Laparoscopic Heller myotomy versus endoscopic balloon dilatation for the treatment of achalasia: a network meta-analysis.
OBJECTIVE
Comparison of short- and long-term effects after laparoscopic Heller myotomy (LHM) and endoscopic balloon dilation (EBD) considering the need for retreatment.


BACKGROUND
Previously published studies have indicated that LHM is the most effective treatment for Achalasia. In contrast to that a recent randomized trial found EBD equivalent to LHM 2 years after initial treatment.


METHODS
A search in Medline, PubMed, and Cochrane Central Register of Controlled Trials was conducted for prospective studies on interventional achalasia therapy with predefined exclusion criteria. Data on success rates after the initial and repeated treatment were extracted. An adjusted network meta-analysis and meta-regression analysis was used, combined with a head-to-head comparison, for follow-up at 12, 24, and 60 months.


RESULTS
Sixteen studies including results of 590 LHM and EBD patients were identified. Odds ratio (OR) was 2.20 at 12 months (95% confidence interval: 1.18-4.09; P = 0.01); 5.06 at 24 months (2.61-9.80; P < 0.00001) and 29.83 at 60 months (3.96-224.68; P = 0.001). LHM was also significantly superior for all time points when therapy included re-treatments [OR = 4.83 (1.87-12.50), 19.61 (5.34-71.95), and 17.90 (2.17-147.98); P ≤ 0.01 for all comparisons) Complication rates were not significantly different. Meta-regression analysis showed that amount of dilations had a significant impact on treatment effects (P = 0.009). Every dilation (up to 3) improved treatment effect by 11.9% (2.8%-21.8%).


CONCLUSIONS
In this network meta-analysis, LHM demonstrated superior short- and long-term efficacy and should be considered first-line treatment of esophageal achalasia.
*Department for General, Visceral, Thoracic and Transplant Surgery, University Medical Center, Leipzig †Central Interdisciplinary Endoscopy ‡Department for Gastroenterology and Hepatology, University Medical Center, Mannheim, Germany §Department for Biostatistics, Heidelberg University, Medical Faculty Mannheim, Germany ¶Department of Medical Biometry and Epidemiology ‖Department of Interdisciplinary Endoscopy **Department for Gastroenterology and Hepatology, University Medical Center, Hamburg-Eppendorf, Germany ††Department of Surgery, Montreal General Hospital, McGill University, Montreal, Québec, Canada.
Markus B
MB
Schoenberg
Svetlana
S
Marx
Jan F
JF
Kersten
Thomas
T
Rösch
Sebastian
S
Belle
Georg
G
Kähler
Melina C
MC
Vassiliou
Stefan
S
Lüth
Daniel
D
von Renteln
D004106:Dilatation / Q000295:instrumentation / Q000379:methods; D004931:Esophageal Achalasia / Q000601:surgery*; D049630:Esophageal Sphincter, Lower / Q000601:surgery*; D004945:Esophagoscopy; D006801:Humans; D010535:Laparoscopy; D011446:Prospective Studies; D013997:Time Factors; D016896:Treatment Outcome