A systematic review and meta-analysis of the Chinese literature for the treatment of achalasia

AIM： To evaluate the effect of different approaches in the treatment of achalasia in China. METHODS： We performed a systematic review and meta-analysis of Chinese literature by searching the Chinese Biomedical Database and Chinese scientific Journals database （up to March 2008）. All cohort studies （controlled or uncontrolled） in which the patients were observed for more than a year were reviewed in detail. Dichotomous outcomes were reported as relative risks （RR） with 95% confidence interval （CI） for controlled trials. The efficacy in uncontrolled trials was assessed by a pooled estimate of response rate with individual studies weighted in proportion to the sample size. RESULTS： Seven controlled trials compared the effect of botulinum toxin injection （BoTx） with pneumatic dilation （PD）. PD was superior to BoTx [65.2% vs 45.3%; RR 1.47 （95% CI 1.23-1.77）, P 〈 0.0001], and had a lower clinical relapse rate （BoTx 30.2% vs PD 10%, RR 0.32 （0.16-0.65）, P = 0.001）. Heller myotomy （HM） had superior remission rate compared to PD [HM 94.0% vs PD 64.1%, RR 1.48 （1.15-1.99）, P = 0.002]. In uncontrolled trials, the effectiveness of PD was 86.6% （23.9%） vs 94.8% （10.6%） for HM. The main complications of PD were perforation and gastroesophageal reflux disease. CONCLUSION： HM is the most effective long-term treatment for patients with achalasia in China. In the future, controlled clinical trials on the treatment of achalasia should focus on comparing laparoscopic myotomy with or without antireflux procedure,including different partial and total fundoplication techniques.