Evaluating Surgical Management of Primary Achalasia - A Systematic Review and Network Meta-Analysis of Randomised Clinical Trials.

BACKGROUND: Achalasia is primary motility disorder of the oesophagus characterised by abnormal peristalsis and impaired lower oesophageal sphincter relaxation. Multiple interventions are available to control the resultant symptoms of dysphagia, regurgitation, chest pain and weight loss. There is a paucity in the data regarding which treatment option provides the best outcome. Our objective was to perform a systematic review and meta-analysis of randomised clinical trials that have evaluated the clinical outcomes of Heller's myotomy, pneumatic dilatation, peroral endoscopic myotomy and botulinum toxin injections in the management of primary achalasia. METHODS: A systematic review was conducted in accordance with the PRISMA guidelines. An electronic search was performed of PubMed, Embase and Cochrane databases yielding 7455 results, which were screened by two independent reviewers, followed by meta-analysis. RESULTS: Fifteen randomised clinical trials which included a total of 1170 patients were included. Overall, botulinum toxin injections resulted in significantly less treatment success at 1 year (OR: 0.10, 95% CI: 0.01-0.89). At 5 years, treatment success was significantly greater following Heller's myotomy (OR: 6.39, 95% CI: 1.24-32.89) and peroral endoscopic myotomy (OR: 6.33, 95% CI: 2.83-14.20). Pneumatic dilatation resulted in a significantly higher lower oesophageal sphincter pressure (MD: 4.72, 95% CI: 1.13-8.31) and greater abnormal oesophageal acid exposure (OR: 2.63, 95% CI: 1.25-5.56). CONCLUSION: Heller's myotomy and peroral endoscopic myotomy show comparable long-term efficacy, though POEM carries a higher, non-significant rate of oesophagitis. Treatment selection should be individualised based on patient factors and local expertise, with further high-quality trials needed to guide optimal management.