Efficacy of surgical or endoscopic treatment of idiopathic achalasia: a systematic review and network meta-analysis.

BACKGROUND: Treatment of achalasia has changed substantially over the past 20 years. Therapeutic options offered to patients vary, depending on access to both resources and expertise, and include pneumatic dilation (PD), laparoscopic Heller's myotomy (LHM), or per-oral endoscopic myotomy (POEM). Although there are head-to-head trials of these interventions, many of these are small and underpowered, so relative efficacy is unknown. We did a systematic review and network meta-analysis to try to resolve this uncertainty. METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and Embase Classic from database inception up to June 11, 2020, for randomised controlled trials (RCTs) assessing the efficacy of POEM, LHM, or PD, compared with each other in adults with idiopathic achalasia. We extracted all data as dichotomous outcomes (treatment success or failure) after completion of therapy. We also extracted country of origin, number of centres, duration of follow-up, and primary outcome measure used to define treatment success or failure. Data were extracted for intention-to-treat analyses, with all dropouts assumed to be treatment failures (ie, symptomatic at final point of follow-up), wherever trial reporting allowed this. We pooled data using a random effects model, and assessed heterogeneity between studies using the I2 statistic. Risk of bias was examined for all studies. The primary outcome was efficacy, in terms of a dichotomous measure of treatment success or failure, after a minimum of 1 year of follow-up. Secondary outcomes were occurrence of perforation, adverse events, serious adverse events (including death), need for reintervention, need for surgery as a result of complications, development of gastro-oesophageal reflux, or erosive oesophagitis. Efficacy was reported as a pooled relative risk (RR) of treatment failure, with a 95% CI, for each comparison tested, and ranked by therapy according to P-score. FINDINGS: Of 1044 studies initially assessed, nine were eligible RCTs, which comprised 911 participants in total. None of the nine studies were at low risk of bias. Of the 911 participants 372 (41%) participants were randomly assigned to LHM, 317 (35%) participants to PD, and 222 (24%) participants to POEM. Of the three strategies, POEM was ranked first (RR of failure of treatment 0·33, 95% CI 0·15-0·71; P-score 0·89), then LHM (RR 0·45, 0·26-0·78, P-score 0·61). There was moderate heterogeneity between studies (I2=61·5%). Both POEM and LHM were superior to PD on direct and indirect comparison, but neither was significantly more effective than the other. There were no significant differences in perforation rates, need for re-intervention or surgery, gastro-oesophageal reflux, erosive oesophagitis, or serious adverse events, but PD was less likely to lead to adverse events than POEM. INTERPRETATION: POEM and LHM should be the preferred treatments for idiopathic achalasia. PD performed worst in terms of treatment success, and therefore its role in the management of patients with achalasia is less certain. FUNDING: None.

Outcomes of acute upper gastrointestinal bleeding in relation to timing of endoscopy and the experience of endoscopist: a tertiary center experience.

INTRODUCTION: Patients with gastrointestinal bleeding admitted out of hours or at the weekends may have an excess mortality rate. The literature reports around this are conflicting. AIMS AND METHODS: We aimed to analyze the outcomes of emergency endoscopies performed out of hours and over the weekends in our center. We retrospectively analyzed data from April 2008 to June 2012. RESULTS: A total of 507 'high risk' emergency gastroscopies were carried out over the study period for various indications. Patients who died within 30 days of the index procedure [22 % (114 /510)] had a significantly higher Rockall score (7.6 vs. 6.0, P < 0.0001), a higher American Society of Anesthesiologists (ASA) status (3.5 vs. 2.7, P < 0.001), and a lower systolic blood pressure (BP) at the time of the examination (94.8 vs 103, P = 0.025). These patients were significantly older (77.7 vs. 67.5 years, P = 0.006), and required more blood transfusion (5.9 versus 3.8 units). Emergency out-of-hours endoscopy was not associated with an increased risk of death [relative risk (RR) 1.09, 95 % confidence interval (CI) 1.12 - 1.95]. Whether the examination was carried out by a senior specialist registrar (senior trainee) or a consultant made no difference to the survival of the patient (RR 0.98, CI 0.77 - 1.32). CONCLUSION: Higher pre-endoscopy Rockall score and ASA status contributed significantly to the 30-day mortality following upper gastrointestinal bleeding, whereas lower BP tended towards significance. Outcomes did not vary with the time of the endoscopy nor was there any difference between a consultant and a senior specialist registrar led service.