Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois.
Department of Surgery, Brigham and Women's Hospital and Boston VA Healthcare System, Harvard Medical School, Boston, Massachusetts, USA.
Br J Surg. 2019 Mar;106(4):332-341. doi: 10.1002/bjs.11049. Epub 2019 Jan 28.
The introduction of high-resolution manometry and the Chicago classification has made it possible to diagnose achalasia and predict treatment response accurately. The aim of this study was to compare the effect of the different treatments available on symptomatic outcomes across all achalasia subtypes.
The study was conducted according to PRISMA and MOOSE guidelines. A literature search of PubMed and MEDLINE databases was undertaken to identify all relevant articles reporting clinical outcomes of patients with achalasia after botulinum toxin injection, pneumatic dilatation, laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM) based on manometric subtypes. Patients were grouped according to the Chicago classification and the success rate in treating symptoms was measured as the primary endpoint.
Twenty studies (1575 patients) were selected, and data on botulinum toxin, pneumatic dilatation, LHM and POEM were extracted. Success rates for LHM in type I, II and III achalasia were 81, 92 and 71 per cent respectively. Those for POEM were 95, 97 and 93 per cent respectively. POEM was more likely to be successful than LHM for both type I (odds ratio (OR) 2·97, 95 per cent c.i. 1·09 to 8·03; P = 0·032) and type III (OR 3·50, 1·39 to 8·77; P = 0·007) achalasia. The likelihood of success of POEM and LHM for type II achalasia was similar.
Pneumatic dilatation had a lower but still acceptable success rate compared with POEM or LHM in patients with type II achalasia. POEM is an excellent treatment modality for type I and type III achalasia, although it did not show any superiority over LHM for type II achalasia.
高分辨率测压和芝加哥分类的引入使得能够准确诊断贲门失弛缓症并预测治疗反应。本研究的目的是比较所有贲门失弛缓症亚型中不同治疗方法对症状结果的影响。
本研究根据 PRISMA 和 MOOSE 指南进行。通过对 PubMed 和 MEDLINE 数据库进行文献检索，确定了所有报告基于测压亚型的贲门失弛缓症患者接受肉毒杆菌毒素注射、气囊扩张、腹腔镜 Heller 肌切开术（LHM）和经口内镜肌切开术（POEM）治疗后临床结局的相关文章。根据芝加哥分类将患者分组，以治疗症状的成功率作为主要终点来衡量。
共选择了 20 项研究（1575 例患者），并提取了肉毒杆菌毒素、气囊扩张、LHM 和 POEM 的数据。LHM 在 I 型、II 型和 III 型贲门失弛缓症中的成功率分别为 81%、92%和 71%。POEM 的成功率分别为 95%、97%和 93%。POEM 治疗 I 型（优势比（OR）2.97，95%置信区间（CI）1.09 至 8.03；P=0.032）和 III 型（OR 3.50，1.39 至 8.77；P=0.007）贲门失弛缓症的成功率均高于 LHM。POEM 和 LHM 治疗 II 型贲门失弛缓症的成功率相似。
与 POEM 或 LHM 相比，气囊扩张在 II 型贲门失弛缓症患者中成功率较低，但仍可接受。POEM 是 I 型和 III 型贲门失弛缓症的极佳治疗方法，尽管其在 II 型贲门失弛缓症中并未显示出优于 LHM 的优势。
