Skip to main content
SpringerLink
Log in

Pneumatic balloon dilatation versus laparoscopic Heller myotomy for achalasia: a failed attempt at meta-analysis

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Markar SR, Mackenzie H, Askari A et al (2018) Population-based cohort study of surgical myotomy and pneumatic dilatation as primary interventions for oesophageal achalasia. Br J Surg 105:1028–1035

    CAS  PubMed  Google Scholar 

  2. Boeckxstaens GE, Annese V, des Varannes SB, et al. Pneumatic dilation versus laparoscopic Heller's myotomy for idiopathic achalasia. N Engl J Med 2011;364:1807–16.

    CAS  PubMed  Google Scholar 

  3. Moonen A, Annese V, Belmans A et al (2016) Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut 65:732–739

    PubMed  Google Scholar 

  4. Bonifacio P, de Moura DTH, Bernardo WM, et al. Pneumatic dilation versus laparoscopic heller's myotomy in the treatment of achalasia: systematic review and meta-analysis based on randomized controlled trials. Dis Esophagus 2019;32–34.

  5. Baniya R, Upadhaya S, Khan J et al (2017) Laparoscopic esophageal myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized controlled trials. Clin Exp Gastroenterol 10:241–248

    PubMed  PubMed Central  Google Scholar 

  6. Illes A, Farkas N, Hegyi P et al 2017 Is Heller myotomy better than balloon dilation? A meta-analysis. J Gastrointestin Liver Dis 26:121–127

    PubMed  Google Scholar 

  7. Cheng JW, Li Y, Xing WQ et al (2017) 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. Medicine (Baltimore) 96:e5525

    Google Scholar 

  8. Yaghoobi M, Mayrand S, Martel M et al (2013) Laparoscopic Heller's myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 78:468–475

    PubMed  Google Scholar 

  9. Schoenberg MB, Marx S, Kersten JF et al (2013) Laparoscopic Heller myotomy versus endoscopic balloon dilatation for the treatment of achalasia: a network meta-analysis. Ann Surg 258:943–952

    PubMed  Google Scholar 

  10. Weber CE, Davis CS, Kramer HJ et al (2012) Medium and long-term outcomes after pneumatic dilation or laparoscopic Heller myotomy for achalasia: a meta-analysis. Surg Laparosc Endosc Percutan Tech 22:289–296

    PubMed  Google Scholar 

  11. Wang L, Li YM, Li L (2009) Meta-analysis of randomized and controlled treatment trials for achalasia. Dig Dis Sci 54:2303–2311

    CAS  PubMed  Google Scholar 

  12. Campos GM, Vittinghoff E, Rabl C et al (2009) Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg 249:45–57

    PubMed  Google Scholar 

  13. Chrystoja CC, Darling GE, Diamant NE et al (2016) Achalasia-specific quality of life after pneumatic dilation or laparoscopic heller myotomy with partial fundoplication: a multicenter randomized clinical trial. Am J Gastroenterol 111:1536–1545

    PubMed  Google Scholar 

  14. Felix VN, Cecconello I, Zilberstein B et al (1998) Achalasia: a prospective study comparing the results of dilatation and myotomy. Hepatogastroenterology 45:97–108

    CAS  PubMed  Google Scholar 

  15. Csendes A, Velasco N, Braghetto I et al (1981) A prospective randomized study comparing forceful dilatation and esophagomyotomy in patients with achalasia of the esophagus. Gastroenterology 80:789–795

    CAS  PubMed  Google Scholar 

  16. Csendes A, Braghetto I, Henriquez A et al (1989) Late results of a prospective randomised study comparing forceful dilatation and oesophagomyotomy in patients with achalasia. Gut 30:299–304

    CAS  PubMed  PubMed Central  Google Scholar 

  17. Kostic S, Kjellin A, Ruth M et al (2007) Pneumatic dilatation or laparoscopic cardiomyotomy in the management of newly diagnosed idiopathic achalasia, results of a randomized controlled trial. World J Surg 31:470–478

    CAS  PubMed  Google Scholar 

  18. Persson J, Johnsson E, Kostic S et al (2015) Treatment of achalasia with laparoscopic myotomy or pneumatic dilatation: long-term results of a prospective, randomized study. World J Surg 39:713–720

    PubMed  Google Scholar 

  19. Borges AA, Lemme EM, Abrahao LJ Jr et al (2014) Pneumatic dilation versus laparoscopic Heller myotomy for the treatment of achalasia: variables related to a good response. Dis Esophagus 27:18–23

    CAS  PubMed  Google Scholar 

  20. Novais PA, Lemme EM (2010) 24-h pH monitoring patterns and clinical response after achalasia treatment with pneumatic dilation or laparoscopic Heller myotomy. Aliment Pharmacol Ther 32:1257–1265

    CAS  PubMed  Google Scholar 

  21. Hamdy E, El Nakeeb A, El Hanfy E et al (2015) Comparative study between laparoscopic heller myotomy versus pneumatic dilatation for treatment of early achalasia: a prospective randomized study. J Laparoendosc Adv Surg Tech A 25:460–464

    PubMed  Google Scholar 

  22. Kummerow Broman K, Phillips SE, Faqih A et al (2018) Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: long-term symptomatic follow-up of a prospective randomized controlled trial. Surg Endosc 32:1668–1674

    PubMed  Google Scholar 

  23. Wang HM, Tai WC, Chuah SK et al (2015) Comparison of treatment outcomes of endoscope-guided pneumatic dilation and laparoscopic Heller myotomy. Kaohsiung J Med Sci 31:639–643

    CAS  PubMed  Google Scholar 

  24. Tabola R, Grabowski K, Lewandowski A et al (2013) Achalasia–balloon dilation or surgery? Med Sci Monit 19:1089–1094

    PubMed  PubMed Central  Google Scholar 

  25. Suarez J, Mearin F, Boque R et al (2002) Laparoscopic myotomy vs endoscopic dilation in the treatment of achalasia. Surg Endosc 16:75–77

    CAS  PubMed  Google Scholar 

  26. Gockel I, Junginger T, Bernhard G et al (2004) Heller myotomy for failed pneumatic dilation in achalasia: how effective is it? Ann Surg 239:371–377

    PubMed  PubMed Central  Google Scholar 

  27. Rodriguez E de Santiago, Mohammed N, Manolakis A et al (2019) Anterior versus posterior myotomy during poem for the treatment of achalasia: systematic review and meta-analysis of randomized clinical trials. J Gastrointestin Liver Dis 28:107–115

    Google Scholar 

  28. Li H, Peng W, Huang S et al (2019) The 2 years' long-term efficacy and safety of peroral endoscopic myotomy for the treatment of achalasia: a systematic review. J Cardiothorac Surg 14:1

    PubMed  PubMed Central  Google Scholar 

  29. Lee Y, Brar K, Doumouras AG et al (2019) Peroral endoscopic myotomy (POEM) for the treatment of pediatric achalasia: a systematic review and meta-analysis. Surg Endosc 33:1710–1720

    PubMed  Google Scholar 

  30. Evensen H, Kristensen V, Larssen L et al (2019) Outcome of peroral endoscopic myotomy (POEM) in treatment-naive patients A systematic review. Scand J Gastroenterol 54:1–7

    PubMed  Google Scholar 

  31. Chandan S, Mohan BP, Chandan OC et al (2019) Clinical efficacy of per-oral endoscopic myotomy (POEM) for spastic esophageal disorders: a systematic review and meta-analysis. Surg Endosc 34:707–718

    PubMed  Google Scholar 

  32. Schlottmann F, Luckett DJ, Fine J et al (2018) Laparoscopic Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM) for Achalasia: A Systematic Review and Meta-analysis. Ann Surg 267:451–460

    PubMed  Google Scholar 

  33. Repici A, Fuccio L, Maselli R et al (2018) GERD after per-oral endoscopic myotomy as compared with Heller's myotomy with fundoplication: a systematic review with meta-analysis. Gastrointest Endosc 87(934–943):e18

    Google Scholar 

  34. Fernandez-Ananin S, Fernandez AF, Balague C et al (2018) What to do when Heller's myotomy fails? Pneumatic dilatation, laparoscopic remyotomy or peroral endoscopic myotomy: a systematic review. J Minim Access Surg 14:177–184

    PubMed  PubMed Central  Google Scholar 

  35. Khan MA, Kumbhari V, Ngamruengphong S et al (2017) Is POEM the answer for management of spastic esophageal disorders? A systematic review and meta-analysis. Dig Dis Sci 62:35–44

    PubMed  Google Scholar 

  36. Crespin OM, Liu LWC, Parmar A et al (2017) Safety and efficacy of POEM for treatment of achalasia: a systematic review of the literature. Surg Endosc 31:2187–2201

    PubMed  Google Scholar 

  37. Awaiz A, Yunus RM, Khan S et al (2017) Systematic review and meta-analysis of perioperative outcomes of peroral endoscopic myotomy (POEM) and laparoscopic heller myotomy (LHM) for achalasia. Surg Laparosc Endosc Percutan Tech 27:123–131

    PubMed  Google Scholar 

  38. Zhang Y, Wang H, Chen X et al (2016) Per-oral endoscopic myotomy versus laparoscopic heller myotomy for achalasia: a meta-analysis of nonrandomized comparative studies. Medicine (Baltimore) 95:e2736

    Google Scholar 

  39. Patel K, Abbassi-Ghadi N, Markar S et al (2016) Peroral endoscopic myotomy for the treatment of esophageal achalasia: systematic review and pooled analysis. Dis Esophagus 29:807–819

    CAS  PubMed  Google Scholar 

  40. Marano L, Pallabazzer G, Solito B et al (2016) Surgery or peroral Esophageal myotomy for achalasia: a systematic review and meta-analysis. Medicine (Baltimore) 95:e3001

    Google Scholar 

  41. Akintoye E, Kumar N, Obaitan I et al (2016) Peroral endoscopic myotomy: a meta-analysis. Endoscopy 48:1059–1068

    PubMed  Google Scholar 

  42. Wei M, Yang T, Yang X et al (2015) Peroral esophageal myotomy versus laparoscopic Heller's myotomy for achalasia: a meta-analysis. J Laparoendosc Adv Surg Tech A 25:123–129

    PubMed  Google Scholar 

  43. Talukdar R, Inoue H, Nageshwar RD (2015) Efficacy of peroral endoscopic myotomy (POEM) in the treatment of achalasia: a systematic review and meta-analysis. Surg Endosc 29:3030–3046

    PubMed  Google Scholar 

  44. Minami H, Inoue H, Haji A et al (2015) Per-oral endoscopic myotomy: emerging indications and evolving techniques. Dig Endosc 27:175–181

    PubMed  Google Scholar 

  45. Barbieri LA, Hassan C, Rosati R et al (2015) Systematic review and meta-analysis: efficacy and safety of POEM for achalasia. United European Gastroenterol J 3:325–334

    PubMed  PubMed Central  Google Scholar 

  46. Ponds FA, Fockens P, Lei A et al (2019) Effect of peroral endoscopic myotomy vs pneumatic dilation on symptom severity and treatment outcomes among treatment-naive patients with achalasia: a randomized clinical trial. JAMA 322:134–144

    PubMed  PubMed Central  Google Scholar 

  47. Werner YB, Hakanson B, Martinek J et al (2019) Endoscopic or surgical myotomy in patients with idiopathic achalasia. N Engl J Med 381:2219–2229

    PubMed  Google Scholar 

  48. Vaezi MF, Pandolfino JE, Vela MF (2013) ACG clinical guideline: diagnosis and management of achalasia. Am J Gastroenterol 108:1238–1249; quiz 1250

    PubMed  Google Scholar 

  49. Leyden JE, Moss AC, MacMathuna P. Endoscopic pneumatic dilation versus botulinum toxin injection in the management of primary achalasia. Cochrane Database Syst Rev 2014:Cd005046.

  50. Zaninotto G, Bennett C, Boeckxstaens G, et al. The 2018 ISDE achalasia guidelines. Dis Esophagus 2018.

  51. Inoue H, Shiwaku H, Iwakiri K et al (2018) Clinical practice guidelines for peroral endoscopic myotomy. Dig Endosc 30:563–579

    PubMed  Google Scholar 

  52. Sami SS, Haboubi HN, Ang Y et al (2018) UK guidelines on oesophageal dilatation in clinical practice. Gut 67:1000–1023

    PubMed  PubMed Central  Google Scholar 

  53. Sawas T, Ravi K, Geno DM et al (2017) The course of achalasia one to four decades after initial treatment. Aliment Pharmacol Ther 45:553–560

    CAS  PubMed  Google Scholar 

  54. Huelsen A, Oumer R, Ashcroft A et al (2016) Achalasia: a 13-year, single-centre experience comparing endoscopic balloon dilatation and laparoscopic Heller myotomy. N Z Med J 129:41–50

    PubMed  Google Scholar 

  55. Ehlers AP, Oelschlager BK, Pellegrini CA et al (2017) Achalasia treatment, outcomes, utilization, and costs: a population-based study from the United States. J Am Coll Surg 225:380–386

    PubMed  PubMed Central  Google Scholar 

  56. Vanuytsel T, Lerut T, Coosemans W et al (2012) Conservative management of esophageal perforations during pneumatic dilation for idiopathic esophageal achalasia. Clin Gastroenterol Hepatol 10:142–149

    PubMed  Google Scholar 

  57. Rosch T, Repici A, Boeckxstaens G (2017) Will Reflux Kill POEM? Endoscopy 49:625–628

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany

    Jocelyn de Heer, Karl-Hermann Fuchs, Guido Schachschal, Thomas Rösch & Yuki Werner

  2. Department of Gastroenterology, Hepatology and Motility, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas, MO, USA

    Madhav Desai & Prateek Sharma

  3. Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium

    Guy Boeckxstaens

  4. Department of Surgery, Imperial College London, London, UK

    Giovanni Zaninotto

  5. Department of General and Abdominal Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany

    Oliver Mann

Authors
  1. Jocelyn de Heer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Madhav Desai
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Guy Boeckxstaens
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Giovanni Zaninotto
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Karl-Hermann Fuchs
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Prateek Sharma
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Guido Schachschal
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Oliver Mann
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Thomas Rösch
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Yuki Werner
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

The study idea was developed by TR in discussion with JdH and GB. Paper search was done by MD, JdH and TR; data analysis by JdH and TR. All co-authors gave their input by reading, commenting and improving the manuscript written by JdH and TR, e.g., adding Fig. 1 (MD, PS, TR). All authors have seen and approved the manuscript.

Corresponding author

Correspondence to Thomas Rösch.

Ethics declarations

Disclosure

None of the authors has anything to disclose with regards to the contents of this paper which does not include any commercial products. In detail, Dr. Jocelyn de Heer, Dr. Madhav Desai, Dr. Guy Boeckxstaens, Dr. Giovanni Zaninotto, Dr. Karl-Hermann Fuchs, Dr. Prateek Sharma, Dr. Guido Schachschal, Dr. Oliver Mann, Dr. Thomas Rösch, and Dr. Yuki Werner have no conflicts of interest or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

de Heer, J., Desai, M., Boeckxstaens, G. et al. Pneumatic balloon dilatation versus laparoscopic Heller myotomy for achalasia: a failed attempt at meta-analysis. Surg Endosc 35, 602–611 (2021). https://doi.org/10.1007/s00464-020-07421-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-020-07421-x

Keywords

Search

Navigation