Meta-analysis Of The Efficacy And Safety Of Oral Endoscopic Myotomy And Pneumatic Dilation In The Treatment Of Achalasia

OBJECTIVE: Cardiac achalasia is a rare form of primary esophageal dyskinesia in digestive diseases.Current treatment options include: pneumatic dilation(PD),endoscopic myotomy(peroral endoscopic myotomy,POEM),Laparoscopic Heller's myotomy(LHM),recent studies have shown that pneumatic dilation and peroral endoscopic myotomy in the treatment of complications and complications There are differences,so this study aims to provide a better treatment plan for clinical comparison of the two methods.Methods: According to the title of the search terms,search electronic database:Pubmed,Embase,The Cochrane Library,Wanfang Medical Network,Weipu,China Biology Medicine disc(CBMdisc),China Journal Full-text Database(China Knowledge Network,Chinese National Knowledge Infrastructure(CNKI),Chinese Science Journal Database(CSJD)and other authoritative databases,from January 2007 to October 2018,screening articles according to the proposed inclusion and exclusion criteria,using Cochrane bias The risk assessment tool evaluates the risk of bias in the randomized controlled trials and uses the NOS scale to assess the risk of bias in the non-randomized controlled trials.The data is extracted by two individuals and cross-checked.When the opinions are inconsistent,it is decided by a third party.The data types were divided into continuous variables and two categorical variables.The data were analyzed and processed using Review Manager 5.3 software.The continuous variables were weighted mean difference(WMD)and 95%confidence interval(95% CI).Analysis,two points The variables were analyzed using Risk ratio(RR)and 95% confidence interval(95% CI).The heterogeneity was judged by the size of I2,and the effect model was selected according to the heterogeneity size.Forest maps and analysis of the results.RESULTS: A total of 10 articles were included in 5 randomized controlled trials and 5 clinical controlled trials,including 692 patients,including 374 patients in the POEM group and 318 patients in the PD group.The results were as follows: 1 Eckardt score: The Eckardt score of the POEM group was comparable to that of the PD group in the first month after surgery(RCT: P=0.10,WMD=-0.34,95% CI:-0.76,0.07,retrospective analysis: P=0.31,WMD =-0.19,95% CI:-0.57,0.18);the Eckardt score of the POEM group was comparable to that of the PD group in the third month after surgery(RCT: P=0.28,WMD=-0.75,95% CI:-2.11,0.61.Sexual analysis: P=0.16,W MD=-0.35,95% CI:-0.84,0.14);Eckardt score was lower in the POEM group than in the PD group in the sixth month after surgery(retrospective analysis: P=0.004,WMD=-0.52),95% CI:-0.88,-0.16;)The Eckardt score of the POEM group was lower than that of the PD group in the twelfth month after surgery(RCT: P<0.00001,WMD=-1.17,95%CI:-1.41,-0.93,review)Sex analysis: P < 0.00001,WMD =-1.95,95% CI:-2.52,-1.38).2LESP: The LEEP of the POEM group was lower than that of the PD group in the first month after surgery(MD=-3.83,95% CI:-5.51,-2.15,I2=51%,P<0.00001),and the third month after the POEM group LESP Compared with the PD group(MD=-0.98,95% CI:-2.21,0.26,I2=0%,P=0.12),the LEEP of the POEM group was lower than the PD group in the sixth month after surgery and the twelfth month after surgery.(MD =-10.44,95% CI:-11.69,-9.2,I2 = 98%,P < 0.00001 and MD =-6.48,95% CI:-7.54,-5.42,I2 =0%,P < 0.00001).3 operative time: The operation time of the POEM group was longer than that of the PD group(RCT: WMD=35.51,95% CI: 29.80,41.22,P<0.00001,retrospective analysis: WMD=37.44,95% CI: 32.38,42.50,P<0.00001).4 Hospitalization time: The length of hospital stay in the POEM group was longer than that in the PD group(RCT: WMD=4.60,95% CI: 3.77,5.43,P<0.00001,retrospective analysis: WMD=0.33,95% CI: 3.33,4.72,P<0.00001).5 Total complications: The overall complication rate was higher in the POEM group than in the PD group(RCT: RR = 1.67,95% CI: 1.10,2.53,P< 0.00001,retrospective analysis: RR = 3.73,95% CI: 1.00,13.85,P=0.05,pooled analysis: RR combined = 1.86,95% CI: 1.25,2.77,P=0.002).6Bleeding: The bleeding rate in the POEM group was comparable to that in the PD group(RCT: RR = 2.27,95% CI: 0.57,9.06,P = 0.24,retrospective analysis: RR = 3.00,95% CI: 0.17,53.86,P = 0.46).Perforation: The perforation rate of the POEM group was comparable to that of the PD group(RCT: RR = 2.33,95% CI: 0.35,15.42,P = 0.38,combined analysis: RR combined = 2.33,95% CI: 0.35,15.42,P = 0.38).Pneumothorax: The pneumothorax rate in the POEM group was comparable to that in the PD group(RCT: RR = 1.76,95% CI: 0.68,4.59,P = 0.25,retrospective analysis: RR =1.00,95% CI: 0.04,23.80,P = 1.00).Subcutaneous emphysema: The subcutaneous emphysema rate in the POEM group was higher than that in the PD group(RCT: RR = 4.67,95% CI: 1.35,16.18,P = 0.01,retrospective analysis: 5.58,95% CI: 1.33,23.42,P = 0.02).7 Gastroesophageal reflux: The gastroesophageal reflux rate in the POEM group was higher than that in the PD group(RCT: RR=1.50,95% CI: 0.39,5.75,P=0.56,retrospective analysis:RR=3.29,95% CI: 1.42,7.65,P=0.006,post-merger analysis: RR consolidation = 2.65,95% CI: 1.31,5.36,P = 0.007).Conclusions: 1.Both POEM and PD can alleviate the clinical symptoms of patients with achalasia.Both have similar short-term effects,but POEM is better for long-term effects.2.The operation of the two groups was relatively safe,but the incidence of POEM was higher than that of PD in the comparison of total complications,subcutaneous emphysema and long-term complications of gastroesophageal reflux.3.comparing the two surgical procedures,POEM surgery time is longer,hospital stay longer.4.Because there are certain quality problems and heterogeneity in the selected articles,it will inevitably lead to the existence of risk of bias.Therefore,more high quality,longer follow-up time and large sample randomized controlled trials are needed to further verify this conclusion.