variations.

Methods Major health databases and registers, including Embase, MEDLINE and Cochrane were searched systematically. The primary outcome was clinical success, while secondary outcomes included change in achalasia severity scores, post-POEM gastroesophageal reflux disease (GERD) measures, procedural time, and adverse events. Meta-analysis was conducted using randomeffects models, with risk ratios (RR) and mean differences (MD) calculated for dichotomous and continuous variables, respectively.

Results Nine observational studies compared FTM and CM in 1,203 patients. FTM was performed in more severe achalasia and demonstrated similar clinical success to CM (RR 1.01, 95% confidence interval [CI] 0.98-1.04; P=0.55; n=6) and procedural time (MD 3.49 min, 95%CI -2.79-9.78; P=0.28, I2=66%; n=3). FTM was associated with increased post-POEM GERD outcomes, post-POEM pain (RR 1.94, 95%CI 1.27-2.95; P=0.002; n=2), and length of stay (LOS) (MD 0.85 days, 95%CI 0.11-1.59; P=0.02; I2=0%; n=2); however, association with esophagitis disappeared when proton pump inhibitors use was accounted for (RR 1.68, 95%CI 0.89-3.16; P=0.11; I2=23%; n=4). CM was associated with higher rates of subcutaneous emphysema (RR 0.59, 95%CI 0.43-0.81;
P=0.001; n=5).

Conclusions FTM and CM have comparable observed clinical efficacy and procedural time, with minimal differences in complications. FTM may be preferred in more severe achalasia and its association with post-POEM GERD may have been overestimated, but it may increase post-POEM pain and LOS.

Keywords Peroral endoscopic myotomy, myotomy depth, efficacy, safety

Ann Gastroenterol 2025; 38 (2): 143-155