Peroral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy for Achalasia: A Meta-Analysis of Randomized Controlled Trials

Peroral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy for Achalasia: A Meta-Analysis of Randomized Controlled Trials | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Peroral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy for Achalasia: A Meta-Analysis of Randomized Controlled Trials Harshawardhan Dhanraj Ramteke , Sanapala Keerthi , Ashesh Das , Bodanam Shreya , Shameek Paul , Bharadwaj Jilakaraju , Bodipudi Vineetha , Virushnee Senthilkumar , Ambala Madhulika , Syeda Hafsa Noor-Ain , Rakhshanda Khan doi: https://doi.org/10.1101/2025.09.16.25335767 Harshawardhan Dhanraj Ramteke 1 Anhui Medical University , Heifei, China Find this author on Google Scholar Find this author on PubMed Search for this author on this site Sanapala Keerthi 2 Andhra Medical College Vishakapatnam , AP, India Find this author on Google Scholar Find this author on PubMed Search for this author on this site Ashesh Das 3 KPC Medical College and Hospital , Kolkata, India Find this author on Google Scholar Find this author on PubMed Search for this author on this site Bodanam Shreya 4 Kamineni Academy of Medical Sciences and Research , Hyderabad, India Find this author on Google Scholar Find this author on PubMed Search for this author on this site Shameek Paul 5 KPC medical College and Hospital hospital , Kolkata Find this author on Google Scholar Find this author on PubMed Search for this author on this site Bharadwaj Jilakaraju 6 Archbold Memorial Center , USA Find this author on Google Scholar Find this author on PubMed Search for this author on this site Bodipudi Vineetha 7 Apollo Institute of Medical Sciences and Research , AP, India Find this author on Google Scholar Find this author on PubMed Search for this author on this site Virushnee Senthilkumar 8 Coimbatore Medical College , Tamilnadu, India Find this author on Google Scholar Find this author on PubMed Search for this author on this site Ambala Madhulika 9 Kamineni Academy of Medical Sciences and Research , Hyderabad, India Find this author on Google Scholar Find this author on PubMed Search for this author on this site Syeda Hafsa Noor-Ain 10 Ayaan Institute of Medical Sciences , Moinabad, India Find this author on Google Scholar Find this author on PubMed Search for this author on this site Rakhshanda Khan 11 Ayaan Institute of Medical Sciences , Moinabad, India Find this author on Google Scholar Find this author on PubMed Search for this author on this site For correspondence: doctorkhan0501{at}gmail.com Abstract Full Text Info/History Metrics Supplementary material Data/Code Preview PDF Abstract Introduction Achalasia is a rare primary esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation and dysphagia. Laparoscopic Heller myotomy (LHM) has long been the standard treatment, while peroral endoscopic myotomy (POEM) has emerged as a minimally invasive alternative. Comparative evidence from randomized controlled trials (RCTs) remains limited, and outcomes such as gastroesophageal reflux disease (GERD) and clinical remission require clarification. Methods We systematically searched PubMed, Embase, Cochrane CENTRAL, and Web of Science to September 2025 for RCTs comparing POEM and LHM in adult patients with achalasia. Data on demographics, previous treatment, dysphagia improvement, GERD incidence, clinical remission, and mortality were extracted. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random-effects model in Stata 18. Results Seven RCTs involving 900 patients (465 POEM; 465 LHM) were included. Dysphagia improvement was similar between groups (log OR 0.14; 95% CI −0.32 to 0.59; p = 0.55). GERD incidence was higher after POEM but not statistically significant (log OR 0.59; 95% CI −0.08 to 1.25; p = 0.08). Clinical remission showed a non-significant trend favoring POEM (log OR 0.39; 95% CI −0.06 to 0.84; p = 0.09). Reduction in pH levels significantly favored LHM (log OR 0.75; 95% CI 0.18 to 1.33; p = 0.01). No mortality was reported. Conclusion POEM and LHM provide comparable dysphagia relief and clinical remission in achalasia. However, POEM is associated with higher GERD risk, particularly on pH monitoring. Treatment choice should balance efficacy against reflux risk, with careful long-term follow-up. Introduction Achalasia is a rare but disabling esophageal motility disorder characterized by failure of the lower esophageal sphincter (LES) to relax and loss or discoordination of esophageal peristalsis. Clinically, patients suffer from progressive dysphagia to both solids and liquids, regurgitation, chest pain, weight loss, and in severe cases, pulmonary complications or mega□esophagus if untreated. The global epidemiology has only recently become clearer: pooled estimates indicate an incidence of ∼ 0.78 cases per 100,000 person□years (95% CI 0.64–0.93) and a prevalence of ∼ 10.8 per 100,000 (95% CI 8.15–13.48) [ 1 ]. Although these numbers remain low compared to many chronic disorders, achalasia imposes substantial burdens—on quality of life, nutritional status, healthcare resource use, and long□term risk of complications [ 2 ]. Over decades, the standard of care for achalasia has evolved. Laparoscopic Heller myotomy (LHM), often combined with a partial fundoplication, has been the benchmark surgical treatment, with many centers reporting durable symptomatic relief, acceptable morbidity, and low mortality. Conversely, more recently developed, peroral endoscopic myotomy (POEM) offers a minimally invasive alternative: through a submucosal tunnel, the circular (and sometimes longitudinal) muscle fibers of the esophagus and LES are divided endoscopically. POEM avoids external incisions, may allow for longer esophageal myotomy tailored to the achalasia subtype (e.g., type II vs type III), and is associated with reduced pain and quicker recovery in several reports [ 3 , 4 , 5 ]. Both LHM and POEM have shown high rates of clinical success in terms of dysphagia relief, with many studies reporting improvement in Eckardt scores, decreased LES pressures, and low rates of immediate complications. A landmark randomized controlled trial (Werner et al., 2019) showed POEM to be non□inferior to LHM + Dor fundoplication at 2-year follow-up in controlling symptoms [ 6 ]. In addition, recent long-term outcome data suggest that POEM maintains clinical success rates of around 80-85% over 3-5 years [ 7 , 8 ]. Nevertheless, while several systematic reviews and meta-analyses have attempted to compare POEM and LHM, there remain important limitations. The meta-analysis by Schlottmann et al. (2017) found that POEM was slightly more effective in dysphagia relief in the short term but was associated with significantly greater risk of gastroesophageal reflux disease (GERD), both symptomatic and objective (via esophagogastroduodenoscopy [EGD] and pH monitoring). However, this and other meta-analyses are hampered by heterogeneity in patient populations (treatment-naïve vs previously treated), variations in follow-up duration (POEM studies generally had much shorter follow-ups than LHM studies), inconsistent definitions of outcomes (especially for GERD), and predominance of nonrandomized observational designs [ 9 , 10 ]. For example, in Schlottmann et al., follow-up for POEM averaged ∼16.2 months versus ∼41.5 months for LHM, raising the possibility that longer□term complications (e.g. reflux, treatment failures) are under-ascertained [ 11 ]. Moreover, many studies do not sufficiently stratify by achalasia subtype (types I, II, III), do not control for learning curve effects (POEM is a newer method), and often do not include standardized or objective assessments of GERD (e.g. pH monitoring or histologic esophagitis). Cost, postoperative quality of life, reintervention (i.e. the need for redo myotomy or dilation), and long-term adverse effects such as Barrett’s esophagus are underreported. These limitations reduce the confidence with which clinicians can judge long-term trade-offs between efficacy and potential harms when choosing POEM vs LHM. In light of these gaps, there is a pressing need to focus on randomized controlled trials and high-quality comparative studies with longer follow-up, consistent outcome definitions, and detailed reporting of adverse events. Such data will better clarify whether POEM truly matches or surpasses LHM in both benefits and risks, especially in domains such as reflux, reinterventions, and durability of symptom control. Therefore, in this meta-analysis based on core randomized controlled trials (and high□quality RCT subsets), we aim to compare POEM versus LHM for adult achalasia in terms of (i) symptomatic relief (e.g., dysphagia / Eckardt score), (ii) safety and adverse events, including GERD (both symptomatic and objective), (iii) reintervention rates, and (iv) long-term durability (minimum follow-up 2-5 years). We hypothesize that while POEM will be non-inferior in symptom relief, it may carry higher rates of pathologic reflux; and that longer-term RCT□driven data will help delineate whether those trade-offs are acceptable or whether surgical myotomy with fundoplication remains superior in specific subgroups. Methods Literature Search A comprehensive literature search was conducted in PubMed, Embase, Cochrane CENTRAL and Scopus from inception to September 2025. Search terms included “achalasia,” “peroral endoscopic myotomy,” “POEM,” “laparoscopic Heller myotomy,” “LHM,” and “randomized controlled trial.” Boolean operators and MeSH terms were applied where appropriate. References of relevant articles and previous systematic reviews were hand-searched to ensure completeness. Only randomized controlled trials directly comparing POEM with LHM were included. No language restrictions were applied, and conference abstracts, case series, and noncomparative studies were excluded. It followed PRISMA guidelines and also registered with Prospero with number CRD420251148413 [ 12 ]. Study Selection and Data Extraction Two reviewers independently screened titles, abstracts, and full texts of all identified records, with disagreements resolved through consensus or third-party adjudication. Eligible studies were randomized controlled trials directly comparing POEM with LHM in adult patients diagnosed with achalasia. Noncomparative designs, case reports, and reviews were excluded. Data were extracted in duplicate using a predesigned template. Extracted variables included study identifiers (author, year, country, sample size), baseline demographics, history of prior treatments for achalasia, and primary outcomes of interest: improvement in dysphagia, incidence of gastroesophageal reflux disease (GERD), and all-cause mortality during follow-up. Statistical Analysis All statistical analyses were conducted using Stata version 18 (StataCorp LLC, College Station, TX, USA). Dichotomous outcomes were summarized as odds ratios (ORs) with 95% confidence intervals (CIs). A random-effects model (DerSimonian–Laird method) was applied to account for between-study variability. Heterogeneity was quantified using the I 2 statistic, with thresholds of 25%, 50%, and 75% representing low, moderate, and high heterogeneity, respectively. Potential publication bias was explored through funnel plot inspection and Egger’s regression test where sufficient studies were available. A two-tailed p value <0.05 was considered statistically significant. Risk of Bias Assessment The methodological quality of included randomized controlled trials was assessed independently by two reviewers using the Cochrane Risk of Bias 2.0 (RoB 2.0) tool [ 13 ]. Domains evaluated included randomization process, deviations from intended interventions, missing outcome data, measurement of outcomes, and selective reporting. Each domain was rated as “low risk,” “some concerns,” or “high risk” of bias, and an overall judgment was assigned to each study. Disagreements were resolved by consensus or discussion with a third reviewer. Certainty of Evidence (GRADE) The certainty of evidence for each outcome—previous treatment history, dysphagia improvement, GERD incidence, and mortality—was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. Evidence quality was rated across five domains: risk of bias, inconsistency, indirectness, imprecision, and publication bias. The certainty of evidence was classified as high, moderate, low, or very low. Summary of Findings (SoF) tables were generated to present pooled effect estimates with corresponding GRADE ratings for each primary outcome. Results Demographics The initial search across PubMed, Embase, Cochrane CENTRAL, and Web of Science yielded 532 records. After removal of duplicates and screening of titles and abstracts, 48 studies were retrieved for full-text review. Of these, 7 randomized controlled trials met the inclusion criteria and were included in the final quantitative synthesis Figure 1 . The seven included trials enrolled a total of 900 patients with achalasia, of whom 510 were male and 420 were female. The pooled population was evenly distributed between the two intervention arms, with 465 patients undergoing peroral endoscopic myotomy (POEM) and 465 undergoing laparoscopic Heller myotomy (LHM). The mean follow-up across studies ranged from 12 to 60 months, with most trials reporting structured clinical and endoscopic assessments. Table S1. Download figure Open in new tab Figure 1. PRISMA Flow Diagram Dysphagia Improvement All seven randomized controlled trials reported outcomes on dysphagia improvement following POEM versus LHM. As shown in Figure 2 , the pooled analysis demonstrated no statistically significant difference between the two interventions. The overall log odds ratio was 0.14 (95% CI −0.32 to 0.59; p = 0.55) , indicating comparable efficacy of POEM and LHM in relieving dysphagia. Individual trials varied in effect estimates, with some favoring POEM and others favoring LHM; however, the consistency across studies was supported by low-to-moderate heterogeneity ( I 2 = 25.7% ). These findings suggest that both procedures provide substantial and durable symptomatic relief in patients with achalasia. Download figure Open in new tab Figure 2. Odds ratio of the number of patients reduced in dysphagia in the LHM vs POEM Gastroesophageal Reflux Disease (GERD) Five randomized controlled trials reported on postoperative GERD outcomes. As illustrated in Figure 3 , the pooled analysis demonstrated a trend toward higher GERD incidence after POEM compared with LHM, although this did not reach statistical significance. The overall log odds ratio was 0.59 (95% CI −0.08 to 1.25; p = 0.08) , suggesting a tendency favoring LHM in reducing reflux. Heterogeneity was low to moderate ( I 2 = 29.5% ), indicating consistent findings across studies. While some trials showed a notable excess of GERD in the POEM group, others reported comparable rates between procedures. Download figure Open in new tab Figure 3. Odds ratio of the number of patients reduced in GERD in the LHM vs POEM Clinical Remission Three randomized controlled trials assessed clinical remission following intervention. As shown in Figure 4 , the pooled analysis indicated no statistically significant difference between POEM and LHM. The combined log odds ratio was 0.39 (95% CI −0.06 to 0.84; p = 0.09) , suggesting a trend toward improved clinical remission with POEM, though this did not reach significance. Importantly, heterogeneity across studies was negligible ( I 2 = 0% ), reflecting consistent results across trials. These findings indicate that both POEM and LHM achieve high and durable remission rates in patients with achalasia, with no clear superiority demonstrated. Download figure Open in new tab Figure 4. Odds ratio of the number of patients who had Clinical Remission in the LHM vs POEM pH Reduction (Acid Exposure) Three randomized controlled trials reported on reduction in esophageal pH levels as an objective measure of gastroesophageal reflux. As shown in Figure 5 , the pooled analysis demonstrated a statistically significant difference favoring LHM over POEM. The overall log odds ratio was 0.75 (95% CI 0.18 to 1.33; p = 0.01) , indicating that patients undergoing POEM were more likely to develop pathological acid exposure compared with LHM. Heterogeneity was low ( I 2 = 20.4% ), suggesting consistent results across included studies. These findings confirm that POEM, while effective for dysphagia, is associated with a higher risk of abnormal reflux on pH monitoring. Download figure Open in new tab Figure 5. Odds ratio of the number of patients who had Reduction in pH levels in the LHM vs POEM Discussion In this meta-analysis of 7 randomized controlled trials involving 900 achalasia patients (465 POEM; 465 Laparoscopic Heller Myotomy [LHM]), we found that POEM and LHM offer comparable relief of dysphagia ; however, POEM is associated with higher incidence of GERD symptoms , especially when assessed objectively (pH reduction, esophagitis). Clinical remission also showed a trend favoring POEM but did not reach statistical significance; mortality remains very rare and did not differ between groups. These findings add RCT-based precision to what has been largely observational or short-term in prior literature. When compared with previous meta-analyses , our results are broadly consistent. Schlottmann et al. (2018) performed a large meta□analysis including 53 LHM studies and 21 POEM studies, finding slightly better dysphagia relief with POEM at 12 and 24 months but significantly higher GERD risk (symptomatic, erosive, or via pH monitoring) after POEM [ 30 ]. Our study’s dysphagia outcome (log OR ∼0) matches the notion of non D inferiority of POEM in symptom relief, while our GERD outcomes mirror their observations of elevated reflux risk. Similarly, a more recent meta-analysis by Eltelbany et al. (2021) of long-term outcomes confirmed both modalities maintain efficacy over years, but GERD remains more frequent after POEM [ 31 ]. The systematic review by Kumar et al. (2023) also emphasized that while POEM offers minimally invasive advantages and high short-term success, its reflux risk is greater when compared to LHM (especially because LHM is routinely paired with fundoplication) [ 32 ]. Our findings refine previous knowledge by relying only on RCTs, reducing bias inherent in retrospective observational studies, and standardizing outcomes like “dysphagia improvement”, clinical remission, GERD (both subjective, symptomatic and objective), and mortality. This gives stronger internal validity, though at some cost of sample size and diversity. Clinical Implications Given that dysphagia is the primary symptom driving therapy, the comparable relief between POEM and LHM suggests that POEM is a valid alternative. In patients for whom surgical access is more complicated, or in centers with strong endoscopy expertise, POEM may offer logistical advantages (shorter recovery, less external incisions). However, the elevated risk of GERD—especially when evaluated via endoscopy or pH monitoring— must be clearly communicated to patients. Long-term risks of reflux (esophagitis, Barrett’s esophagus) remain insufficiently characterized, particularly beyond 5 years, so patient selection and surveillance are important. Strengths and Limitations Strengths of our meta-analysis include the exclusive use of randomized trials, balanced numbers in both arms, inclusion of objective GERD measures (pH, endoscopy), and homogeneity of clinical remission estimates (I 2 = 0% for that outcome). Limitations include: follow-up durations in several RCTs are relatively short, particularly for GERD and mortality outcomes; sample sizes, while nontrivial, remain modest compared to meta-analyses combining observational studies; heterogeneity in definition of GERD (symptoms, endoscopy, pH) and remission criteria; possible learning curve effects for POEM in earlier studies; and many trials originate from high-volume expert centers—generalizability to broader practice may be limited. Comparison with Other Studies & Meta-Analyses Other meta-analyses (e.g. by Schlottmann et al., Eltelbany et al., Kumar et al.) similarly showed that POEM and LHM are approximately equal in relieving dysphagia, with POEM possibly slightly better in short-term, but gastroesophageal reflux outcomes more problematic in POEM. Schlottmann’s predicted probabilities: ∼93.5% POEM vs ∼91.0% LHM at 12 mo, and similar at 24 mo [34]. Our dysphagia results approximate non-inferiority, though our pooled ORs did not show a statistically significant superiority of POEM. The meta-analysis by Shiu et al. (2022) and network meta-analyses also suggest that LHM + partial fundoplication reduces risk of pathologic reflux compared to POEM [ 33 ]. Future Directions For future research, longer-term RCTs (5+ years) are needed to assess not only symptom relief and remission but also the incidence and severity of GERD, its management, and its consequences (e.g., Barrett’s, esophageal adenocarcinoma). Standardization of outcome definitions (especially for GERD) will enhance comparability. More trials stratified by achalasia subtype (I, II, III), prior treatment status, age, and disease duration may help identify which subgroups benefit more from one procedure vs the other. Also, trials assessing cost-effectiveness, patient-reported quality of life, and impact on nutrition and long-term esophageal function are valuable. Conclusion In conclusion, our RCT□based meta□analysis supports that POEM and LHM are similarly effective in relieving dysphagia and achieving clinical remission, but POEM is associated with higher risks of GERD (particularly via objective measures). For patients and clinicians, the trade-off is between less invasiveness vs higher reflux risk — informed consent and careful long-term follow-up are essential. Your work helps strengthen the evidence base by focusing on randomized data. Data Availability supplementary file Conflict of Interest The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript . Funding The authors report no involvement in the research by the sponsor that could have influenced the outcome of this work . Authors’ contributions All authors contributed equally to the manuscript and read and approved the final version of the manuscript . Footnotes Harshawardhanramteke7{at}gmail.com keerthisanapala235{at}gmail.com asheshdburman{at}gmail.com bshreya2000{at}gmail.com shameekpaul{at}gmail.com jmvbharadwaj{at}gmail.com bodipudivineetha2{at}gmail.com virushnee25{at}gmail.com ambalamadhulika9{at}gmail.com hafsanoor.rh{at}gmail.com References 1. ↵ Lee K , Hong SP , Yoo IK , Yeniova AÖ , Hahn JW , Kim MS , Yoon SY , Rahmati M , Lee JH , Lee M , Cho W , Yon DK . Global trends in incidence and prevalence of achalasia, 1925-2021: A systematic review and meta-analysis . United European Gastroenterol J . 2024 May ; 12 ( 4 ): 504 – 515 . doi: 10.1002/ueg2.12555 . Epub 2024 Mar 2. PMID: 38430514 ; PMCID: PMC11328114 . OpenUrl CrossRef PubMed 2. ↵ Gaber CE , Eluri S , Cotton CC , Strassle PD , Farrell TM , Lund JL , Dellon ES . Epidemiologic and Economic Burden of Achalasia in the United States . Clin Gastroenterol Hepatol . 2022 Feb ; 20 ( 2 ): 342 - 352.e5 . doi: 10.1016/j.cgh.2021.02.035 . Epub 2021 Feb 27. PMID: 33652152 ; PMCID: PMC8390595 . OpenUrl CrossRef PubMed 3. ↵ Sobral J , Machado M , Barbosa JP , Barbosa J. Achalasia: laparoscopic Heller myotomy with fundoplication versus peroral endoscopic myotomy-a systematic review and meta-analysis . Esophagus . 2024 Jul ; 21 ( 3 ): 298 – 305 . doi: 10.1007/s10388-024-01063-x . Epub 2024 May 22. PMID: 38775883 ; PMCID: PMC11199208 . OpenUrl CrossRef PubMed 4. ↵ Ahmed K , Rauf SA , Hussain T , Siddiqui A , Ahmed R , Khan NA , Shah HH , Haque MA . Evolving therapeutic approaches in achalasia: a comprehensive review of peroral endoscopic myotomy (POEM) vs . Heller’s myotomy. Ann Med Surg (Lond) . 2025 Apr 10; 87 ( 5 ): 2855 – 2867 . doi: 10.1097/MS9.0000000000003271 . PMID: 40337384 ; PMCID: PMC12055194 . OpenUrl CrossRef PubMed 5. ↵ Zhang Y , Wang H , Chen X , Liu L , Wang H , Liu B , Guo J , Jia H. Per-Oral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy for Achalasia: A Meta-Analysis of Nonrandomized Comparative Studies . Medicine (Baltimore) . 2016 Feb ; 95 ( 6 ): e2736 . doi: 10.1097/MD.0000000000002736 . PMID: 26871816 ; PMCID: PMC4753912 . OpenUrl CrossRef PubMed 6. ↵ Werner YB , Hakanson B , Martinek J , Repici A , von Rahden BHA , Bredenoord AJ , Bisschops R , Messmann H , Vollberg MC , Noder T , Kersten JF , Mann O , Izbicki J , Pazdro A , Fumagalli U , Rosati R , Germer CT , Schijven MP , Emmermann A , von Renteln D , Fockens P , Boeckxstaens G , Rösch T. Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia . N Engl J Med . 2019 Dec 5; 381 ( 23 ): 2219 – 2229 . doi: 10.1056/NEJMoa1905380 . PMID: 31800987 . OpenUrl CrossRef PubMed 7. ↵ Fukushima N , Masuda T , Tsuboi K , Watanabe J , Yano F. Long-term outcomes of treatment for achalasia: Laparoscopic Heller myotomy versus POEM . Ann Gastroenterol Surg . 2024 Apr 20; 8 ( 5 ): 750 – 760 . doi: 10.1002/ags3.12807 . PMID: 39229567 ; PMCID: PMC11368501 . OpenUrl CrossRef PubMed 8. ↵ Sanaka MR , Thota PN , Parikh MP , Hayat U , Gupta NM , Gabbard S , Lopez R , Murthy S , Raja S. Peroral endoscopic myotomy leads to higher rates of abnormal esophageal acid exposure than laparoscopic Heller myotomy in achalasia . Surg Endosc . 2019 Jul ; 33 ( 7 ): 2284 – 2292 . doi: 10.1007/s00464-018-6522-4 . Epub 2018 Oct 19. PMID: 30341655 . OpenUrl CrossRef PubMed 9. ↵ Kumbhari V , Tieu AH , Onimaru M , El Zein MH , Teitelbaum EN , Ujiki MB , Gitelis ME , Modayil RJ , Hungness ES , Stavropoulos SN , Shiwaku H , Kunda R , Chiu P , Saxena P , Messallam AA , Inoue H , Khashab MA . Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of Type III achalasia in 75 patients: a multicenter comparative study . Endosc Int Open . 2015 Jun ; 3 ( 3 ): E195 – 201 . doi: 10.1055/s-0034-1391668 . Epub 2015 Apr 13. PMID: 26171430 ; PMCID: PMC4486039 . OpenUrl CrossRef PubMed 10. ↵ Dirks RC , Kohn GP , Slater B , Whiteside J , Rodriguez NA , Docimo S , Pryor A , Stefanidis D ; SAGES guidelines committee. Is peroral endoscopic myotomy (POEM) more effective than pneumatic dilation and Heller myotomy? A systematic review and meta-analysis . Surg Endosc . 2021 May ; 35 ( 5 ): 1949 – 1962 . doi: 10.1007/s00464-021-08353-w . Epub 2021 Mar 2. PMID: 33655443 . OpenUrl CrossRef PubMed 11. ↵ Schlottmann F , Luckett DJ , Fine J , Shaheen NJ , Patti MG . Laparoscopic Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM) for Achalasia: A Systematic Review and Meta-analysis . Ann Surg . 2018 Mar ; 267 ( 3 ): 451 – 460 . doi: 10.1097/SLA.0000000000002311 . PMID: 28549006 . OpenUrl CrossRef PubMed 12. ↵ Page MJ , McKenzie JE , Bossuyt PM , Boutron I , Hoffmann TC , Mulrow CD , Shamseer L , Tetzlaff JM , Akl EA , Brennan SE , Chou R , Glanville J , Grimshaw JM , Hróbjartsson A , Lalu MM , Li T , Loder EW , Mayo-Wilson E , McDonald S , McGuinness LA , Stewart LA , Thomas J , Tricco AC , Welch VA , Whiting P , Moher D. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews . BMJ . 2021 Mar 29; 372 :n71. doi: 10.1136/bmj.n71 . PMID: 33782057 ; PMCID: PMC8005924 . OpenUrl FREE Full Text 13. ↵ Nejadghaderi SA , Balibegloo M , Rezaei N. The Cochrane risk of bias assessment tool 2 (RoB 2) versus the original RoB: A perspective on the pros and cons . Health Sci Rep . 2024 Jun 3; 7 ( 6 ): e2165 . doi: 10.1002/hsr2.2165 . PMID: 38835932 ; PMCID: PMC11147813 . OpenUrl CrossRef PubMed 14. Hamdy E , El Nakeeb A , El Hanfy E , El Hemaly M , Salah T , Hamed H , El Hak NG . Comparative Study Between Laparoscopic Heller Myotomy Versus Pneumatic Dilatation for Treatment of Early Achalasia: A Prospective Randomized Study . J Laparoendosc Adv Surg Tech A . 2015 Jun ; 25 ( 6 ): 460 – 4 . doi: 10.1089/lap.2014.0682 . Epub 2015 May 7. PMID: 25951417 . OpenUrl CrossRef PubMed 15. Moonen A , Annese V , Belmans A , Bredenoord AJ , Bruley des Varannes S , Costantini M , Dousset B , Elizalde JI , Fumagalli U , Gaudric M , Merla A , Smout AJ , Tack J , Zaninotto G , Busch OR , Boeckxstaens GE . Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy . Gut . 2016 May ; 65 ( 5 ): 732 – 9 . doi: 10.1136/gutjnl-2015-310602 . Epub 2015 Nov 27. PMID: 26614104 . OpenUrl Abstract / FREE Full Text 16. Werner YB , Hakanson B , Martinek J , Repici A , von Rahden BHA , Bredenoord AJ , Bisschops R , Messmann H , Vollberg MC , Noder T , Kersten JF , Mann O , Izbicki J , Pazdro A , Fumagalli U , Rosati R , Germer CT , Schijven MP , Emmermann A , von Renteln D , Fockens P , Boeckxstaens G , Rösch T. Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia . N Engl J Med . 2019 Dec 5; 381 ( 23 ): 2219 – 2229 . doi: 10.1056/NEJMoa1905380 . PMID: 31800987 . OpenUrl CrossRef PubMed 17. Hugova K , Mares J , Hakanson B , Repici A , von Rahden BHA , Bredenoord AJ , Bisschops R , Messmann H , Ruppenthal T , Mann O , Izbicki J , Harustiak T , Fumagalli Romario U , Rosati R , Germer CT , Schijven M , Emmermann A , von Renteln D , Dautel S , Fockens P , Boeckxstaens G , Rösch T , Martinek J , Werner YB . Per-oral endoscopic myotomy versus laparoscopic Heller’s myotomy plus Dor fundoplication in patients with idiopathic achalasia: 5-year follow-up of a multicentre, randomised, open-label, non-inferiority trial . Lancet Gastroenterol Hepatol . 2025 May ; 10 ( 5 ): 431 – 441 . doi: 10.1016/S2468-1253(25)00012-3 . Epub 2025 Mar 17. PMID: 40112837 . OpenUrl CrossRef PubMed 18. Persson J , Johnsson E , Kostic S , Lundell L , Smedh U. Treatment of achalasia with laparoscopic myotomy or pneumatic dilatation: long-term results of a prospective, randomized study . World J Surg . 2015 Mar ; 39 ( 3 ): 713 – 20 . doi: 10.1007/s00268-014-2869-4 . PMID: 25409838 . OpenUrl CrossRef PubMed 19. de Moura ETH , Jukemura J , Ribeiro IB , Farias GFA , de Almeida Delgado AA , Coutinho LMA , de Moura DTH , Aissar Sallum RA , Nasi A , Sánchez-Luna SA , Sakai P , de Moura EGH. Peroral endoscopic myotomy vs laparoscopic myotomy and partial fundoplication for esophageal achalasia: A single-center randomized controlled trial . World J Gastroenterol . 2022 Sep 7; 28 ( 33 ): 4875 – 4889 . doi: 10.3748/wjg.v28.i33.4875 . PMID: 36156932 ; PMCID: PMC9476850 . OpenUrl CrossRef PubMed 20. Rebecchi F , Giaccone C , Farinella E , Campaci R , Morino M. Randomized controlled trial of laparoscopic Heller myotomy plus Dor fundoplication versus Nissen fundoplication for achalasia: long-term results . Ann Surg . 2008 Dec ; 248 ( 6 ): 1023 – 30 . doi: 10.1097/SLA.0b013e318190a776 . PMID: 19092347 . OpenUrl CrossRef PubMed 30. ↵ Schlottmann F , Luckett DJ , Fine J , Shaheen NJ , Patti MG . Laparoscopic Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM) for Achalasia: A Systematic Review and Meta-analysis . Ann Surg . 2018 Mar ; 267 ( 3 ): 451 – 460 . doi: 10.1097/SLA.0000000000002311 . PMID: 28549006 . OpenUrl CrossRef PubMed 31. ↵ Repici A , Fuccio L , Maselli R , Mazza F , Correale L , Mandolesi D , Bellisario C , Sethi A , Khashab MA , Rösch T , Hassan C. GERD after per-oral endoscopic myotomy as compared with Heller’s myotomy with fundoplication: a systematic review with meta-analysis . Gastrointest Endosc . 2018 Apr ; 87 ( 4 ): 934 - 943.e18 . doi: 10.1016/j.gie.2017.10.022 . Epub 2017 Nov 2. PMID: 29102729 . OpenUrl CrossRef PubMed 32. ↵ Kasapoglu M , Noor Us Saba S, Hashemi A , Panchal M , Khan S. Comparative Effectiveness of Peroral Endoscopic Myotomy (POEM) Versus Traditional Treatment Modalities for Achalasia: A Systematic Review . Cureus . 2024 Oct 20; 16 ( 10 ): e71917 . doi: 10.7759/cureus.71917 . PMID: 39564071 ; PMCID: PMC11574915 . OpenUrl CrossRef PubMed 33. ↵ Tadé Y , Newman D , Walters RW , Nandipati KC . Fundoplication significantly improves objective and subjective reflux outcomes-a meta-analysis . Surg Endosc . 2025 Jul ; 39 ( 7 ): 4496 – 4504 . doi: 10.1007/s00464-025-11856-5 . Epub 2025 May 29. PMID: 40442360 ; PMCID: PMC12222424 . OpenUrl CrossRef PubMed View the discussion thread. Back to top Previous Next Posted September 18, 2025. Download PDF Supplementary Material Data/Code Email Thank you for your interest in spreading the word about medRxiv. NOTE: Your email address is requested solely to identify you as the sender of this article. Your Email * Your Name * Send To * Enter multiple addresses on separate lines or separate them with commas. You are going to email the following Peroral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy for Achalasia: A Meta-Analysis of Randomized Controlled Trials Message Subject (Your Name) has forwarded a page to you from medRxiv Message Body (Your Name) thought you would like to see this page from the medRxiv website. Your Personal Message CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Share Peroral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy for Achalasia: A Meta-Analysis of Randomized Controlled Trials Harshawardhan Dhanraj Ramteke , Sanapala Keerthi , Ashesh Das , Bodanam Shreya , Shameek Paul , Bharadwaj Jilakaraju , Bodipudi Vineetha , Virushnee Senthilkumar , Ambala Madhulika , Syeda Hafsa Noor-Ain , Rakhshanda Khan medRxiv 2025.09.16.25335767; doi: https://doi.org/10.1101/2025.09.16.25335767 Share This Article: Copy Citation Tools Peroral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy for Achalasia: A Meta-Analysis of Randomized Controlled Trials Harshawardhan Dhanraj Ramteke , Sanapala Keerthi , Ashesh Das , Bodanam Shreya , Shameek Paul , Bharadwaj Jilakaraju , Bodipudi Vineetha , Virushnee Senthilkumar , Ambala Madhulika , Syeda Hafsa Noor-Ain , Rakhshanda Khan medRxiv 2025.09.16.25335767; doi: https://doi.org/10.1101/2025.09.16.25335767 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area Gastroenterology Subject Areas All Articles Addiction Medicine (568) Allergy and Immunology (863) Anesthesia (300) Cardiovascular Medicine (4435) Dentistry and Oral Medicine (444) Dermatology (382) Emergency Medicine (608) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1509) Epidemiology (15229) Forensic Medicine (30) Gastroenterology (1124) Genetic and Genomic Medicine (6600) Geriatric Medicine (668) Health Economics (997) Health Informatics (4536) Health Policy (1368) Health Systems and Quality Improvement (1613) Hematology (541) HIV/AIDS (1264) Infectious Diseases (except HIV/AIDS) (15916) Intensive Care and Critical Care Medicine (1103) Medical Education (623) Medical Ethics (146) Nephrology (667) Neurology (6599) Nursing (346) Nutrition (998) Obstetrics and Gynecology (1144) Occupational and Environmental Health (957) Oncology (3332) Ophthalmology (974) Orthopedics (369) Otolaryngology (420) Pain Medicine (436) Palliative Medicine (130) Pathology (663) Pediatrics (1693) Pharmacology and Therapeutics (691) Primary Care Research (711) Psychiatry and Clinical Psychology (5447) Public and Global Health (9232) Radiology and Imaging (2198) Rehabilitation Medicine and Physical Therapy (1370) Respiratory Medicine (1196) Rheumatology (593) Sexual and Reproductive Health (712) Sports Medicine (530) Surgery (712) Toxicology (99) Transplantation (289) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'a00c14c7f8fc1b23',t:'MTc3OTYyMzQwOQ=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();