Supervisors info:
Αλμπανόπουλος Κωνσταντίνος, Αναπληρωτής Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Θεοδώρου Δημήτριος, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Θεοδωρόπουλος Γεώργιος, Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Summary:
Introduction. Achalasia of the esophagus (AO) is a rare motility disorder in children. Similarly, to the disease found in adults, children experience symptoms of dysphagia, regurgitation, and chest pain. Standard diagnostic approaches include barium meal, upper endoscopy, and esophageal manometry. Current available data suggest laparoscopic Heller myotomy (LHM) and per-oral endoscopic myotomy (POEM) as the best treatment modalities. This systematic review and meta-analysis aim to compare the safety and efficacy of LHM and POEM for AO.
Methods. A systematic electronic literature search was performed in PubMed/Medline, Google Scholar and Web of Science for original articles comparing LHM and POEM limited to English texts full articles. After a detailed review, all articles collected were analyzed further in depth with respect to treatment protocols, Primary outcomes included pre- and post-Eckardt score (ES) and pre- and postoperative lower esophageal sphincter (LES) pressure. Secondary outcomes included intraoperative complications, conversions, re-interventions and type, gastroesophageal reflux (GER), success ratea, and mortality.
Results. A total of 32 articles reporting on 800 patients were selected, tabulated and reviewed. There were 800 children (female: 345, M/F: 1:0.73), aging 1-17 years. LHM underwent 293 patients, and POEM 507. The meta-analysis due to missing diagnostic values of ES and LES in the LHM group was limited to the POEM results. According to the random effects model the mean ES difference pre- and pos-operatively was 4.387 (95% C.I.: 3.799-4.974), significantly different to zero (z=14.64, p<0.001), while the mean LES pressure difference pre- and postoperatively was 3.63 (95% C.I.: 2247-3.879), significantly different to zero (z=7.36, p<0.001). Moreover, our results showed no statistical differences regarding intraoperative complications, conversions, post-operative GER, re-interventions and success rates (p=0.139, p=0.118, p=0.125, p=0.50 and p=0.53 respectively), while no conversions with POEM were noticed. No mortality was reported either with LHM or POEM method.
Conclusions. Both LHM and POEM demonstrated similar results regarding intraoperative complications, conversions, postoperative GER, re-interventions and success rates. Moreover, no conversions were identified with POEM technique. However, our study was failed to compare the two methods regarding their impact on ES and LES, due to inappropriate design of LHM procedure. Therefore, we were limited to the POEM results that showed statistically better outcomes regarding ES and LES pressure pre-and postoperatively. These results showed that POEM is effective and durable for treating AO in children. Well-designed studies are warranted in the future to further clarify differences between the two methods.
Keywords:
Εsophageal achalasia, Children, Laparoscopic surgery, Thoracoscopic surgery, Per pral endoscopic myotomy
