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Endoscopic and Surgical Treatments for Achalasia: A Systematic Review and Meta-Analysis

Campos, Guilherme M. MD, PhD*; Vittinghoff, Eric PhD; Rabl, Charlotte MD*; Takata, Mark MD*; Gadenstätter, Michael MD; Lin, Feng MS; Ciovica, Ruxandra MD*

doi: 10.1097/SLA.0b013e31818e43ab

Background: Although rare, esophageal achalasia is the best described primary esophageal motility disorder. Commonly used treatments are endoscopic botulin toxin injection (EBTI), endoscopic balloon dilation (EBD), and surgical myotomy with or without a fundoplication; however, reported outcomes mostly come from cohort studies.

Objective: To summarize and compare the safety and efficacy of endoscopic and surgical treatments for esophageal achalasia.

Methods: A systematic electronic Medline literature search of articles on esophageal achalasia. Treatment options reviewed included EBTI, EBD, and surgical myotomy using open and minimally invasive techniques. Main outcome measures were frequency of symptom relief, prevalence of post-treatment gastroesophageal reflux (GER), and complications. Outcome probability was estimated using weighted averages of the sample prevalence in each study, with weights equal to the number of patients. Outcomes, within or across studies, were compared using meta-analysis and meta-regression, respectively.

Results: A total of 105 articles reporting on 7855 patients were selected, tabulated and reviewed. Symptom relief after EBD was better than after EBTI (68.2% vs. 40.6%; OR 3.4; 95% CI, 1.2–9.8; P = 0.02), and the need for additional therapy was greater for patients receiving EBTI (46.6% vs. 25%; OR, 2.6; 95% CI, 1.05–6.5; P = 0.04). Laparoscopic myotomy, when combined with an antireflux procedure, provided better symptom relief (90%) than all endoscopic and other surgical approaches and a low complication rate (6.3%). The incidence of postoperative GER was lower when a fundoplication was added to a laparoscopic myotomy (31.5% without a fundoplication vs. 8.8% with; OR, 6.3; 95% CI, 2.0–19.4; P = 0.003).

Conclusions: EBD is superior to EBTI. Laparoscopic myotomy with fundoplication was the most effective surgical technique and can be considered the operative procedure of choice.

The aim of this study was to summarize and compare the safety and efficacy of endoscopic methods (botulinum toxin injection and balloon dilation) and surgical myotomy (open and minimally invasive techniques) in the treatment of esophageal achalasia. The results of a systematic literature review and meta-analysis of 105 articles reporting on 7855 patients is presented.

From the Departments of *Surgery and †Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California; and ‡Department of Surgery, General Hospital Krems, Krems, Austria.

This work was supported by grant KL2 RR024130 from the National Center for Research Resources (NCRR), a component of the NIH and NIH Roadmap for Medical Research.

Reprints: Guilherme M. Campos, MD, FACS, Department of Surgery, University of California San Francisco, 521 Parnassus Ave, C-341, San Francisco, CA 94143-0790. E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.