title: Laparoscopic Heller's myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized, controlled trials.
abstract: BACKGROUND
  Pneumatic dilation (PD) and laparoscopic Heller's myotomy (LHM) are the mainstays of therapy in idiopathic achalasia. Equipoise exists in choosing the first-line therapy.
  
  
  OBJECTIVE
  To assess comparative efficacies and adverse event rates of these methods.
  
  
  METHODS
  Intention-to-treat, fixed-model, Mantel-Haenszel meta-analysis of randomized, controlled trials comparing PD with LHM.
  
  
  METHODS
  Randomized controlled trial comparing PD versus LHM.
  
  
  METHODS
  Patients with newly diagnosed idiopathic achalasia.
  
  
  METHODS
  Comprehensive electronic and manual literature search from 1966 to March 2012 independently by two reviewers.
  
  
  METHODS
  Response rate, rate of different adverse events, and quality of life after each therapy.
  
  
  RESULTS
  Three of 161 retrieved studies between 2007 and 2011, including 346 patients, were included. At 1 year, the cumulative response rate was significantly higher with LHM (86% vs 76%, odds ratio 1.98 (confidence interval 1.14-3.45); P = .02), with no significant heterogeneity (P = .39; I(2) 0%). Rates of major mucosal tears requiring subsequent intervention with LHM were significantly lower than those of esophageal perforation with PD requiring postprocedural medical or surgical therapy (0.6% and 4.8%, respectively; P = .04). Postprocedural rates of gastroesophageal reflux, lower esophageal sphincter pressures, and quality of life scores did not differ in trials with sufficient data. Data on longer follow-up were not available.
  
  
  CONCLUSIONS
  Lack of data on follow-ups over 1 year and a small number of included studies.
  
  
  CONCLUSIONS
  This meta-analysis suggests that LHM may provide greater response rates as compared with graded PD in the treatment of newly diagnosed idiopathic achalasia, with lesser rates of major adverse events, in up to 1 year after treatment, although additional data are needed to confirm the validity of this conclusion in long-term follow-up.
authors.affiliation: Division of Gastroenterology, McGill University Health Sciences, Montreal, Quebec, Canada.
authors.forename: Mohammad
authors.initials: M
authors.lastname: Yaghoobi
authors.forename: Serge
authors.initials: S
authors.lastname: Mayrand
authors.forename: Myriam
authors.initials: M
authors.lastname: Martel
authors.forename: Ira
authors.initials: I
authors.lastname: Roshan-Afshar
authors.forename: Raheleh
authors.initials: R
authors.lastname: Bijarchi
authors.forename: Alan
authors.initials: A
authors.lastname: Barkun
mesh_terms: D002404:Catheterization / Q000009:adverse effects; D004106:Dilatation / Q000009:adverse effects; D004931:Esophageal Achalasia / Q000628:therapy*; D004939:Esophageal Perforation / Q000209:etiology*; D049630:Esophageal Sphincter, Lower / Q000503:physiopathology / Q000601:surgery*; D005764:Gastroesophageal Reflux / Q000209:etiology; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects; D007902:Length of Stay; D008365:Manometry; D009092:Mucous Membrane / Q000293:injuries*; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic
keywords: European Organisation for Research and Treatment of Cancer disease-specific questionnaire module; GER; LES; LHM; Medical Outcomes Study 36-item short-form health survey; PD; QLQ-OES24; SF-36; gastroesophageal reflux; laparoscopic Heller's myotomy; lower esophageal sphincter; pneumatic dilation