Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
Endoscopy. 2017 Aug;49(8):736-744. doi: 10.1055/s-0043-113440. Epub 2017 Jun 28.
Peroral endoscopic myotomy (POEM) is now an established treatment for esophageal achalasia. The standard protocol ensures a smooth operation in most patients, but technical challenges and failures exist and little is known about the incidence, causes, and impact of aborted procedures. Here, using a large patient cohort, we attempted to answer these questions. All patients admitted for planned POEM between August 2010 and July 2015 underwent chart review. Aborted POEM was defined as the inability to finish the procedure after submucosal injection. The cause of the failure, clinical course, management, and follow-up data were analyzed. Thirteen of the 1693 POEMs (0.77 %) were aborted. Out of the 13 failures, 12 (92.3 %) were due to severe submucosal fibrosis, which precluded tunneling, and one (7.7 %) was due to atrial fibrillation related to the electric current of the endoscopic knife. Submucosal fibrosis, prior Heller myotomy, and age ( ≥ 60 years) were related to technical failure, while a disease duration of ≥ 6 years, sigmoid esophagus, mucosal edema, and prior interventions were risk factors for the presence of fibrotic changes. In turn, fibrosis was correlated with a prolonged operation, longer hospital stay, more mucosal injuries, and more major perioperative adverse events. Finally, the yearly frequency of aborted POEMs decreased after the second year as operators became more experienced. Aborted POEM is a rare event and is largely due to the presence of submucosal fibrosis, which not only causes increased procedural difficulties, but also gives rise to major adverse events.
经口内镜下肌切开术（POEM）现已成为治疗食管失弛缓症的一种既定疗法。标准方案可确保大多数患者的手术顺利进行，但仍存在技术挑战和失败的情况，而且对于手术失败的发生率、原因和影响知之甚少。在此，我们利用大样本患者队列来尝试解答这些问题。回顾了 2010 年 8 月至 2015 年 7 月期间所有因计划进行 POEM 而入院的患者的病历。将 POEM 术失败定义为黏膜下注射后无法完成手术。分析了失败的原因、临床过程、处理方法和随访数据。在 1693 例 POEM 中，有 13 例（0.77%）术失败。在这 13 例失败中，12 例（92.3%）是由于严重的黏膜下纤维化，妨碍了隧道的建立，1 例（7.7%）是由于与电刀电流相关的心房颤动。黏膜下纤维化、既往 Heller 肌切开术和年龄（≥60 岁）与技术失败有关，而疾病持续时间≥6 年、食管呈乙状结肠型、黏膜水肿和既往干预是纤维化改变存在的危险因素。反过来，纤维化与手术时间延长、住院时间延长、更多的黏膜损伤和更多的围手术期不良事件相关。最后，随着术者经验的增加，第二年以后术失败的 POEM 年发生率逐渐降低。术失败是一种罕见的情况，主要是由于黏膜下纤维化的存在，这不仅增加了手术的难度，还导致了严重的不良事件。
