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Laparoscopic Heller Myotomy Versus Endoscopic Balloon Dilatation for the Treatment of Achalasia: A Network Meta-Analysis

Schoenberg, Markus B. MD*,†; Marx, Svetlana PhD§; Kersten, Jan F. PhD; Rösch, Thomas MD; Belle, Sebastian MD; Kähler, Georg MD; Vassiliou, Melina C. MD††; Lüth, Stefan MD**; von Renteln, Daniel MD

doi: 10.1097/SLA.0000000000000212

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.

Supplemental Digital Content is Available in the Text.This study compares short- and long-term success, reintervention, and complication rates of laparoscopic Heller myotomy (LHM) with endoscopic balloon dilation for treatment of achalasia. Outcomes demonstrate superiority of LHM regarding short- and long-term success rates and amount of reinterventions. LHM should be considered first-line treatment for 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.

Reprints: Daniel von Renteln, MD, Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr 52, 20246 Hamburg, Germany. E-mail:

Disclosure: No external financial support was required or granted to complete this study. None of the authors have commercial associations that might be a conflict of interest in relation to this article.

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© 2013 by Lippincott Williams & Wilkins.