Department of Surgery and Center for Esophageal Diseases and Swallowing, University of North Carolina, Chapel Hill, NC.
Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC.
Ann Surg. 2018 Mar;267(3):451-460. doi: 10.1097/SLA.0000000000002311.
To compare the outcome of per oral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) for the treatment of esophageal achalasia.
Over the last 2 decades, LHM has become the primary form of treatment in many centers. However, since the first description of POEM in 2010, this technique has widely disseminated, despite the absence of long-term results and randomized trials.
A systematic Medline literature search of articles on LHM and POEM for the treatment of achalasia was performed. The main outcomes measured were improvement of dysphagia and posttreatment gastroesophageal reflux disease (GERD). Linear regression was used to model the effect of each procedure on the different outcomes.
Fifty-three studies reported data on LHM (5834 patients), and 21 articles examined POEM (1958 patients). Mean follow-up was significantly longer for studies of LHM (41.5 vs. 16.2 mo, P < 0.0001). Predicted probabilities for improvement in dysphagia at 12 months were 93.5% for POEM and 91.0% for LHM (P = 0.01), and at 24 months were 92.7% for POEM and 90.0% for LHM (P = 0.01). Patients undergoing POEM were more likely to develop GERD symptoms (OR 1.69, 95% CI 1.33-2.14, P < 0.0001), GERD evidenced by erosive esophagitis (OR 9.31, 95% CI 4.71-18.85, P < 0.0001), and GERD evidenced by pH monitoring (OR 4.30, 95% CI 2.96-6.27, P < 0.0001). On average, length of hospital stay was 1.03 days longer after POEM (P = 0.04).
Short-term results show that POEM is more effective than LHM in relieving dysphagia, but it is associated with a very high incidence of pathologic reflux.
比较经口内镜下肌切开术（POEM）和腹腔镜 Heller 肌切开术（LHM）治疗食管失弛缓症的效果。
在过去的 20 年中，LHM 已成为许多中心的主要治疗形式。然而，自 2010 年首次描述 POEM 以来，尽管缺乏长期结果和随机试验，该技术已经得到了广泛的传播。
对 LHM 和 POEM 治疗失弛缓症的文献进行了系统的 Medline 文献检索。主要观察指标为吞咽困难的改善和治疗后胃食管反流病（GERD）。线性回归用于对每种手术对不同结果的影响进行建模。
53 项研究报告了 LHM（5834 例患者）的数据，21 篇文章研究了 POEM（1958 例患者）。LHM 研究的平均随访时间明显长于 POEM（41.5 与 16.2 个月，P < 0.0001）。POEM 治疗 12 个月时吞咽困难改善的预测概率为 93.5%，LHM 为 91.0%（P = 0.01）；POEM 治疗 24 个月时吞咽困难改善的预测概率为 92.7%，LHM 为 90.0%（P = 0.01）。接受 POEM 治疗的患者更有可能出现 GERD 症状（OR 1.69，95%CI 1.33-2.14，P < 0.0001）、经侵蚀性食管炎证实的 GERD（OR 9.31，95%CI 4.71-18.85，P < 0.0001）和经 pH 监测证实的 GERD（OR 4.30，95%CI 2.96-6.27，P < 0.0001）。平均而言，POEM 后住院时间延长 1.03 天（P = 0.04）。
短期结果表明，POEM 在缓解吞咽困难方面比 LHM 更有效，但与很高的病理性反流发生率相关。
