Peroral plication for end-stage esophageal achalasia and delayed gastric conduit emptying after esophagectomy ? A systematic review of case series and case reports

INTRODUCTION: Sump formation can occur in end-stage esophageal achalasia or following esophagectomy and is associated with severe esophageal dilatation, luminal stasis, increased aspiration risk, and malnutrition. Peroral plication of the esophagus (POPE) is a novel endoscopic technique designed to remodel the esophageal lumen; however, current evidence remains limited. This systematic review assesses the available evidence on POPE in patients with end-stage achalasia and delayed gastric conduit emptying (DGCE) after esophagectomy. METHODS: This systematic review was conducted across four databases. Case series and case reports describing POPE in patients with achalasia or postesophagectomy were included to evaluate feasibility, clinical outcomes, and safety. Conference abstracts were included only when sufficient data on key outcomes could be extracted. The main analysis was limited to full-text publications, with a secondary analysis incorporating conference abstracts. Certainty of evidence was assessed using an adapted GRADE approach based on full-text studies. RESULTS: Nine studies were included, comprising 59 patients (four case series, three case reports, and two conference abstracts). The primary analysis, including 39 patients, revealed technical success and symptom improvement in 39/39 (100%) and 31/39 patients (79.5%), respectively. A new session of POPE (re-POPE) was performed in 12/39 patients (30.8%). No intraprocedural adverse events occurred, and 5/39 cases exhibited postprocedural adverse events (12.8%). When conference abstracts (59 patients) were included, technical success was reported in all patients (100%), with symptom improvement in 51/59 (86.4%). The secondary analysis demonstrated that re-POPE was performed in 13/59 patients (22.0%). CONCLUSIONS: POPE appears to be a feasible intervention with an acceptable safety profile based on published case reports and series and may provide symptomatic benefit in selected patients. However, current evidence is limited and heterogeneous. Prospective studies and multicenter registries with standardized results are needed to confirm its efficacy and durability.