Is Dor fundoplication optimum after laparoscopic Heller myotomy for achalasia? A meta-analysis

Table 1 Checklist of quality assessment and scoring of non-random controlled studies

Checklist
Selection
Is the subject definition adequate or described? (if yes, one star)
Were the subjects representative of the total population? (one star, if truly or obviously; no stars if subjects were selected group or not described)
Comparability
Did the study have no differences between Dor fundoplication and no fundoplication or other types of fundoplication? Major factors for consideration were age, gender, symptoms, preoperative therapy (pneumatic dilation and botulin toxin injection), and preoperative diagnostic test (endoscopy parameter and barium swallow) (if yes, two stars; one star if there were no other differences between the two groups even if one or more of these five characteristics was not reported; no star was assigned if the two groups differed)
Outcome assessment
Clearly defined outcome of interest (if yes, one star)
Adequacy of follow-up (one star if less than 20% of achalasia patients lost to follow-up, otherwise no stars)

Table 2 Basic characteristics of all pooled studies in the meta-analysis (Dor-other/no group)

Ref.	Patients (n)		Follow-up (mean ± SD or range)		Age (mean ± SD or range)	Type offundoplication in control group	Study design	Country
	Dor group	Control group	Dor group	Control group
Di Martino et al[13], 2011	30	26	24	24	42.8 ± 14.7	Other1	Prospective	Italy
Oelschlager et al[15], 2003	52	58	46 (1-85)	16 (1-38)	42.6 ± 15.5	Other2	Retrospective	United States
Rawlings et al[17], 2012	36	24	12	12	48.8 ± 13.0	Other2	RCT	United States
Rebecchi et al[18], 2008	72	72	125 (60-168)	125 (60-168)	49 (11-80)	Other1	RCT	Italy
Richardson et al[20], 2006	18	20	37 (2-97)	37 (2-97)	69 (15-80)	Other2	Retrospective	United States
Wright et al[24], 2007	52	63	46 ± 24	45 ± 17	42.5 (15.4)	Other2	Retrospective	United States
Dempsey et al[12], 2004	22	29	39 ± 22	26 ± 19	47.5 (12.6)	No	Retrospective	United States
Finley et al[14], 2007	71	24	6.9 ± 3.5	6.9 ± 3.5	47.9 (16-84)	No	Retrospective	Canada
Ramacciato et al[16], 2005	17	15	12	12	42.0 (14-77)	No	Retrospective	Italy
Richards et al[19], 2004	22	21	6	6	50 ± 12.7	No	RCT	United States
Richardson et al[20], 2006	18	14	37 (2-97)	37 (2-97)	69 (15-80)	No	Retrospective	United States
Simić et al[21], 2010	36	22	36	36	49.6 ± 29.2	No	RCT	Serbia
Tapper et al[22], 2008	75	99	8.4 ± 12.0	48.7 ± 34.6	47.0 ± 16.8	No	Prospective	United States
Torquati et al[23], 2006	22	21	NA	NA	50 ± 12.7	No	RCT	United States

¹Other: Nissen fundoplication;

²Other: Toupet fundoplication. NA: Not available; RCT: Random controlled trail.

Table 3 Quality assessment of random controlled studies in the meta-analysis based on the Cochrane Handbook version 5.1.0

Ref.	Random sequence generation	Allocation concealment	Blinding of participants and personnel	Blinding of outcome assessment	Incomplete outcome data	Selective reporting	Other sources of bias
Rawlings et al[17], 2012	Low	Unclear	High	Low	Low	Low	Unclear
Rebecchi et al[18], 2008	Low	Low	High	Low	Low	Low	Unclear
Richards et al[19], 2004	Low	Low	Low	Low	Low	Low	Unclear
Simić et al[21], 2010	Low	Low	High	High	Unclear	low	Unclear
Torquati et al[23], 2006	Low	Low	Low	Low	Low	Low	Unclear

Table 4 Quality assessment of non-random controlled studies in the meta-analysis based on modified Newcastle-Ottawa Scale judgment

Ref.	Selection		Comparability	Outcome assessment		Quality judgment
	1	2	3	4	5
Dempsey et al[12], 2004	*	*	**	*	*	******
Di Martino et al[13], 2011	*	*	**	*	*	******
Finley et al[14], 2007	*	*	*	*	*	*****
Oelschlager et al[15], 2003	*	*	*	*	--	****
Ramacciato et al[16], 2005	*	*	*	*	*	*****
Richardson et al[20], 2006	*	*	**	*	--	*****
Tapper et al[22], 2008	*	--	*	*	*	****
Wright et al[24], 2007	*	*	*	*	--	****

Table 5 Pooled outcomes of random controlled studies and non-random controlled studies for postoperative physiological testing and operation-related data

	Studies (n)	Participants		Test of heterogeneity		MD (95%CI)	P value for effect size
		Dor group	Control group	I2	P value
LES pressure
Dor-other group	2	47	43	94%	< 0.0001	-1.02 (-9.90, 7.86)	0.821
Dor-no group	2	58	43	65%	0.09	1.97 (-0.93, 4.86)	0.182
DeMeester score
Dor-other group	2	40	39	48%	0.17	-7.13 (-18.37, 4.12)	0.212
Dor-no group	1	21	18	Not applicable		-25.00 (-58.40, 8.40)	0.14
Percent total time pH ≤ 4
Dor-other group	4	154	142	63%	0.05	0.96 (0.00, 1.91)	0.051
Dor-no group	1	21	18	Not applicable		-7.20 (-13.34, -1.06)	0.02
Surgery time
Dor-other group	3	138	122	14%	0.31	-5.37 (-7.71, -3.03)	< 0.000012
Dor-no group	2	39	36	0%	0.35	24.14 (7.21, 41.08)	0.0052
Hospital stay time
Dor-other group	4	171	176	94%	< 0.00001	0.10 (-0.59, 0.80)	0.771
Dor-no group	1	22	21	Not applicable		0.00 (-0.15, 0.15)	1.00

¹Random-effect model;

²Fixed-effect model. RCT: Random controlled trial.