Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
Gastrointest Endosc. 2019 Apr;89(4):769-778. doi: 10.1016/j.gie.2018.09.003. Epub 2018 Sep 13.
Mucosal injury (MI) is one of the most common perioperative adverse events of per-oral endoscopic myotomy (POEM). Severe undertreated MI may lead to contamination of the tunnel and even mediastinitis. This study explored the characteristics, predictors, and management approaches of intraoperative MI.
A retrospective review of the prospectively collected database at a large tertiary referral endoscopy unit was conducted for all patients undergoing POEM between August 2010 and March 2016. MI was graded according to the difficulty of repair (I, easy to repair; II, difficult to repair). The primary outcomes were the incidence and predictors of intraoperative MI. Secondary outcomes were MI details and the corresponding treatment.
POEM was successfully performed in 1912 patients. A total of 338 patients experienced 387 MIs, for an overall frequency of 17.7% (338/1912). Type II MI was rare, with a frequency of 1.7% (39/1912). Major adverse events were more common in patients with MI than in those without MI (6.2% vs 2.5%, P < .001). On multivariable analysis, MI was independently associated with previous Heller myotomy (odds ratio [OR], 2.094; P = .026), previous POEM (OR, 2.441; P = .033), submucosal fibrosis (OR, 4.530; P < .001), mucosal edema (OR, 1.834; P = .001), and tunnel length ≥13 cm (OR, 2.699; P < .001). Previous POEM (OR, 5.005; P = .030) and submucosal fibrosis (OR, 12.074; P < .001) were significant predictors of type II MI. POEM experience >1 year was a protective factor for MI (OR, .614; P = .042) and type II MI (OR, .297; P = .042).
MI during POEM is common, but type II injury is rare. Previous POEM and submucosal fibrosis were significant predictors of type II mucosal injury. POEM experience after the learning curve reduces the risk of MI.
黏膜损伤（MI）是经口内镜肌切开术（POEM）围手术期最常见的不良事件之一。严重治疗不足的 MI 可能导致隧道污染，甚至纵隔炎。本研究探讨了术中 MI 的特征、预测因素和处理方法。
对 2010 年 8 月至 2016 年 3 月在一家大型三级转诊内镜中心行 POEM 的所有患者的前瞻性数据库进行回顾性分析。根据修复难度对 MI 进行分级（I 级，容易修复；II 级，难以修复）。主要结局是术中 MI 的发生率和预测因素。次要结局是 MI 的详细情况和相应的治疗方法。
POEM 成功完成于 1912 例患者。共有 338 例患者发生 387 例 MI，总体发生率为 17.7%（338/1912）。II 型 MI 罕见，发生率为 1.7%（39/1912）。MI 患者的主要不良事件发生率高于无 MI 患者（6.2% vs 2.5%，P<.001）。多变量分析显示，MI 与既往 Heller 肌切开术（比值比 [OR]，2.094；P=.026）、既往 POEM（OR，2.441；P=.033）、黏膜下纤维化（OR，4.530；P<.001）、黏膜水肿（OR，1.834；P=.001）和隧道长度≥13 cm（OR，2.699；P<.001）有关。既往 POEM（OR，5.005；P=.030）和黏膜下纤维化（OR，12.074；P<.001）是 II 型 MI 的显著预测因素。POEM 经验>1 年是 MI（OR，.614；P=.042）和 II 型 MI（OR，.297；P=.042）的保护因素。
POEM 术中 MI 很常见，但 II 型损伤很少见。既往 POEM 和黏膜下纤维化是 II 型黏膜损伤的显著预测因素。学习曲线后的 POEM 经验可降低 MI 的风险。
