SNFGE SNFGE
 
Thématique :
- Endoscopie/Imagerie
Originalité :
Intermédiaire
Solidité :
Très solide
Doit faire évoluer notre pratique :
Dans certains cas
 
 
Nom du veilleur :
Professeur Emmanuel CORON
Coup de coeur :
 
 
Gut
  2016/05  
 
  2016 May;65(5):732-9  
  doi: 10.1136/gutjnl-2015-310602  
 
  Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy.  
 
  Moonen A, Annese V, Belmans A, Bredenoord AJ, Bruley des Varannes S, Costantini M, Dousset B, Elizalde JI, Fumagalli U, Gaudric M, Merla A, Smout AJ, Tack J, Zaninotto G, Busch OR, Boeckxstaens GE  
  http://www.ncbi.nlm.nih.gov/pubmed/?term=Long-term+results+of+the+European+achalasia+trial%3A+a+multicentre+randomised+controlled+trial+comparing+pneumatic+dilation+versus+laparoscopic+Heller+myotomy.  
 
 

OBJECTIVE:

Achalasia is a chronic motility disorder of the oesophagus for which laparoscopic Heller myotomy (LHM) and endoscopic pneumodilation (PD) are the most commonly used treatments. However, prospective data comparing their long-term efficacy is lacking.

DESIGN:

201 newly diagnosed patients with achalasia were randomly assigned to PD (n=96) or LHM (n=105). Before randomisation, symptoms were assessed using the Eckardt score, functional test were performed and quality of life was assessed. The primary outcome was therapeutic success (presence of Eckardt score ≤3) at the yearly follow-up assessment. The secondary outcomes included the need for re-treatment, lower oesophageal sphincter pressure, oesophageal emptying and the rate of complications.

RESULTS:

In the full analysis set, there was no significant difference in success rate between the two treatments with 84% and 82% success after 5 years for LHM and PD, respectively (p=0.92, log-rank test). Similar results were obtained in the per-protocol analysis (5-year success rates: 82% for LHM vs 91% for PD, p=0.08, log-rank test). After 5 years, no differences in secondary outcome parameter were observed. Redilation was performed in 24 (25%) of PD patients. Five oesophageal perforations occurred during PD (5%) while 12 mucosal tears (11%) occurred during LHM.

CONCLUSIONS:

After at least 5 years of follow-up, PD and LHM have a comparable success rate with no differences in oesophageal function and emptying. However, 25% of PD patients require redilation during follow-up. Based on these data, we conclude that either treatment can be proposed as initial treatment for achalasia.

TRIAL REGISTRATION NUMBERS:

Netherlands trial register (NTR37) and Current Controlled Trials registry (ISRCTN56304564).

 
Question posée
 
Le traitement de l’achalasie par myotomie de Heller est-il supérieur à la dilatation pneumatique à long terme ?
 
Question posée
 
Les résultats à 5 ans de cette étude randomisée, menée chez 208 patients naïfs de traitement, confirment que ces 2 modalités ont une efficacité similaire - de plus de 80% dans les 2 cas.
 
Commentaires

Ces données devront être comparées aux études en cours comparant la myotomie per-orale endoscopique (ou POEM) à la dilatation pneumatique et à la chirurgie.

 
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