PD versus Botox: ?
In a systematic review of seven randomized controlled trials aggregating 178 patients, it was found that short-term outcomes at a follow-up of 4 weeks from the initial procedure were similar. However, three studies within the review recorded a 12-month follow-up that discovered a significant difference in response (73.3% PD vs 37.5% Botox).
Therefore, current evidence supports that PD is more effective than Botox in achieving long-term symptomatic response.
PD versus LHM:
A meta-analysis was published by Weber et al included 36 studies with 3211 patients in the PD group and 1526 patients in the LHM group. In PD group, the mean 5-year remission rate was 61.9% and mean 10-year remission rate was 47.9%, compared to mean 5-year remission rate of 76.1% and mean 10-year remission rate of 79.6 yrs in LHM group respectively.
Therefore, based on the available evidence, success rates for PD and LHM are believed to be comparable although LHM may be associated with greater long-term durability, especially in younger males.
Comparison of POEM vs. LHM:
A meta analysis by Talukdar R et al comparing POEM and LHMT showed no differences between POEM and LHM in reduction in Eckhart’s score, post-operative pain scores and analgesic requirements, length of hospital stay, adverse events, and symptomatic gastroesophageal reflux/reflux esophagitis. However, operative times were lower for POEM with compared with LHM.
POEM appears to be a safe and effective treatment for achalasia, resulting in equivalent short-term symptom relief when compared with LHM. Therapeutic success (Eckardt score < 3) does not differ significantly between both procedures, POEM and LHM. Efficacies of PD, LHM and POEM also vary according to subtypes of achalasia. Response rates of type II achalasia patients treated with PD or LHM are excellent (90- 100%); however subtype III and I respond poorly. Young patients do not respond as well to PD as their older counterparts and require repeated sessions of PD over the time. Hence, the management of achalasia needs to be tailored according to the subtype of achalasia on High Resolution Manometry (HRM). Other patient characteristic like age and surgical risk should also be taken into consideration while deciding for optimal therapy for achalasia.