Pneumatic dilation versus laparoscopic Heller's myotomy in the treatment of achalasia: systematic review and meta-analysis based on randomized controlled trials

Achalasia is a primary esophageal motor disorder with a variety of causes. It is most common in Central and South America, where Chagas disease is endemic. In addition to the infectious etiology, achalasia can be idiopathic, autoimmune, or drug induced. It is an incurable, progressive condition that destroys the intramural nerve plexus, causing aperistalsis of the esophageal body and impaired relaxation of the lower esophageal sphincter. The literature on the treatment of achalasia comparing pneumatic dilation (PD) and laparoscopic Heller's myotomy (LHM) shows conflicting results. Therefore, a systemic review and meta-analysis are needed. A systematic review and meta-analysis of randomized controlled trials of PD and LHM, based on the preferred reporting items for systematic reviews and meta-analyses recommendations, was presented. The primary outcome was symptom remission based on the Eckardt score. Secondary outcomes were lower esophageal sphincter pressure (LESP), gastroesophageal reflux (GER), and perforation. A total of four studies were included in this analysis. The total number of patients was 404. Posttreatment symptom remission rates did not differ significantly between LHM and PD at 2 years (RD = 0.03, 95% CI [-0.05, 0.12], P = 0.62), or 5 years (RD = 0.13, 95% CI [-0.12, 0.39], P = 0.32). The posttreatment perforation rate was lower for LHM (RD = 0.04, 95% CI [-0.08, -0.01], P = 0.03). There was no significant difference in terms of LESP or GER. For the treatment of esophageal achalasia, LHM and PD were found to be similar in terms of their long-term efficacy, as well as in terms of the posttreatment GER rates. However, the perforation rate appears to be lower when LHM is employed.