经口内镜肌切开术与腹腔镜 Heller 肌切开术相比，胃延长长度重要吗？
Per oral endoscopic myotomy vs. laparoscopic Heller myotomy, does gastric extension length matter?
机构信息
Esophageal Institute, Hospital Universitario Fundacion Favaloro, Av. Beolgrano 1746, Buenos Aires, Argentina.
出版信息
Surg Endosc. 2018 Jan;32(1):282-288. doi: 10.1007/s00464-017-5675-x. Epub 2017 Jun 28.
OBJECTIVE
To report our experience in POEM vs. LHM, with particular focus on myotomy extension.
BACKGROUND
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.
METHODS
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.
RESULTS
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%).
CONCLUSIONS
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.
目的
报告我们在 POEM 与 LHM 方面的经验，尤其关注肌切开术的延伸。
背景
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。
方法
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。
结果
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%）。
结论
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。
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