Digestive Diseases and Sciences

, Volume 54, Issue 11, pp 2303–2311 | Cite as

Meta-Analysis of Randomized and Controlled Treatment Trials for Achalasia

  • Lan Wang
  • You-Ming LiEmail author
  • Lan Li


Pharmacological therapy, botulinum toxin injection, pneumatic dilatation, and surgical myotomy are the primary therapeutic modalities for achalasia, for which laparoscopic myotomy is recommended as state-of-the-art therapy. However, its efficacy and safety remain unclear compared with other approaches in the treatment of achalasia. We searched electronic databases (MEDLINE, EMBASE, Cochrane Central Registry of Controlled Trials, LILACS-Latin American, Caribbean health science literature, and Science Citation Index Expanded) for randomized controlled trials to evaluate which therapeutic measures are temporary and reversible and which measures are definitive and effective by pooling data including remission rate, relapse rate, complications, and adverse effects. Seventeen studies with 761 patients met our inclusion criteria. There was better remission rate in pneumatic dilation than in botulinum toxin injection for initial intervention [relative risk (RR) 2.20, 95% confidence interval (CI) 1.51–3.20], Pneumatic dilation had lower relapse rate than did botulinum toxin injection (RR 0.12, 95% CI 0.04–0.32). Compared with pneumatic dilation, laparoscopic myotomy further increased remission rate (RR 1.48, 95% CI 1.48–1.87), and reduced clinical relapse rate (RR 0.14, 95% CI 0.04–0.58), and there was no difference in complication rate (RR 1.48, 95% CI 0.37–5.99). Based on limited randomized and controlled trials, laparoscopic myotomy is the preferred method for patients with achalasia. Future trials should investigate whether laparoscopic myotomy combined with different modalities of fundoplication is superior to isolated laparoscopic myotomy.


Meta-analysis Achalasia Treatment Pneumatic dilation Botulinum toxin injection Laparoscopic myotomy 


  1. 1.
    Pohl D, Tutuian R. Achalasia: an overview of diagnosis and treatment. J Gastrointestin Liver Dis. 2007;16(3):297–303.PubMedGoogle Scholar
  2. 2.
    Cowgill SM, Villalodid D, Al-Saadi S, Hedgecock J, Rosemurgy AS. Postmyotomy recollection of premyotomy symptoms of achalasia is very accurate, supporting longitudinal studies of symptom. Surg Endosc. 2007;21:2183–2186. doi: 10.1007/s00464-007-9332-7.CrossRefPubMedGoogle Scholar
  3. 3.
    Hoogerwerf WA, Pasricha PJ. Achalasia: treatment options revisited. Can J Gastroenterol. 2000;14:406–409.PubMedGoogle Scholar
  4. 4.
    Roberts KE, Duffy AJ, Bell RL. Controversies in the treatment of gastroesophageal reflux and achalasia. World J Gastroenterol. 2006;12:3155–3161.PubMedGoogle Scholar
  5. 5.
    Gideon RM, Castell DO, Yarze J. Prospective randomized comparison of pneumatic dilatation technique in patients with idiopathic achalasia. Dig Dis Sci. 1999;44(9):1853–1857. doi: 10.1023/A:1018898824135.CrossRefPubMedGoogle Scholar
  6. 6.
    Ruiz de Leon Juan A. Therapeutical alternatives in achalasia. Rev Esp Enferm Dig. 2003;95(1):5–8. 9–12.Google Scholar
  7. 7.
    Massey BT. Management of idiopathic achalasia: short-term and long-term outcomes. Curr Gastroenterol Rep. 2000;2:196–200. doi: 10.1007/s11894-000-0061-5.CrossRefPubMedGoogle Scholar
  8. 8.
    Cheng YS, Li MH, Chen WX, Chen NW, Zhuang QX, Shang KZ. Selection and evaluation of three interventional procedures for achalasia based on long-term follow-up. World J Gastroenterol. 2003;9:2370–2373.PubMedGoogle Scholar
  9. 9.
    Da Silveira EB, Rogers AI. Achalasia: a review of therapeutic options and outcomes. Compr Ther. 2002;28:15–22. doi: 10.1007/s12019-002-0038-4.CrossRefPubMedGoogle Scholar
  10. 10.
    Khajanchee YS, Kanneganti S, Leatherwood AE, Hansen PD, Swanström LL. Laparoscopic heller myotomy with toupet fundoplication. Arch Surg. 2005;140:827–834. doi: 10.1001/archsurg.140.9.827.CrossRefPubMedGoogle Scholar
  11. 11.
    Kostic S, Kjellin A, Ruth M, et al. Pneumatic dilatation or laparoscopic cardiomyotomy in the management of newly diagnosed idiopathic achalasia: results of a randomized controlled trial. World J Surg. 2007;31:470–478. doi: 10.1007/s00268-006-0600-9.CrossRefPubMedGoogle Scholar
  12. 12.
    Rakita S, Bloomston M, Villadolid D, Thometz D, Zervos E, Rosemurgy A. Esophagotomy during laparoscopic heller myotomy cannot be predicted by preoperative therapies and does not influence long-term outcome. J Gastrointest Surg. 2005;9:159–164. doi: 10.1016/j.gassur.2004.10.015.CrossRefPubMedGoogle Scholar
  13. 13.
    Mattioli G, Esposito C, Pini Prato A, et al. Results of the laparoscopic Heller-Dor procedure for pediatric esophageal achalasia. Surg Endosc. 2003;17:1650–1652. doi: 10.1007/s00464-002-9257-0.CrossRefPubMedGoogle Scholar
  14. 14.
    Coccia G, Bortolotti M, Michetti P, Dodero M. Prospective clinical and manometric study comparing pneumatic dilatation and sublingual nifedipine in the treatment of oesophageal achalasia. Gut. 1991;32:604–606. doi: 10.1136/gut.32.6.604.CrossRefPubMedGoogle Scholar
  15. 15.
    Vaezi MF, Richter JE, Wilcox CM, et al. Botulinum toxin versus pneumatic dilatation in the treatment of achalasia: a randomised trial. Gut. 1999;44:231–239.PubMedCrossRefGoogle Scholar
  16. 16.
    Annese V, Basciani M, Perri F, et al. Controlled trial of botulinum toxin injection versus placebo and pneumatic dilation in achalasia. Gastroenterology. 1996;111(6):1418–1424. doi: 10.1016/S0016-5085(96)70002-1.CrossRefPubMedGoogle Scholar
  17. 17.
    Ghoshal UC, Chaudhuri S, Pal BB, Dhar K, Ray G, Banerjee PK. Randomized controlled trial of intrasphincteric botulinum toxin A injection versus balloon dilatation in treatment of achalasia cardia. Dis Esophagus. 2001;14:227–231. doi: 10.1046/j.1442-2050.2001.00189.x.CrossRefPubMedGoogle Scholar
  18. 18.
    Mikaeli J, Fazel A, Montazeri G, et al. Randomized controlled trial comparing botulinum toxin injection to pneumatic dilatation for the treatment of achalasia. Aliment Pharmacol Ther. 2001;15:1389–1396. doi: 10.1046/j.1365-2036.2001.01065.x.CrossRefPubMedGoogle Scholar
  19. 19.
    Bansal R, Nostrant TT, Scheiman IM, et al. Intrasphincteric botulinum toxin versus pneumatic balloon dilation for treatment of primary achalasia. J Clin Gastroenterol. 2003;36(3):209–214. doi: 10.1097/00004836-200303000-00005.CrossRefPubMedGoogle Scholar
  20. 20.
    Mikaeli J, Bishehsari F, Montazeri G, et al. Injection of botulinum toxin before pneumatic dilatation in achalasia treatment: a randomized-controlled trial. Aliment Pharmacol Ther. 2006;24:983–989. doi: 10.1111/j.1365-2036.2006.03083.x.CrossRefPubMedGoogle Scholar
  21. 21.
    Zaninotto G, Annese V, Costantini M, et al. Randomized controlled trial of botulinum toxin versus laparoscopic heller myotomy for esophageal achalasia. Ann Surg. 2004;239:364–370. doi: 10.1097/01.sla.0000114217.52941.c5.CrossRefPubMedGoogle Scholar
  22. 22.
    Zaninotto G, Vergadoro V, Annese V, et al. Botulinum toxin injection versus laparoscopic myotomy for the treatment of esophageal achalasia. Surg Endosc. 2004;18:691–695. doi: 10.1007/s00464-003-8910-6.CrossRefPubMedGoogle Scholar
  23. 23.
    Suárez J, Mearin F, Boque R, et al. Laparoscopic myotomy versus endoscopic dilation in the treatment of achalasia. Surg Endosc. 2002;16:75–77. doi: 10.1007/s00464-001-0032-4.CrossRefPubMedGoogle Scholar
  24. 24.
    Kostic S, Johnsson E, Kjellin A, et al. Health economic evaluation of therapeutic strategies in patients with idiopathic achalasia: results of a randomized trial comparing pneumatic dilatation with laparoscopic cardiomyotomy. Surg Endosc. 2007;21:1184–1189. doi: 10.1007/s00464-007-9310-0.CrossRefPubMedGoogle Scholar
  25. 25.
    Patti MG, Pellegrini CA, Horgan S, et al. Minimally invasive surgery for achalasia: an 8-year experience with 168 patients. Ann Surg. 1999;230(4):587–594. doi: 10.1097/00000658-199910000-00014.CrossRefPubMedGoogle Scholar
  26. 26.
    Pasricha PJ, Ravich WJ, Hendrix TR, Sostre S, Jones B, Kalloo AN. Intrasphincteric botulinum toxin for the treatment of achalasia. N Engl J Med. 1995;332:774–778. doi: 10.1056/NEJM199503233321203.CrossRefPubMedGoogle Scholar
  27. 27.
    Yi A, Shin JH, Song HY, et al. Esophageal achalasia: comparison of fluoroscopically-guided double vs. endoscopically-guided single balloon dilation. Abdom Imaging. 2008;33:177–182. doi: 10.1007/s00261-007-9199-z.CrossRefPubMedGoogle Scholar
  28. 28.
    Richards WO, Torquati A, Holzman MD, et al. Heller myotomy versus heller myotomy with dor fundoplication for achalasia. Ann Surg. 2004;240:405–415. doi: 10.1097/01.sla.0000136940.32255.51.CrossRefPubMedGoogle Scholar
  29. 29.
    Csendes A, Braghetto I, Henríquez A, Cortés C. Late results of a prospective randomised study comparing forceful dilatation and oesophagomyotomy in patients with achalasia. Gut. 1989;30:299–304. doi: 10.1136/gut.30.3.299.CrossRefPubMedGoogle Scholar
  30. 30.
    Mearin F, Armengol JR, Chicharro L, Papo M, Balboa A, Malagelada JR. Forceful dilatation under endoscopic control in the treatment of achalasia: a randomised trial of pneumatic versus metallic dilator. Gut. 1994;35:1360–1362. doi: 10.1136/gut.35.10.1360.CrossRefPubMedGoogle Scholar
  31. 31.
    Bassotti G, Onofrio D’, Baataglia E, et al. Treatment with botulinum toxin of octo-nonagerians with oesophageal achalasia: a two-year follow-up. Aliment Pharmacol Ther. 2006;23(11):1615–1619. doi: 10.1111/j.1365-2036.2006.02907.x.CrossRefPubMedGoogle Scholar
  32. 32.
    Horgan S, Galvani C, Gorodner MV, et al. Robotic-assisted Heller myotomy versus laparoscopic Heller myotomy for the treatment of esophageal. J Gastrointest Surg. 2005;9:1020–1030. doi: 10.1016/j.gassur.2005.06.026.CrossRefPubMedGoogle Scholar
  33. 33.
    Patti MG, Molena D, Fisichella PM, et al. Laparoscopic Heller myotomy and Dor fundoplication for achalasia: analysis of successes and failures. Arch Surg. 2001;136:870–877. doi: 10.1001/archsurg.136.8.870.CrossRefPubMedGoogle Scholar
  34. 34.
    Peters JH. An antireflux procedure is critical to the long term outcome of esophageal myotomy for achalasia. J Gastrointest Surg. 2000;5:17–20. doi: 10.1016/S1091-255X(01)80008-1.CrossRefGoogle Scholar
  35. 35.
    Abir F, Modlin I, Kidd M, Bell R. Surgical treatment of achalasia: current status and controversies. Dig Surg. 2004;21(3):165–167. doi: 10.1159/000079341.CrossRefPubMedGoogle Scholar
  36. 36.
    Lyass S, Thoman D, Steiner JP, Phillips E. Current status of an antireflux procedure in laparoscopic Heller myotomy. Surg Endosc. 2003;17:554–558. doi: 10.1007/s00464-002-8604-5.CrossRefPubMedGoogle Scholar
  37. 37.
    Torquati A, Lutfi R, Khaitan L, Sharp KW, Richards WO. Heller myotomy versus Heller myotomy plus Dor fundoplication: cost–utility analysis of a randomized trial. Surg Endosc. 2006;20:389–393. doi: 10.1007/s00464-005-0116-7.CrossRefPubMedGoogle Scholar
  38. 38.
    Richards WO, Sharp KW, Holzman MD. An antireflux procedure should not routinely be added to a Heller myotomy. J Gastrointest Surg. 2001;5:13–16. doi: 10.1016/S1091-255X(01)80007-X.CrossRefPubMedGoogle Scholar
  39. 39.
    Hunter JG, Trus TL, Branum GD, Waring JP. Laparoscopic Heller myotomy and fundoplication for achalasia. Ann Surg. 1997;225:655–664. doi: 10.1097/00000658-199706000-00003.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  1. 1.Department of GastroenterologyThe First Affiliated Hospital, Medical College, Zhejiang UniversityHangzhouPeople’s Republic of China

Personalised recommendations