经口内镜下肌切开术（POEM）与腹腔镜下Heller肌切开术（LHM）治疗贲门失弛缓症围手术期结果的系统评价和荟萃分析
Systematic Review and Meta-Analysis of Perioperative Outcomes of Peroral Endoscopic Myotomy (POEM) and Laparoscopic Heller Myotomy (LHM) for Achalasia.
作者信息
Awaiz Aiman, Yunus Rossita M, Khan Shahjahan, Memon Breda, Memon Muhammed A
机构信息
*Jinnah Sindh Medical University, Karachi, Pakistan †Institute of Mathematical Sciences, University of Malaya, Kuala Lumpur, Malaysia ‡School of Agricultural, Computing and Environmental Sciences, International Centre for Applied Climate Science, University of Southern Queensland, Toowoomba §Mayne Medical School, School of Medicine, University of Queensland, Brisbane ∥South East Queensland Surgery and Sunnybank Obesity Centre, Sunnybank ¶Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia #Faculty of Health and Social Science, Bolton University, Bolton, Lancashire, UK.
出版信息
Surg Laparosc Endosc Percutan Tech. 2017 Jun;27(3):123-131. doi: 10.1097/SLE.0000000000000402.
AIMS AND OBJECTIVES
Laparoscopic Heller myotomy (LHM) is the preferred surgical method for treating achalasia. However, peroral endoscopic myotomy (POEM) is providing good short-term results. The objective of this systematic review and meta-analysis was to compare the safety and efficacy of LHM and POEM.
MATERIALS AND METHODS
A search of PubMed, Cochrane database, Medline, Embase, Science Citation Index, and current contents for English-language articles comparing LHM and POEM between 2007 and 2016 was performed. Variables analyzed included prior endoscopic treatment, prior medical treatment, prior Heller myotomy, operative time, overall complications rate, postoperative gastroesophageal reflux disease (GERD), length of hospital stay, postoperative pain score, and long-term GERD.
RESULTS
Seven trials consisting of 483 (LHM=250, POEM=233) patients were analyzed. Preoperative variables, for example, prior endoscopic treatment [odds ratio (OR), 1.32; 95% confidence interval (CI), 0.23-4.61; P=0.96], prior medical treatment [weighted mean difference (WMD), 1.22; 95% CI, 0.52-2.88; P=0.65], and prior Heller myotomy (WMD, 0.47; 95% CI, 0.13-1.67; P=0.25) were comparable. Operative time was 26.28 minutes, nonsignificantly longer for LHM (WMD, 26.28; 95% CI, -11.20 to 63.70; P=0.17). There was a comparable overall complication rate (OR, 1.25; 95% CI, 0.56-2.77; P=0.59), postoperative GERD rate (OR, 1.27; 95% CI, 0.70-2.30; P=0.44), length of hospital stay (WMD, 0.30; 95% CI, -0.24 to 0.85; P=0.28), postoperative pain score (WMD, -0.26; 95% CI, -1.58 to 1.06; P=0.70), and long-term GERD (WMD, 1.06; 95% CI, 0.27-4.1; P=0.08) for both procedures. There was a significantly higher short-term clinical treatment failure rate for LHM (OR, 9.82; 95% CI, 2.06-46.80; P<0.01).
CONCLUSIONS
POEM compares favorably to LHM for achalasia treatment in short-term perioperative outcomes. However, there was a significantly higher clinical treatment failure rate for LHM on short-term postoperative follow-up. Presently long-term postoperative follow-up data for POEM beyond 1 year are unavailable and eagerly awaited.
目的和目标
腹腔镜贲门肌切开术（LHM）是治疗贲门失弛缓症的首选手术方法。然而，经口内镜下肌切开术（POEM）也取得了良好的短期效果。本系统评价和荟萃分析的目的是比较LHM和POEM的安全性和有效性。
材料和方法
检索了PubMed、Cochrane数据库、Medline、Embase、科学引文索引和近期目次，以查找2007年至2016年间比较LHM和POEM的英文文章。分析的变量包括既往内镜治疗、既往药物治疗、既往贲门肌切开术、手术时间、总体并发症发生率、术后胃食管反流病（GERD）、住院时间、术后疼痛评分和长期GERD。
结果
分析了7项试验，共483例患者（LHM组250例，POEM组233例）。术前变量，如既往内镜治疗[比值比（OR），1.32；95%置信区间（CI），0.23 - 4.61；P = 0.96]、既往药物治疗[加权均数差（WMD），1.22；95% CI，0.52 - 2.88；P = 0.65]和既往贲门肌切开术（WMD，0.47；95% CI，0.13 - 1.67；P = 0.25）具有可比性。手术时间为26.28分钟，LHM组手术时间稍长，但差异无统计学意义（WMD，26.28；95% CI， - 11.20至63.70；P = 0.17）。两种手术的总体并发症发生率（OR，1.25；95% CI，0.56 - 2.77；P = 0.59）、术后GERD发生率（OR，1.27；95% CI，0.70 - 2.30；P = 0.44）、住院时间（WMD，0.30；95% CI， - 0.24至0.85；P = 0.28）、术后疼痛评分（WMD， - 0.26；95% CI， - 1.58至1.06；P = 0.70）和长期GERD（WMD，1.06；95% CI，0.27 - 4.1；P = 0.08）具有可比性。LHM组短期临床治疗失败率显著更高（OR，9.82；95% CI，2.06 - 46.80；P < 0.01）。
结论
在短期围手术期结果方面，POEM与LHM相比，在治疗贲门失弛缓症方面具有优势。然而，LHM术后短期随访的临床治疗失败率显著更高。目前，POEM超过1年的长期术后随访数据尚未获得，亟待获取。
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