Division of Gastroenterology, McGill University Health Sciences, Montreal, Quebec, Canada.
Gastrointest Endosc. 2013 Sep;78(3):468-75. doi: 10.1016/j.gie.2013.03.1335. Epub 2013 May 15.
Pneumatic dilation (PD) and laparoscopic Heller's myotomy (LHM) are the mainstays of therapy in idiopathic achalasia. Equipoise exists in choosing the first-line therapy.
To assess comparative efficacies and adverse event rates of these methods.
Intention-to-treat, fixed-model, Mantel-Haenszel meta-analysis of randomized, controlled trials comparing PD with LHM.
Randomized controlled trial comparing PD versus LHM.
Patients with newly diagnosed idiopathic achalasia.
Comprehensive electronic and manual literature search from 1966 to March 2012 independently by two reviewers.
Response rate, rate of different adverse events, and quality of life after each therapy.
Three of 161 retrieved studies between 2007 and 2011, including 346 patients, were included. At 1 year, the cumulative response rate was significantly higher with LHM (86% vs 76%, odds ratio 1.98 (confidence interval 1.14-3.45); P = .02), with no significant heterogeneity (P = .39; I(2) 0%). Rates of major mucosal tears requiring subsequent intervention with LHM were significantly lower than those of esophageal perforation with PD requiring postprocedural medical or surgical therapy (0.6% and 4.8%, respectively; P = .04). Postprocedural rates of gastroesophageal reflux, lower esophageal sphincter pressures, and quality of life scores did not differ in trials with sufficient data. Data on longer follow-up were not available.
Lack of data on follow-ups over 1 year and a small number of included studies.
This meta-analysis suggests that LHM may provide greater response rates as compared with graded PD in the treatment of newly diagnosed idiopathic achalasia, with lesser rates of major adverse events, in up to 1 year after treatment, although additional data are needed to confirm the validity of this conclusion in long-term follow-up.
在特发性贲门失弛缓症的治疗中，气动扩张（PD）和腹腔镜 Heller 肌切开术（LHM）是主要方法。在选择一线治疗方法时存在均衡。
评估这些方法的疗效和不良事件发生率。
对比较 PD 与 LHM 的随机对照试验进行意向治疗、固定模型、Mantel-Haenszel 荟萃分析。
比较 PD 与 LHM 的随机对照试验。
新诊断的特发性贲门失弛缓症患者。
由两位评审员独立进行全面的电子和手动文献搜索，时间从 1966 年至 2012 年 3 月。
每种治疗方法后的反应率、不同不良事件的发生率和生活质量。
在 2007 年至 2011 年期间检索到的 161 项研究中，有 3 项研究，共包括 346 名患者，被纳入研究。在 1 年时，LHM 的累积缓解率明显更高（86%对 76%，比值比 1.98（置信区间 1.14-3.45）；P =.02），且无显著异质性（P =.39；I(2) 0%）。LHM 术后主要黏膜撕裂的发生率明显低于 PD 术后需要后续药物或手术治疗的食管穿孔（分别为 0.6%和 4.8%；P =.04）。在有足够数据的试验中，术后胃食管反流、食管下括约肌压力和生活质量评分无差异。缺乏超过 1 年的随访数据。
缺乏 1 年以上随访数据和纳入研究数量较少。
本荟萃分析表明，与分级 PD 相比，LHM 可能在治疗新诊断的特发性贲门失弛缓症时提供更高的缓解率，且在治疗后 1 年内不良事件发生率更低，但需要更多数据来确认这一结论在长期随访中的有效性。
