Peroral plication of esophagus for end-stage achalasia: a systematic review

End-stage achalasia is marked by persistent symptoms even after lower esophageal sphincter (LES)-directed therapies and may require esophagectomy, which is associated with significant adverse events. Peroral plication of the esophagus (POPE) is a novel minimally invasive, intermediate alternative. This review aimed to assess the safety and efficacy of POPE in treating end-stage achalasia.

A systematic search was performed in PubMed, Embase, Web of Science, and the Cochrane Library from January 2016 to May 2025 for studies on POPE in end-stage achalasia. Primary outcomes included clinical success, defined as symptom improvement. Secondary outcomes were technical success, adverse events, need for repeat POPE, or esophagectomy. Continuous variables were summarized as means with standard deviations, whereas categorical variables were reported as pooled proportions.

Four studies including 45 patients with end-stage achalasia were analyzed. The cohort included 21 males (46.7%), with subtypes reported in 2 studies: 17 type I, 13 type II, and unknown or unreported subtypes (n = 15). Prior durable LES interventions included peroral endoscopic myotomy (n = 21), pneumatic dilation (n = 19), and Heller myotomy (n = 17). Regurgitation (75%) and dysphagia (65%) were the 2 most common symptoms. Pooled technical success was 100% (45/45), and pooled clinical success was 90% (37/41). Symptom improvement was observed across studies using Eckardt, gastroesophageal reflux disease Health-Related Quality of Life (GERD-HRQL), and Reflux Symptom Index scores. Eight patients required repeat POPE, and no patients underwent esophagectomy. Adverse events were observed in 7 patients (15.7%), including 2 cases of bleeding, 3 mucosal perforations, 1 readmission for pain, and 1 instance of aspiration pneumonia occurring 2 weeks after a second POPE procedure. All adverse events were managed conservatively, and no deaths were reported.

POPE may offer a minimally invasive option for selected patients with end-stage achalasia and persistent symptoms after LES-directed therapy, but high rates of repeat procedures and considerable adverse events raise concerns about durability and safety. Larger long-term prospective studies are needed to clarify its true efficacy, safety, and ideal patient candidates.