Shiwaku Hironari, Inoue Haruhiro, Sasaki Takamitsu, Yamashita Kanefumi, Ohmiya Toshihiro, Takeno Shinsuke, Nimura Satoshi, Yamashita Yuichi
Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.
Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan.
Surg Endosc. 2016 Jun;30(6):2496-504. doi: 10.1007/s00464-015-4507-0. Epub 2015 Sep 28.
Peroral endoscopic myotomy (POEM) is an emerging, minimally invasive procedure capable of overcoming limitations of achalasia treatments, but gastroesophageal reflux disease (GERD) after POEM is of concern and its risk factors have not been evaluated. This prospective study examined GERD and the association of POEM with reflux esophagitis.
Achalasia patients were recruited from a single center. The pre- and postoperative assessments included Eckardt scores, manometry, endoscopy, and pH monitoring.
Between September 2011 and November 2014, 105 patients underwent POEM; 70 patients were followed up 3 months after POEM. Postoperatively, significant reductions were observed in lower esophageal sphincter (LES) pressure [from 40.0 ± 22.8 to 20.7 ± 14.0 mmHg (P < 0.05)], LES residual pressure [from 22.1 ± 13.3 to 11.4 ± 6.6 mmHg (P < 0.05)], and Eckardt scores [from 5.7 ± 2.5 to 0.7 ± 0.8 (P < 0.05)]. Symptomatic GERD and moderate reflux esophagitis developed in 5 and 11 patients (grade B, n = 8; grade C, n = 3), respectively, and were well controlled with proton pump inhibitors. Univariate logistic regression analysis revealed integrated relaxation pressure was a predictor of ≥grade B reflux esophagitis. No POEM factors were found to be associated with reflux esophagitis.
POEM is effective and safe in treating achalasia, with no occurrence of clinically significant refractory GERD. Myotomy during POEM, especially of the gastric side, was not associated with ≥grade B (requiring medical intervention) reflux esophagitis. Extended gastric myotomy (2-3 cm) during POEM is recommended to improve outcomes.
经口内镜下肌切开术（POEM）是一种新兴的微创手术，能够克服贲门失弛缓症治疗的局限性，但POEM术后的胃食管反流病（GERD）令人担忧，其危险因素尚未得到评估。这项前瞻性研究调查了GERD以及POEM与反流性食管炎的关联。
从单一中心招募贲门失弛缓症患者。术前和术后评估包括埃卡德特评分、测压、内镜检查和pH监测。
2011年9月至2014年11月，105例患者接受了POEM；70例患者在POEM术后3个月接受随访。术后，食管下括约肌（LES）压力[从40.0±22.8降至20.7±14.0 mmHg（P<0.05）]、LES残余压力[从22.1±13.3降至11.4±6.6 mmHg（P<0.05）]和埃卡德特评分[从5.7±2.5降至0.7±0.8（P<0.05）]均显著降低。分别有5例和11例患者出现有症状的GERD和中度反流性食管炎（B级，n = 8；C级，n = 3），使用质子泵抑制剂后得到良好控制。单因素逻辑回归分析显示综合松弛压力是≥B级反流性食管炎的预测因素。未发现POEM相关因素与反流性食管炎有关。
POEM治疗贲门失弛缓症有效且安全，未发生具有临床意义的难治性GERD。POEM术中的肌切开术，尤其是胃侧的肌切开术，与≥B级（需要药物干预）反流性食管炎无关。建议在POEM术中延长胃肌切开术（2 - 3 cm）以改善治疗效果。
