To evaluate the feasibility, clinical effectiveness, and safety of per-oral plication of the esophagus (POPE) in patients with sump-related refractory esophageal emptying due to end-stage achalasia or delayed gastric conduit emptying (DGCE) after esophagectomy. Evidence remains limited to case reports and small series.

A systematic review was conducted in PubMed, Embase, Scopus, and Web of Science through July 2025. We included case reports and case series reporting extractable clinical information on POPE performed for end-stage achalasia or DGCE after esophagectomy. Clinical and endoscopic data were collected. Study selection followed PRISMA guidelines.

Nine publications were identified (4 case series, 3 case reports, 2 conference abstracts), comprising 59 patients aged 28–86 years (mean 70 years). Forty-eight patients were treated for end-stage esophageal achalasia with sump formation and 11 for DGCE after esophagectomy. All achalasia patients had undergone previous interventions at the esophagogastric junction (endoscopic and/or surgical); in the DGCE group, 72.7% had undergone pyloromyotomy or pyloroplasty before POPE. Technical success was 100% with a mean procedure time 71.4 minutes (Range 48-97). Clinical improvement (complete or partial) was reported in 89.6% of end-stage achalasia cases and 72.7% of DGCE cases, with overall clinical benefit in 86.4% of the pooled population. Re-intervention (Re-POPE) was required in 22% of patients to maintain symptom response. Adverse events were uncommon and generally mild. Intraprocedural events included three mucosal perforations and one bleeding event, all successfully managed endoscopically. Post-procedural events consisted mainly of aspiration pneumonia (n=2), mild delayed bleeding, or transient pain. No related mortality was reported. Hospital stay was typically ≤3 days. Mean reported follow-up across publications was 13.5 months, ranging from 4 months to 6 years.

Table  Demographic data, clinical outcomes, and adverse events

POPE appears to be a feasible and safe endoscopic option for patients with refractory esophageal sump formation due to end-stage achalasia or DGCE after esophagectomy. Clinical improvement was frequent and the technique was repeatable, with low rates of significant adverse events. Given that all available evidence originates from uncontrolled case reports and small series, these findings should be interpreted as exploratory. Prospective studies with standardized outcomes and long-term follow-up are needed to validate the durability and comparative effectiveness of POPE.