title: Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis.
abstract: BACKGROUND
  Although rare, esophageal achalasia is the best described primary esophageal motility disorder. Commonly used treatments are endoscopic botulin toxin injection (EBTI), endoscopic balloon dilation (EBD), and surgical myotomy with or without a fundoplication; however, reported outcomes mostly come from cohort studies.
  
  
  OBJECTIVE
  To summarize and compare the safety and efficacy of endoscopic and surgical treatments for esophageal achalasia.
  
  
  METHODS
  A systematic electronic Medline literature search of articles on esophageal achalasia. Treatment options reviewed included EBTI, EBD, and surgical myotomy using open and minimally invasive techniques. Main outcome measures were frequency of symptom relief, prevalence of post-treatment gastroesophageal reflux (GER), and complications. Outcome probability was estimated using weighted averages of the sample prevalence in each study, with weights equal to the number of patients. Outcomes, within or across studies, were compared using meta-analysis and meta-regression, respectively.
  
  
  RESULTS
  A total of 105 articles reporting on 7855 patients were selected, tabulated and reviewed. Symptom relief after EBD was better than after EBTI (68.2% vs. 40.6%; OR 3.4; 95% CI, 1.2-9.8; P = 0.02), and the need for additional therapy was greater for patients receiving EBTI (46.6% vs. 25%; OR, 2.6; 95% CI, 1.05-6.5; P = 0.04). Laparoscopic myotomy, when combined with an antireflux procedure, provided better symptom relief (90%) than all endoscopic and other surgical approaches and a low complication rate (6.3%). The incidence of postoperative GER was lower when a fundoplication was added to a laparoscopic myotomy (31.5% without a fundoplication vs. 8.8% with; OR, 6.3; 95% CI, 2.0-19.4; P = 0.003).
  
  
  CONCLUSIONS
  EBD is superior to EBTI. Laparoscopic myotomy with fundoplication was the most effective surgical technique and can be considered the operative procedure of choice.
authors.affiliation: Department of Surgery, University of California San Francisco, San Francisco, CA 94143-0790, USA. guilherme.campos@ucsfmedctr.org
authors.forename: Guilherme M
authors.initials: GM
authors.lastname: Campos
authors.forename: Eric
authors.initials: E
authors.lastname: Vittinghoff
authors.forename: Charlotte
authors.initials: C
authors.lastname: Rabl
authors.forename: Mark
authors.initials: M
authors.lastname: Takata
authors.forename: Michael
authors.initials: M
authors.lastname: Gadenstätter
authors.forename: Feng
authors.initials: F
authors.lastname: Lin
authors.forename: Ruxandra
authors.initials: R
authors.lastname: Ciovica
mesh_terms: D013505:Digestive System Surgical Procedures / Q000379:methods; D004931:Esophageal Achalasia / Q000601:surgery*; D004945:Esophagoscopy; D006801:Humans