title: Laparoscopic Heller myotomy is not superior to pneumatic dilation in the management of primary achalasia: Conclusions of a systematic review and meta-analysis of randomized controlled trials.
abstract: BACKGROUND
  Achalasia is an esophageal motility disorder, of unknown cause, which results in increased lower esophageal sphincter tone and symptoms of difficulty swallowing. Current major therapeutic options include laparoscopic Heller myotomy (LHM) and pneumatic dilation (PD). We undertake a systematic review comparing the efficacy and safety of these 2 treatments in the treatment of esophageal achalasia.
  
  
  METHODS
  PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched for randomized controlled trial investigating LHM versus PD in the treatment of primary achalasia. The primary outcome was symptom remission rates. The Mantel-Haenszel method with fixed-effect or random-effects model was used to calculate relative risks and 95% confidence intervals (CIs).
  
  
  RESULTS
  Five studies involving 498 participants were included. The cumulative remission rate was significantly higher with LHM at 3 months and 1 year (short-term), with a risk ratio of 1.16 (95% CI 1.01-1.35, P = 0.04) and 1.14 (95% CI 1.02-1.27, P = 0.02), respectively. There were no significant differences between LHM and PD in 2-year and 5-year remission rate (long-term), with a risk ratio of 1.05 (95% CI 0.91-1.22, P = 0.49) and 1.17 (95% CI 0.84-1.64, P = 0.34), respectively. 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, with a risk ratio of 0.25 (95% CI 0.08-0.81, P = 0.02). Postprocedural rates of gastroesophageal reflux, lower esophageal sphincter pressures, and quality of life scores did not differ in trials with sufficient data.
  
  
  CONCLUSIONS
  There were no significant differences between LHM and PD in 2-year and 5-year remission rate. This study indicates that either treatment can be proposed as initial treatment for achalasia.
authors.affiliation: Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital Zhengzhou, Henan, PR China.
authors.forename: Ji-Wei
authors.initials: JW
authors.lastname: Cheng
authors.forename: Yin
authors.initials: Y
authors.lastname: Li
authors.forename: Wen-Qun
authors.initials: WQ
authors.lastname: Xing
authors.forename: Hong-Wei
authors.initials: HW
authors.lastname: Lv
authors.forename: Hao-Ran
authors.initials: HR
authors.lastname: Wang
mesh_terms: D013505:Digestive System Surgical Procedures; D004106:Dilatation; D004931:Esophageal Achalasia / Q000601:surgery*; D049630:Esophageal Sphincter, Lower / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome