Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Humanitas University, Rozzano (MI), Italy.
Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, Bologna, Italy.
Gastrointest Endosc. 2018 Apr;87(4):934-943.e18. doi: 10.1016/j.gie.2017.10.022. Epub 2017 Nov 2.
Per-oral endoscopic myotomy (POEM) represents a less invasive alternative to conventional laparoscopic Heller's myotomy (LHM) for patients with achalasia. It cannot be excluded, however, that the lack of fundoplication after POEM may result in a higher incidence of reflux disease, as compared with LHM. The aim of our study was to conduct a systematic review of prospective studies reporting the incidence of reflux disease developed after POEM and LHM.
A literature search with electronic databases was performed (up to February 2017) to identify full articles on the incidence of gastroesophageal reflux symptoms and endoscopic monitoring and pH monitoring findings after POEM and LHM (with fundoplication). Proportions and rates were pooled by means of random or fixed-effects models, according to the level of heterogeneity between studies.
After we applied the selection criteria, 17 and 28 studies, including 1542 and 2581 participants who underwent POEM and LHM, respectively, were included. The pooled rate of postprocedural symptoms was 19.0% (95% confidence interval [CI], 15.7%-22.8%) after POEM and 8.8% (95% CI, 5.3%-14.1%) after LHM, respectively. The pooled rate estimate of abnormal acid exposure at pH monitoring was 39.0% (95% CI, 24.5%-55.8%) after POEM and 16.8% (95% CI, 10.2%-26.4%) after LHM, respectively. The rate of esophagitis after POEM was 29.4% (95% CI, 18.5%-43.3%) after POEM and 7.6% (95% CI, 4.1%-13.7%) after LHM. At meta-regression, heterogeneity was explained partly by the POEM approach and study population.
The incidence of reflux disease appears to be significantly more frequent after POEM than after LHM with fundoplication. Monitoring pH and ensuring appropriate treatment after POEM should be considered in order to prevent long-term reflux-related adverse events.
经口内镜下肌切开术（POEM）代表了一种比传统腹腔镜 Heller 肌切开术（LHM）更具侵入性的选择，适用于贲门失弛缓症患者。然而，不能排除 POEM 后缺乏胃底折叠术可能会导致反流性疾病的发生率高于 LHM。本研究的目的是对报告 POEM 和 LHM（带胃底折叠术）后发生反流性疾病的前瞻性研究进行系统评价。
进行了电子数据库文献检索（截至 2017 年 2 月），以确定关于 POEM 和 LHM（带胃底折叠术）后胃食管反流症状发生率以及内镜监测和 pH 监测结果的全文文章。根据研究之间的异质性水平，采用随机或固定效应模型汇总比例和发生率。
应用选择标准后，纳入了 17 项和 28 项研究，分别包括 1542 名和 2581 名接受 POEM 和 LHM 治疗的患者。POEM 后术后症状的累积发生率为 19.0%（95%置信区间[CI]，15.7%-22.8%），LHM 后为 8.8%（95% CI，5.3%-14.1%）。POEM 后 pH 监测异常酸暴露的累积发生率估计为 39.0%（95% CI，24.5%-55.8%），LHM 后为 16.8%（95% CI，10.2%-26.4%）。POEM 后食管炎的发生率为 29.4%（95% CI，18.5%-43.3%），LHM 后为 7.6%（95% CI，4.1%-13.7%）。在荟萃回归中，异质性部分由 POEM 方法和研究人群解释。
与带胃底折叠术的 LHM 相比，POEM 后反流性疾病的发生率明显更高。为了预防长期与反流相关的不良事件，应考虑在 POEM 后监测 pH 值并确保进行适当的治疗。
