Aiolfi Alberto, Asti Emanuele, Bonitta Gianluca, Bonavina Luigi
Division of General Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, Piazza Edmondo Malan, 1, 20097, San Donato Milanese, MI, Italy.
World J Surg. 2018 May;42(5):1469-1476. doi: 10.1007/s00268-017-4298-7.
Indications for surgery and clinical outcomes of esophagectomy in the management of end-stage achalasia are not clearly defined. The aim of this systematic review and meta-analysis was to provide evidence-based information to help in the decision-making and in the choice of surgical technique.
An extensive literature search was conducted to identify all reports on esophagectomy for end-stage achalasia patients over the past three decades. MEDLINE, Embase and Cochrane databases were thoroughly consulted matching the terms "achalasia," "end-stage achalasia," "esophagectomy" and "esophageal resection" with "AND" and "OR." Short- and long-term outcome data were extracted. Pooled prevalence of pneumonia, anastomotic leakage and mortality were calculated using Freeman-Tukey double arcsine transformation and DerSimonian-Laird estimator in random effect meta-analysis. Heterogeneity among studies was evaluated using I -index and Cochrane Q test. Meta-regression was used to address the effect of potential confounders.
Eight papers published between 1989 and 2014 matched the inclusion criteria. In total, 1307 patients were included. Esophagectomy was performed through a transthoracic (78.7%) or a transhiatal (21.3%) approach. The stomach was used as an esophageal substitute in 95% of patients. Pooled prevalence of pneumonia, anastomotic leakage and mortality were 10% (95% CI 4-18%), 7% (95% CI 4-10%) and 2% (95% CI 1-3%), respectively.
Esophagectomy for end-stage achalasia is safe and effective. Based on the results of this study, esophagectomy should be performed without hesitation in patients who are fit for major surgery and present with disabling symptoms, poor quality of life and dolichomegaesophagus recalcitrant to multiple endoscopic dilatations and/or surgical myotomies.
在终末期贲门失弛缓症的治疗中，食管切除术的手术指征及临床疗效尚未明确界定。本系统评价和荟萃分析的目的是提供循证信息，以辅助决策及手术技术的选择。
进行广泛的文献检索，以识别过去三十年中所有关于终末期贲门失弛缓症患者食管切除术的报告。全面查阅MEDLINE、Embase和Cochrane数据库，将“贲门失弛缓症”“终末期贲门失弛缓症”“食管切除术”和“食管切除”等术语用“AND”和“OR”进行匹配。提取短期和长期结局数据。在随机效应荟萃分析中，使用Freeman-Tukey双反正弦变换和DerSimonian-Laird估计器计算肺炎、吻合口漏和死亡率的合并患病率。使用I指数和Cochrane Q检验评估研究间的异质性。采用Meta回归分析潜在混杂因素的影响。
1989年至2014年间发表的8篇论文符合纳入标准。共纳入1307例患者。食管切除术通过经胸（78.7%）或经腹（21.3%）入路进行。95%的患者使用胃作为食管替代物。肺炎、吻合口漏和死亡率的合并患病率分别为10%（95%CI 4-18%）、7%（95%CI 4-10%）和2%（95%CI 1-3%）。
终末期贲门失弛缓症的食管切除术安全有效。基于本研究结果，对于适合进行大手术、出现致残症状、生活质量差且经多次内镜扩张和/或手术肌切开术治疗无效的巨食管患者，应毫不犹豫地进行食管切除术。
