Endoscopic Therapy For Achalasia: A Systematic Review Of Randomized Controlled Tirals

Backgound: Achalasia is a kind of common primary esophageal motor disorder of unknown etiology,which the prevalence is very low. However, have a chance to squamous cell carcinoma along with pathogenetic condition development. The poorly defined multifactorial pathogenesis of achalasia has hampered efforts to develop effective treatments. So far, Endoscopic therapy has been used widely to treatment achalasia,but the exact effectiveness has no distinct conclusion.Objective: This review aims to determine the effectiveness and safety of endoscopic therapy (major including: pneumatic balloon dilatation and intrasphincteric injection of botulinum toxin) in patients with achalasia.Materials and Methods: Trials were located through electronic searches of the Cochrane Central Register of Controlled Trails(CENTRAL), MEDLINE or PUBMED, EMBASE, ISI, OVID Database,Chinese Biological Medicine database(CBMDisc), CNKI,Chinese VIP Database and WANFANG database. We also handsearched the bibliographies of retrieved articles and correlated proceedings. Two reviewers assessed the quality of studies, extracted data independently. Disagreements were resolved by discussion or the third party if needed. The primary outcomes were assessed: Short (＜6 months) and long term (＞6months) symptom relief, clinical relapse rate and side effect et al.Statistical analysis was performed by Revman 4.2.8 software.Results: thirty trials involving 1377 patients were included in the systematic review. Most of trials were of poor quality.(1) Short term symptom relief: Intrasphincteric injection of botulinum toxinwere superior to placebo(P＜0.0001); Pneumatic balloon dilatation were superior to intrasphincteric injection of botulinum toxin (P=0.0007);Laparoscopic myotomy were superior to intrasphincteric injection of botulinum toxin (P＜0.05);Combination of both balloon dilatation and intrasphincteric injection of botulinum toxin were superior to balloon dilatation (P＜0.05). (2) Long term symptom relief: Pneumatic balloon dilatation were superior to intrasphincteric injection of botulinum toxin (P=0.005); surgical esophagomyotomy were not superior to balloon dilatation (P=0.14); Combination of both balloon dilatation and intrasphincteric injection of botulinum toxin were superior to balloon dilatation(P=0.0006).(3) clinical relapse rate: Intrasphincteric injection of botulinum toxin were superior to balloon dilatation(P＜0.0001);(4) Complications directly related to the endoscopic therapy: Balloon dilatation were superior to intrasphincteric injection of botulinum toxin(P=0.0008); surgical esophagomyotomy were superior to balloon dilatation(P=0.0006).Conclusions: The limited current evidence showed that: Intrasphincteric injection of botulinum toxin was superior to placebo, Balloon dilatation were superior to intrasphincteric injection of botulinum toxin, Laparoscopic myotomy were superior to intrasphincteric injection of botulinum toxin, Combination of both balloon dilatation and intrasphincteric injection of botulinum toxin were superior to balloon dilatation in improvement of short term symptom.Balloon dilatation were superior to intrasphincteric injection of botulinum toxin, surgical esophagomyotomy were not superior to balloon dilatation, Combination of both balloon dilatation and intrasphincteric injection of botulinum toxin were superior to balloon dilatation in improvement of long term symptom. Intrasphincteric injection of botulinum toxin were superior to balloon dilatation in clinical relapse rate. Balloon dilatation were superior to intrasphinctcric injection of botulinum toxin, surgical esophagomyotomy were superior to balloon dilatation in Complications directly related to the endoscopic therapy. Because most of the included trials were poor of quality, the conclusions were needed to be cautious to be applicated. More randomized trials with enough sample size, uniform standard, further high-quality and scientically sound methodology should be performed.