Department of Surgery, Baystate Medical Center, University of Massachusetts Medical School, 759 Chestnut Street, Springfield, MA, 01199, USA.
Division of Gastroenterology, Department of Medicine, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA, USA.
Surg Endosc. 2019 Mar;33(3):886-894. doi: 10.1007/s00464-018-6356-0. Epub 2018 Jul 27.
High-resolution esophageal manometry (HREM) is essential in characterizing achalasia subtype and the extent of affected segment to plan the myotomy starting point during per-oral endoscopic myotomy (POEM). However, evidence is lacking that efficacy is improved by tailoring myotomy to the length of the spastic segment on HREM. We sought to investigate whether utilizing HREM to dictate myotomy length in POEM impacts postoperative outcomes.
Comparative analysis of HREM-tailored to non-tailored patients from a prospectively collected database of all POEMs at our institution January 2011 through July 2017. A tailored myotomy is defined as extending at least the length of the diseased segment, as initially measured on HREM.
Forty patients were included (11 tailored versus 29 non-tailored). There were no differences in patient age (p = 0.6491) or BMI (p = 0.0677). Myotomy lengths were significantly longer for tailored compared to non-tailored overall (16.6 ± 2.2 versus 13.5 ± 1.8; p < 0.0001), and for only type III achalasia (15.9 ± 2.4 versus 12.7 ± 1.2; p = 0.0453), likely due to more proximal starting position in tailored cases (26.0 ± 2.2 versus 30.0 ± 2.7; p < 0.0001). Procedure success (Eckardt < 3) was equivalent across groups overall (p = 0.5558), as was postoperative Eckardt score (0.2 ± 0.4 versus 0.8 ± 2.3; p = 0.4004). Postoperative Eckardt score was significantly improved in the tailored group versus non-tailored for type III only (0.2 ± 0.4 versus 1.3 ± 1.5; p = 0.0435). A linear correlation was seen between increased length and greater improvement in Eckardt score in the non-tailored group (p = 0.0170).
Using HREM to inform surgeons of the proximal location of the diseased segment resulted in longer myotomies, spanning the entire affected segment in type III achalasia, and in lower postoperative Eckardt scores. Longer myotomy length is often more easily achieved with POEM than with Heller myotomy, which raises the question of whether POEM results in better outcomes for type III achalasia, as types I and II do not generally have measurable spastic segments.
高分辨率食管测压（HREM）对于确定贲门失弛缓症的亚型以及受影响节段的范围至关重要，有助于在经口内镜肌切开术（POEM）中确定肌切开术的起始点。然而，尚无证据表明根据 HREM 确定的痉挛段长度来调整肌切开术可以提高疗效。我们旨在研究在 POEM 中利用 HREM 来确定肌切开术长度是否会影响术后结果。
对 2011 年 1 月至 2017 年 7 月在我院行 POEM 的所有患者前瞻性数据库中符合 HREM 定制或非定制患者的比较分析。定制的肌切开术是指在 HREM 上初始测量的病变段的至少长度。
共纳入 40 例患者（11 例定制组和 29 例非定制组）。两组患者的年龄（p=0.6491）或 BMI（p=0.0677）均无差异。与非定制组相比，定制组的肌切开术长度明显更长（16.6±2.2 与 13.5±1.8；p<0.0001），且仅在 III 型贲门失弛缓症中（15.9±2.4 与 12.7±1.2；p=0.0453），可能是由于定制组的起始位置更靠近近端（26.0±2.2 与 30.0±2.7；p<0.0001）。两组的整体手术成功率（Eckardt<3）相当（p=0.5558），术后 Eckardt 评分（0.2±0.4 与 0.8±2.3；p=0.4004）也相当。仅在 III 型贲门失弛缓症中，与非定制组相比，定制组的术后 Eckardt 评分明显改善（0.2±0.4 与 1.3±1.5；p=0.0435）。定制组中，肌切开术长度的增加与 Eckardt 评分的改善呈线性相关（p=0.0170）。
利用 HREM 向外科医生告知病变段的近端位置，可使肌切开术的长度更长，跨越 III 型贲门失弛缓症的整个受累节段，并降低术后 Eckardt 评分。与 Heller 肌切开术相比，POEM 通常更容易实现更长的肌切开术，这就提出了一个问题，即 POEM 是否会为 III 型贲门失弛缓症带来更好的结果，因为 I 型和 II 型通常没有可测量的痉挛段。
Zotero 插件