Abstract

Introduction

The advent of peroral endoscopic myotomy (POEM) shed some light on the role of the current standards in the treatment of idiopathic achalasia, namely endoscopic pneumatic dilatation (PD) and laparoscopic Heller myotomy (LHM). We analyzed the quality of the current evidence comparing LHM and PD.

Methods

A systematic literature search was performed in Pubmed/Medline, Web of Science, Google Scholar and Cochrane for meta-analyses/systematic reviews comparing PD and LHM or open surgery, limited to English language full-text articles. After a detailed review of these meta-analyses, all studies included were analyzed further in depth with respect to treatment protocol, assessment of success, complications and sequelae such as gastroesophageal reflux (GER), as well as follow-up details.

Results

Six randomized controlled trials (RCT), 5 with LHM and 1 with open surgery, were found, published in 10 papers. In contrast to a rather homogeneous LHM technique, PD regimens as well as the clinical dysphagia scores were different in every RCT; most RCTs also showed methodological limitations. There were nine meta-analyses which included a variable number of these RCTs or other cohort studies. Meta-analyses between 2009 and 2013 favored surgery, while the 4 most recent ones reached divergent conclusions. The main difference might have been whether repeated dilatation was regarded as part of the PD protocol or as failure.

Conclusions

The variability in PD techniques and in definition of clinical success utilized in the achalasia RCTs on PD versus LHM render the conclusions of meta-analyses unreliable. Further randomized studies should be based on uniform criteria; in the meantime, publication of even more meta-analyses should be avoided.

中文翻译：

---

气动球囊扩张与腹腔镜海勒肌切开术治疗门失弛缓症的荟萃分析失败

摘要

介绍

经口内镜下肌切开术（POEM）的问世为当前标准在特发性门失弛缓症治疗中的作用提供了一些启示，即内镜下气管扩张术（PD）和腹腔镜Heller肌切开术（LHM）。我们分析了比较LHM和PD的当前证据的质量。

方法

在Pubmed / Medline，Web of Science，Google Scholar和Cochrane中进行了系统的文献检索，以比较PD和LHM或开放手术（仅限英语全文文章）进行的荟萃分析/系统评价。在对这些荟萃分析进行详细审查之后，将对所有纳入研究的治疗方案，成功率，并发症和后遗症（如胃食管反流（GER））的评估进行深入分析，并进行详细的随访。

结果

共发现6篇随机对照试验（RCT），其中5篇采用LHM，1篇采用开放手术，发表在10篇论文中。与相当均质的LHM技术相反，PD方案以及临床吞咽困难评分在每个RCT中均不同。大多数RCT也显示出方法学上的局限性。有九项荟萃分析，其中包括数量不等的这些RCT或其他队列研究。2009年至2013年的荟萃分析偏向于手术治疗，而最近的4项分析得出了不同的结论。主要区别可能是重复扩张被视为PD方案的一部分还是失败。

结论

PD技术与LHM的al门失弛缓性随机对照试验中PD技术的可变性以及临床成功的定义，使得荟萃分析的结论不可靠。进一步的随机研究应基于统一的标准；同时，应避免发表更多的荟萃分析。