Endoscopic Center and Endoscopic Research Institute, Zhongshan Hospital affiliated to Fudan University, Shanghai, China; Department of Medicine, Mount Sinai St. Luke's-West Hospital Center, New York, USA.
Division of Gastroenterology, Hepatology & Nutrition, NYU-Winthrop Hospital, Mineola, New York, USA.
Gastrointest Endosc. 2018 Apr;87(4):972-985. doi: 10.1016/j.gie.2017.10.039. Epub 2017 Nov 6.
Heller's myotomy (HM) is one of the most effective treatments for esophageal achalasia. However, failures do exist, and the success rate tends to decrease with time. The efficacy of rescue treatments for patients with failed HM is limited. A few small-scale studies have reported outcomes of per-oral endoscopic myotomy (POEM) in these patients. We conducted this study to systematically assess feasibility, safety, and efficacy of POEM on patients who have had HM.
Patients at least 3 months out from POEM were selected from our prospective database: 318 consecutive POEMs performed from October 2009 to October 2016. The efficacy and safety of POEM were compared between the 46 patients with prior HM and the remaining 272 patients.
Patients with prior HM had longer disease history, more advanced disease, more type I and less type II achalasia, lower before-POEM Eckardt scores, and lower before-POEM lower esophageal sphincter (LES) pressure (all P < .01). Procedure parameters and follow-up results (clinical success rate, Eckardt score, LES pressure, GERD score, esophagitis, and pH testing) showed no significant difference between the 2 groups. For the 46 HM-POEM patients, no clinically significant perioperative adverse events occurred. Their overall clinical success rate (Eckardt score ≤3 and no other treatment needed) was 95.7% at a median follow-up of 28 months.
POEM as a rescue treatment for patients with achalasia who failed HM is feasible, safe, and highly effective. It should be the treatment of choice in managing these challenging cases at centers with a high level of experience with POEM.
Heller 肌切开术（HM）是治疗食管失弛缓症最有效的方法之一。然而，仍存在失败的情况，且随着时间的推移，成功率趋于下降。对于 HM 失败的患者，挽救性治疗的效果有限。一些小规模的研究已经报道了这些患者行经口内镜肌切开术（POEM）的结果。我们进行这项研究是为了系统评估 POEM 治疗 HM 失败患者的可行性、安全性和疗效。
从我们的前瞻性数据库中选择 HM 术后至少 3 个月的患者：2009 年 10 月至 2016 年 10 月期间连续进行的 318 例 POEM。比较了 46 例 HM 后 POEM 患者与其余 272 例患者的疗效和安全性。
HM 后 POEM 患者的疾病史更长，疾病更严重，更常见的是Ⅰ型，较少为Ⅱ型，术前 Eckardt 评分和食管下括约肌（LES）压力更低（均 P<0.01）。两组的手术参数和随访结果（临床成功率、Eckardt 评分、LES 压力、GERD 评分、食管炎和 pH 值检测）无显著差异。46 例 HM-POEM 患者无明显围手术期不良事件。在中位随访 28 个月时，其总体临床成功率（Eckardt 评分≤3 分且无需其他治疗）为 95.7%。
POEM 作为 HM 失败的贲门失弛缓症患者的挽救性治疗方法是可行、安全且高度有效的。在具有丰富 POEM 经验的中心，它应该是治疗这些具有挑战性病例的首选方法。
