Esophageal Institute, Hospital Universitario Fundacion Favaloro, Av. Beolgrano 1746, Buenos Aires, Argentina.
Surg Endosc. 2018 Jan;32(1):282-288. doi: 10.1007/s00464-017-5675-x. Epub 2017 Jun 28.
To report our experience in POEM vs. LHM, with particular focus on myotomy extension.
POEM has been adopted worldwide as a treatment for achalasia. While resolution of dysphagia is above 90%, postoperative reflux ranges from 10 to 57%. Myotomy length has been a controversial topic.
Thirty-five cases of POEM were prospectively analyzed and compared retrospectively to the last 35 patients that underwent LHM, from December 2010 to August 2016. Mean follow-up was 10 months (6/32) for POEM and 20 months (6/68) for LHM. All patients with LHM had a myotomy extension ≥3 cm on the gastric side. In POEM cases, extension was defined by direct vision (Hill type II) and never exceeded 2 cm.
Follow-up was completed in 100% of patients. Efficacy (ES ≤ 3) was 33/35 (94.2%) for POEM and 32/35 (91.4%) for LHM in a short-term follow-up (p = 1.000) and 31/35 (88.6%) and 27/35 (77.1%), respectively, in a long-term follow-up (p = 1.000), with average ES drop from 9 to 1.2 (p = 0.0001) in POEM vs. 9.2 to 1.3 (p = 0.0001) in LHM. Major Postoperative complications occurred in 1 patient (leak) for LHM and 1 patient (massive capnothorax) in POEM. Hospital stay was shorter for POEM than for LHM (1.3 vs. 2.1, respectively) (p = 0.0001). Symptomatic reflux cases included 7/35 POEM (20%) vs. 6/35 LHM (17.1%) (p = 0.4620). Esophagitis signs in endoscopy appeared in 1/21 POEM (4.7%) vs. 1/22 LHM (4.5%) (p = 1.000). Patients requiring PPI included 8/35 POEM (22.8%) vs. 7/35 LHM (20%) (p = 0.6642). Further treatment (endoscopic dilation) was performed in 10/35 POEM (28.5%) vs. 8/35 LHM (22.8%).
A shorter myotomy on the gastric side in POEM may contribute to an acceptable reflux rate with comparable relief of dysphagia. Although our follow-up for POEM is shorter than for LHM, the trends are promising and warrant future prospective studies to address this topic.
报告我们在 POEM 与 LHM 方面的经验，尤其关注肌切开术的延伸。
POEM 已在全球范围内被采用为治疗贲门失弛缓症的方法。尽管吞咽困难的缓解率超过 90%，但术后反流的发生率为 10%至 57%。肌切开术的长度一直是一个有争议的话题。
前瞻性分析了 35 例 POEM 病例，并回顾性比较了 2010 年 12 月至 2016 年 8 月期间最后 35 例接受 LHM 的患者。POEM 的平均随访时间为 10 个月（6/32），LHM 为 20 个月（6/68）。所有接受 LHM 的患者在胃侧的肌切开术延伸长度均≥3cm。在 POEM 病例中，延伸通过直接观察（Hill Ⅱ型）定义，且从未超过 2cm。
100%的患者完成了随访。在短期随访中，POEM 的疗效（ES≤3）为 33/35（94.2%），LHM 为 32/35（91.4%）（p=1.000），在长期随访中，POEM 为 31/35（88.6%），LHM 为 27/35（77.1%）（p=1.000），POEM 组的 ES 从 9 降至 1.2（p=0.0001），而 LHM 组从 9.2 降至 1.3（p=0.0001）。LHM 组有 1 例（漏）和 POEM 组有 1 例（大量气胸）发生主要术后并发症。POEM 的住院时间短于 LHM（分别为 1.3 和 2.1）（p=0.0001）。POEM 组有 7/35（20%）和 LHM 组有 6/35（17.1%）出现症状性反流（p=0.4620）。内镜下食管炎征象出现在 1/21 POEM（4.7%）和 1/22 LHM（4.5%）（p=1.000）。需要质子泵抑制剂治疗的患者包括 POEM 组 8/35（22.8%）和 LHM 组 7/35（20%）（p=0.6642）。POEM 组中有 10/35（28.5%）需要进一步治疗（内镜扩张），而 LHM 组中有 8/35（22.8%）。
POEM 胃侧的肌切开术较短可能有助于获得可接受的反流率，并具有相当的吞咽困难缓解率。尽管我们对 POEM 的随访时间短于 LHM，但趋势是有希望的，需要未来的前瞻性研究来解决这个问题。
