Comparative Effectiveness of Peroral Endoscopic Myotomy, Laparoscopic Heller Myotomy, Pneumatic Dilation, and Botulinum Toxin for Achalasia

Background: Available achalasia therapies include peroral endoscopic myotomy (POEM), laparoscopic Heller myotomy (LHM), pneumatic dilation (PD), and botulinum toxin injection (BT). Head-to-head trials comparing these therapies are limited. We conducted this network meta-analysis to evaluate the efficacy and safety of these interventions. Methods: We searched online databases for randomized controlled trials (RCTs) evaluating therapies for achalasia. The primary outcomes were treatment success at 1, 2, and 5 years. Secondary outcomes included the Eckardt score, symptoms of gastroesophageal reflux disease (GERD), erosive esophagitis, and serious adverse events. Risk ratios (RRs) were used in the analysis, using a random-effects model, and the quality of evidence was assessed using the GRADE approach. Results: A total of 14 RCTs with 1171 patients were included. At 1 year, all treatments were more effective than botulinum toxin, and POEM and LHM outperformed PD, with POEM ranked highest (SUCRA 86%). At 2 and 5 years, POEM remained superior to PD. POEM and LHM showed comparable effectiveness across all time points. PD and LHM were associated with a lower risk of GERD than POEM at 5 years: PD versus POEM (RR: 0.35; 95% CI: 0.14-0.89) and LHM versus POEM (RR: 0.49; 95% CI: 0.29-0.84). Erosive esophagitis was more frequent with POEM than PD at 2 years. Conclusions: POEM and LHM demonstrated comparable success rates, and both had significantly higher success rates than PD at all time points. However, the quality of the evidence was rated low to very low. POEM was associated with higher rates of GERD at 5 years. Future trials should directly compare these modalities using standardized protocols to enable meaningful comparisons, and follow-up beyond 5 years is needed to establish their long-term outcomes.