Pneumatic Balloon Dilation versus Heller's Myotomy in Pediatric Achalasia: A Systematic Review and Meta-Analysis

The optimal surgical treatment for achalasia in children remains controversial. Pneumatic balloon dilation (PBD) and Heller's myotomy (HM) are the most commonly used interventions, but comparative evidence is limited and based mainly on small observational studies. This study aimed to compare clinical outcomes of PBD and HM in children with achalasia through a systematic review and meta-analysis. PubMed, EMBASE, and Cochrane were searched through June 2025. Comparative studies evaluating PBD and HM in patients younger than 18 years were included. Outcomes of interest included symptom recurrence, reoperation, gastroesophageal reflux disease (GERD), and complications. Random-effects models were used due to expected heterogeneity. Nine observational studies comprising 317 patients were included (PBD: 184; HM: 133). HM was associated with lower odds of reoperation (odds ratio [OR] = 11.01; 95% confidence interval [CI]: 6.01–20.17; p = 0.0001) and symptom recurrence (OR = 8.00; 95% CI: 1.65–38.75; p = 0.0098). PBD was associated with a lower risk of GERD (OR = 0.14; CI: 0.02–0.98; p = 0.0477). No significant differences were observed in perforation rates. All studies were retrospective cohorts with heterogeneous reporting of techniques and outcomes, and some analyses were based on a limited number of studies. HM was associated with lower recurrence and reoperation rates, while PBD showed a lower risk of GERD. However, evidence is limited by small observational studies, with heterogeneity in treatment techniques, outcome definitions, and follow-up durations. Results should be interpreted cautiously, and prospective multicenter studies are needed to determine the optimal treatment strategy.