Evaluating surgical management of primary achalasia—a systematic review and network meta-analysis of randomized clinical trials

Background Achalasia is a primary motility disorder of the esophagus characterized by abnormal peristalsis and impaired lower esophageal sphincter relaxation. Multiple interventions are available to control the resultant symptoms of dysphagia, regurgitation, chest pain, and weight loss. There is a paucity of data regarding which treatment option provides the best outcome. Our objective was to perform a systematic review and meta-analysis of randomized clinical trials (RCTs) that have evaluated the clinical outcomes of Heller’s myotomy, pneumatic dilatation, peroral endoscopic myotomy (POEM), and botulinum toxin injections in the management of primary achalasia. Methods A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes guidelines. An electronic search of PubMed, Embase, and Cochrane databases was performed, yielding 7455 results, which were screened by 2 independent reviewers, followed by meta-analysis. Results Fifteen RCTs, comprising a total of 1170 patients, were included. Overall, botulinum toxin injections were associated with significantly lower treatment success at 1 year (odds ratio [OR], 0.10; 95% CI, 0.01–0.89). At 5 years, treatment success was significantly greater after Heller’s myotomy (OR, 6.39; 95% CI, 1.24–32.89) and POEM (OR, 6.33; 95% CI, 2.83–14.0). Pneumatic dilatation resulted in a significantly higher lower esophageal sphincter pressure (mean difference, 4.72; 95% CI, 1.13–8.31) and greater abnormal esophageal acid exposure (OR, 2.63; 95% CI, 1.25–5.56). Conclusion Heller's myotomy and POEM show comparable long-term efficacy, though POEM carries a higher, nonsignificant rate of esophagitis. Treatment selection should be individualized based on patient factors and local expertise, with further high-quality trials needed to guide optimal management. © 2026 Society for Surgery of the Alimentary Tract.