Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA.
Division of Gastroenterology, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
Eur J Cardiothorac Surg. 2017 Oct 1;52(4):686-691. doi: 10.1093/ejcts/ezx144.
The standard of care for achalasia remains laparoscopic Heller myotomy with partial fundoplication. Peroral endoscopic myotomy (POEM) has been introduced as an alternative, but safety and long-term comparative efficacy are not yet established. We report our experience in developing a POEM program using a novel hybrid approach.
We developed a hybrid approach to POEM with a POEM followed by laparoscopic evaluation, extension of the myotomy, if necessary, and partial fundoplication. We reviewed the results of the programme from April 2012 until May 2015. Starting in 2014, we began offering patients stand-alone POEM. Patient data were collected. Preoperative and postoperative Eckardt scores were compared.
A total of 28 patients underwent POEM or POEM plus laparoscopic evaluation with partial fundoplication. Patient characteristics and perioperative and postoperative data were recorded. The median preoperative Eckardt score was 6 (range 4-11). The mean follow-up period was 136 days (range 41-330) and the median postoperative Eckardt score was 0 (range 0-6) at 6 weeks. Of our initial 10 patients, 6 required laparoscopic extension of the myotomy; 7 subsequent patients did not require an additional myotomy. Three patients who underwent POEM without laparoscopy continued to have dysphagia postoperatively. One patient had an attempted POEM that was aborted secondary to bleeding, and a standard laparoscopic modified Heller myotomy with partial fundoplication was performed.
The excellent results of laparoscopic myotomy with partial fundoplication are challenging to duplicate during the initial adoption of a POEM approach. We present a program developed to steepen the learning curve and enhance patient safety while implementing this new procedure.
贲门失弛缓症的标准治疗仍是腹腔镜 Heller 肌切开术加部分胃底折叠术。经口内镜肌切开术（POEM）已被引入作为一种替代方法，但安全性和长期疗效尚不确定。我们报告了使用新型混合方法开发 POEM 计划的经验。
我们开发了一种 POEM 混合方法，首先进行 POEM，然后进行腹腔镜评估，如果需要，还可以进行肌切开术延伸，并进行部分胃底折叠术。我们回顾了 2012 年 4 月至 2015 年 5 月期间该项目的结果。从 2014 年开始，我们开始为患者提供单独的 POEM。收集患者数据。比较术前和术后 Eckardt 评分。
共有 28 例患者接受了 POEM 或 POEM 加腹腔镜评估加部分胃底折叠术。记录了患者特征、围手术期和术后数据。术前 Eckardt 评分中位数为 6（范围 4-11）。平均随访时间为 136 天（范围 41-330），术后 6 周 Eckardt 评分中位数为 0（范围 0-6）。在最初的 10 例患者中，有 6 例需要腹腔镜下肌切开术延伸；随后的 7 例患者不需要进一步的肌切开术。3 例未经腹腔镜检查的患者在 POEM 后仍有吞咽困难。1 例患者因出血而中止 POEM 尝试，随后行标准腹腔镜改良 Heller 肌切开术加部分胃底折叠术。
腹腔镜肌切开术加部分胃底折叠术的优异效果在最初采用 POEM 方法时很难复制。我们提出了一个旨在加深学习曲线并提高患者安全性的方案，同时实施这一新程序。
