Providence Portland Cancer Center, Portland, OR 97213, USA.
JAMA Surg. 2013 Jan;148(1):85-90. doi: 10.1001/jamasurgery.2013.409.
To review transabdominal esophagocardiomyotomy (surgical treatment of achalasia) of the esophagus and to compare outcomes of partial anterior vs partial posterior fundoplication.
An electronic search was conducted among studies published between January 1976 and September 2011 using the keywords achalasia, myotomy, antireflux surgery, and fundoplication.
Prospective studies of transabdominal esophagocardiomyotomy were selected.
Outcomes selected were recurrent or persistent postoperative dysphagia and an abnormal 24-hour pH test result. Studies were divided into the following 3 groups: myotomy only, myotomy with anterior fundoplication, and myotomy with posterior fundoplication. Studies were weighted by the number of patients and by the follow-up duration. Event rates were calculated using meta-regression of the log-odds with the inverse variance method.
Thirty-nine studies with a total of 2998 patients were identified. The odds of postoperative dysphagia were 0.06 (95% CI, 0.03-0.12) for myotomy only, 0.11 (95% CI, 0.09-0.14) for myotomy with anterior fundoplication, and 0.06 (95% CI, 0.04-0.08) for myotomy with posterior fundoplication. The odds of a postoperative abnormal 24-hour pH test result were 0.37 (95% CI, 0.12-1.08) for myotomy only, 0.16 (95% CI, 0.11-0.24) for myotomy with anterior fundoplication, and 0.18 (95% CI, 0.13-0.25) for myotomy with posterior fundoplication. The increased odds of postoperative dysphagia in the group undergoing myotomy with anterior fundoplication compared with the group undergoing myotomy with posterior fundoplication were statistically significant (P < .001). However, the incidence of a postoperative abnormal 24-hour pH test result was statistically similar.
Partial posterior fundoplication when combined with an esophagocardiomyotomy may be associated with significantly lower reintervention rates for postoperative dysphagia, while providing similar reflux control compared with partial anterior fundoplication.
回顾经腹食管裂孔肌切开术（贲门失弛缓症的手术治疗），并比较部分前壁与部分后壁胃底折叠术的结果。
使用关键词“贲门失弛缓症、肌切开术、抗反流手术和胃底折叠术”，对 1976 年 1 月至 2011 年 9 月期间发表的研究进行了电子检索。
选择了经腹食管裂孔肌切开术的前瞻性研究。
选择的结果为术后复发性或持续性吞咽困难和异常 24 小时 pH 检测结果。研究分为以下 3 组：仅肌切开术、肌切开术加前壁胃底折叠术和肌切开术加后壁胃底折叠术。研究采用加权法，根据患者数量和随访时间对其进行加权。使用逆方差法的对数优势的荟萃回归计算事件率。
共确定了 39 项研究，共计 2998 例患者。仅肌切开术的术后吞咽困难的几率为 0.06（95%可信区间，0.03-0.12），肌切开术加前壁胃底折叠术的几率为 0.11（95%可信区间，0.09-0.14），肌切开术加后壁胃底折叠术的几率为 0.06（95%可信区间，0.04-0.08）。仅肌切开术的术后 24 小时 pH 检测异常的几率为 0.37（95%可信区间，0.12-1.08），肌切开术加前壁胃底折叠术的几率为 0.16（95%可信区间，0.11-0.24），肌切开术加后壁胃底折叠术的几率为 0.18（95%可信区间，0.13-0.25）。与后壁胃底折叠术相比，行前壁胃底折叠术的肌切开术组术后吞咽困难的几率增加具有统计学意义（P<0.001）。然而，术后 24 小时 pH 检测异常的发生率无统计学差异。
与部分前壁胃底折叠术相比，食管裂孔肌切开术联合部分后壁胃底折叠术可能与术后吞咽困难的再干预率显著降低相关，同时提供了类似的反流控制效果。
