Redo Heller myotomy vs. POEM after failed Heller myotomy: a systematic review and meta-analysis.

BACKGROUND: The optimal management of patients with recurrent symptoms after laparoscopic Heller myotomy (LHM) remains elusive. The aim of this study was to compare the effectiveness and safety between redo Heller myotomy and peroral endoscopic myotomy (POEM) after failed LHM. METHODS: A systematic review using the Medline and Cochrane databases was conducted to identify original studies evaluating outcomes after redo Heller myotomy or POEM following LHM. The primary endpoint was to assess symptomatic improvement. Intraoperative complications, postoperative morbidity, and post-procedural gastroesophageal reflux disease (GERD) were included as secondary outcomes. A meta-analysis of proportions, paired comparisons, and linear regression models were used to assess the effect of each procedure on different outcomes. RESULTS: A total of 26 studies comprising 631 patients were included: 306 (48.5%) redo LHM and 325 (51.5%) POEM. Both procedures achieved a significant and similar Eckardt score reduction (Redo LHM: 6.64 to 1.22 vs. POEM: 6.71 to 1.82 points; p=0.57) and obtained a similar overall symptom improvement (Redo LHM: 76% vs. POEM: 82%; p=0.96). POEM was associated with shorter procedural time (89.0 vs. 180.0 min; p<0.001), lower intraoperative complication rates (9% vs. 19%; p=0.01) and reduced major morbidity (4% vs. 11%; p=0.003). The pool weighted incidence of GERD was 43% (95% CI 25-64) and 31% (95% CI 9-68) after POEM and redo LHM, respectively. CONCLUSIONS: Both redo Heller myotomy and POEM are effective treatment modalities for patients with recurrent symptoms after LHM. POEM, however, is associated with lower rates of intra-procedural complications and reduced major morbidity.