Laparoscopic esophageal myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized controlled trials

Abstract

BackgroundAchalasia is a primary esophageal motility disorder of unknown etiology associated with abnormalities in peristalsis and lower esophageal sphincter relaxation. The disease is incurable; however, definitive treatment procedures like pneumatic dilation (PD)/balloon dilation and laparoscopic esophageal myotomy (LEM) are performed to relieve dysphagia and related symptoms. Currently, there is paucity of data comparing the outcomes of these procedures. The aim of this meta-analysis is to compare the short- and long-term success rates of PD and LEM.MethodsA thorough systematic search of PubMed, Scopus, clinicaltrials.gov, and Cochrane library was conducted for randomized controlled trials (RCTs) comparing the outcomes of PD versus LEM in the treatment of achalasia. The Mantel-Haenszel method and random effect model were used to analyze the data. RCTs with outcome data at 3-month, 1-year, and 5-year intervals were analyzed.ResultsA total of 437,378 and 254 patients at 3-month, 1-year, and 5-year intervals were analyzed for outcome data. At 3 months and 1 year, PD was not as effective as LEM (odds ratio [OR]: 0.50; confidence interval [CI] 0.31–0.82; P = 0.009 and OR: 0.47; CI 0.22–0.99; P = 0.21) but at 5 years, one procedure was non-inferior to the other (OR: 0.62; 0.33–1.19; P = 0.34).ConclusionPD was as effective as LEM in relieving symptoms of achalasia in the long-term.

Mortality rate after pneumatic dilatation for achalasia

“…In this study, the mortality rate 30 days after PD was surprisingly high with a staggering 1.9% 1. This is contradictory to previous recent literature, in which the mortality rate after pneumatic dilatation was generally 0% 2–4. In the current study, subjects were excluded if they had a prior diagnosis of achalasia in the preceding 5 years since the introduction of ICD-10 coding in 2001.…”

“…The perforation rate (1.6%) was at the lower end of the range provided by the literature (0%–5%), which seems unexpected given the high mortality found 2 3. The authors state that under-reporting of complications is possible in HES data, which could explain the lower perforation rate.…”

Effects of preoperative endoscopic pneumatic balloon dilatation on postoperative achalasia symptoms after Heller esophageal myotomy plus Dor fundoplication

“…The results of a meta-analysis including 361 patients showed that LHM may provide greater response rates than graded endoscopic PBD in the treatment of newly diagnosed idiopathic achalasia (5). Two recent meta-analysis comparing the outcomes of endoscopic PBD and LHM revealed similar results at 5-year intervals (16,17). An evidence-based approach study, which searched PubMed/ Medline electronic databases and the Cochrane Library, stated that LHM+partial fundoplication was associated with lower complication rates and provided excellent long-term results with lower need for the additional treatment of recurrent dysphagia than endoscopic PBD (18).…”

Esophageal two-phase supine/standing scintigraphy and balloon dilatation in achalasia: 20 years of experience

“…Besides BD, other therapeutic possibilities are developing [27][28][29][30][31][32] but this method will remain the most convenient option for most patients.…”