Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA.
Department of Pediatric Surgery, MassGeneral Hospital for Children, Boston, MA, USA.
Surg Endosc. 2019 Oct;33(10):3355-3360. doi: 10.1007/s00464-018-06625-6. Epub 2018 Dec 14.
There is limited and conflicting data on the optimal intervention for the treatment of achalasia in adolescents and young adults (AYA), Heller myotomy (HM), esophageal dilation (ED) or botulinum toxin injection (botox). The goal of this study is to determine the most appropriate index intervention for achalasia in the AYA population.
We completed a longitudinal, population-based analysis of the California (2005-2010) and New York (1999-2014) statewide databases. We included patients 9-25 years old with achalasia who underwent HM, ED or botox. Comparisons were made based on the patients' index procedure. Rates of 30-day complications, long-term complications, and re-intervention up to 14 years were calculated. Cox regression was performed to determine the risk of re-intervention, adjusting for patient demographics.
A total of 442 AYAs were analyzed, representing the largest cohort of young patients with this disease studied to date. Median follow-up was 5.2 years (IQR 1.8-8.0). The overall rate of re-intervention was 29.3%. Rates of re-intervention for ED and botox were equivalent and higher than HM (65.0% for ED, 47.4% for botox and 16.4% for HM, p < 0.001). Ultimately, 46.9% of ED and botox patients underwent HM. The overall short-term complication rate was 4.3% and long-term, 1.9%. There was no difference in the short-term and long-term complication rates between intervention groups (p > 0.05). On adjusted analysis, ED and botox were associated with increased risks of re-intervention when compared to HM (HR 5.9, HR 4.8, respectively, p < 0.01). Black patients were found to have a risk of re-intervention twice that of white patients (HR 2.0, p = 0.05).
HM has a similar risk of complications but a significantly lower risk of re-intervention when compared to ED and botox. Based on our findings, we recommend HM as the optimal index procedure for AYAs with achalasia.
目前关于青少年和年轻成人（AYA）中贲门失弛缓症的最佳治疗干预措施，即 Heller 肌切开术（HM）、食管扩张术（ED）或肉毒杆菌毒素注射（botox），相关数据有限且存在争议。本研究旨在确定 AYA 人群中贲门失弛缓症最合适的介入治疗方法。
我们对加利福尼亚州（2005-2010 年）和纽约州（1999-2014 年）全州数据库进行了一项纵向、基于人群的分析。纳入年龄在 9-25 岁且接受 HM、ED 或 botox 治疗的贲门失弛缓症患者。根据患者的初始治疗方法进行比较。计算 30 天并发症、长期并发症和最长 14 年的再干预率。使用 Cox 回归确定再干预的风险，并对患者人口统计学因素进行调整。
共分析了 442 例 AYA，这是迄今为止研究该病年轻患者最大的队列。中位随访时间为 5.2 年（IQR 1.8-8.0）。总体再干预率为 29.3%。ED 和 botox 的再干预率相当且高于 HM（ED 为 65.0%，botox 为 47.4%，HM 为 16.4%，p<0.001）。最终，46.9%的 ED 和 botox 患者接受了 HM。总体短期并发症发生率为 4.3%，长期并发症发生率为 1.9%。干预组之间短期和长期并发症发生率无差异（p>0.05）。调整分析显示，与 HM 相比，ED 和 botox 与再干预风险增加相关（HR 5.9，HR 4.8，均 p<0.01）。与白人患者相比，黑人患者再干预风险是其两倍（HR 2.0，p=0.05）。
与 ED 和 botox 相比，HM 具有相似的并发症风险，但再干预风险显著降低。基于我们的研究结果，我们建议 HM 作为 AYA 贲门失弛缓症的最佳初始治疗方法。
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