Sanaka Madhusudhan R, Hayat Umar, Thota Prashanthi N, Jegadeesan Ramprasad, Ray Monica, Gabbard Scott L, Wadhwa Neha, Lopez Rocio, Baker Mark E, Murthy Sudish, Raja Siva
Madhusudhan R Sanaka, Umar Hayat, Prashanthi N Thota, Ramprasad Jegadeesan, Monica Ray, Scott L Gabbard, Neha Wadhwa, Rocio Lopez, Department of Gastroenterology, Q3 Cleveland Clinic, Cleveland, OH 44195, United States.
World J Gastroenterol. 2016 May 28;22(20):4918-25. doi: 10.3748/wjg.v22.i20.4918.
To assess and compare the esophageal function after peroral endoscopic myotomy (POEM) vs other conventional treatments in achalasia.
Chart review of all achalasia patients who underwent POEM, laparoscopic Heller myotomy (LHM) or pneumatic dilation (PD) at our institution between January 2012 and March 2015 was performed. Patient demographics, type of achalasia, prior treatments, pre- and post-treatment timed barium swallow (TBE) and high-resolution esophageal manometry (HREM) findings were compared between the three treatment groups. Patients who had both pre- and 2 mo post-treatment TBE or HREM were included in the final analysis. TBE parameters compared were barium column height, width and volume of barium remaining at 1 and 5 min. HREM parameters compared were basal lower esophageal sphincter (LES) pressures and LES-integrated relaxation pressures (IRP). Data are presented as mean ± SD, median [25(th), 75(th) percentiles] or frequency (percent). Analysis of variance, Kruskal-Wallis test, Pearsons χ(2) test and Fishers Exact tests were used for analysis.
A total of 200 achalasia patients were included of which 36 underwent POEM, 22 underwent PD and 142 underwent LHM. POEM patients were older (55.4 ± 16.8 years vs 46.5 ± 15.7 years, P = 0.013) and had higher BMI than LHM (29.1 ± 5.9 kg/m(2) vs 26 ± 5.1 kg/m(2), P = 0.012). More number of patients in POEM and PD groups had undergone prior treatments compared to LHM group (72.2% vs 68.2% vs 44.3% respectively, P = 0.003). At 2 mo post-treatment, all TBE parameters including barium column height, width and volume remaining at 1 and 5 min improved significantly in all three treatment groups (P = 0.01 to P < 0.001) except the column height at 1 min in PD group (P = 0.11) . At 2 mo post-treatment, there was significant improvement in basal LES pressure and LES-IRP in both LHM (40.5 mmHg vs 14.5 mmHg and 24 mmHg vs 7.1 mmHg respectively, P < 0.001) and POEM groups (38.7 mmHg vs 11.4 mmHg and 23.6 mmHg vs 6.6 mmHg respectively, P < 0.001). However, when the efficacy of three treatments were compared to each other in terms of improvement in TBE or HREM parameters at 2 mo, there was no significant difference (P > 0.05).
POEM, PD and LHM were all effective in improving esophageal function in achalasia at short-term. There was no difference in efficacy between the three treatments.
评估并比较经口内镜下肌切开术（POEM）与贲门失弛缓症其他传统治疗方法后的食管功能。
对2012年1月至2015年3月期间在本机构接受POEM、腹腔镜下Heller肌切开术（LHM）或气囊扩张术（PD）的所有贲门失弛缓症患者进行病历回顾。比较三个治疗组患者的人口统计学资料、贲门失弛缓症类型、既往治疗情况、治疗前后的定时钡餐吞咽造影（TBE）和高分辨率食管测压（HREM）结果。最终分析纳入治疗前和治疗后2个月均进行了TBE或HREM检查的患者。比较的TBE参数包括钡柱高度、宽度以及1分钟和5分钟时残留钡剂的体积。比较的HREM参数包括基础下食管括约肌（LES）压力和LES综合松弛压力（IRP）。数据以均数±标准差、中位数[第25(th)，第75(th)百分位数]或频数（百分比）表示。采用方差分析、Kruskal-Wallis检验、Pearson χ(2)检验和Fisher精确检验进行分析。
共纳入200例贲门失弛缓症患者，其中36例行POEM，22例行PD，142例行LHM。POEM组患者年龄较大（55.4±16.8岁 vs 46.5±15.7岁，P = 0.013），且BMI高于LHM组（29.1±5.9 kg/m(2) vs 26±5.1 kg/m(2)，P = 0.012）。与LHM组相比，POEM组和PD组中接受过既往治疗的患者更多（分别为72.2% vs 68.2% vs 44.3%，P = 0.003）。治疗后2个月，除PD组1分钟时的钡柱高度（P = 0.11）外，所有三个治疗组的所有TBE参数，包括1分钟和5分钟时的钡柱高度、宽度和残留体积均有显著改善（P = 0.01至P < 0.001）。治疗后2个月，LHM组（基础LES压力分别为40.5 mmHg vs 14.5 mmHg，LES-IRP分别为24 mmHg vs 7.1 mmHg，P < 0.001）和POEM组（基础LES压力分别为38.7 mmHg vs 11.4 mmHg，LES-IRP分别为23.6 mmHg vs 6.6 mmHg，P < 0.001）的基础LES压力和LES-IRP均有显著改善。然而，在比较三种治疗方法在治疗后2个月时TBE或HREM参数改善方面的疗效时，差异无统计学意义（P > 0.05）。
POEM、PD和LHM在短期内均能有效改善贲门失弛缓症患者的食管功能。三种治疗方法的疗效无差异。
