Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Tokyo, Japan;Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal. University of Alcala. Instituto Ramón y Cajal de Investigación Sanitaria, Madrid,
Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Tokyo, Japan;Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.
J Gastrointestin Liver Dis. 2019 Mar;28(1):107-115. doi: 10.15403/jgld.2014.1121.281.pom.
The optimal orientation of the myotomy during peroral endoscopic myotomy (POEM) is unknown. This meta-analysis aims to compare anterior and posterior myotomy regarding clinical success and safety.
PubMed, Embase, Cochrane Library, WOK, and clinicaltrials.gov were searched to identify randomized clinical trials (RCTs) comparing anterior and posterior myotomy during POEM for the treatment of achalasia. The primary outcome was clinical success. Secondary outcomes included postprocedural gastroesophageal reflux disease (GERD), adverse events (AEs), manometric findings, and procedure-related parameters. Random-effects models were used for the primary analysis.
Four RCTs enrolling 488 patients were included. Overall clinical success 3-12 months after POEM was 97% (95% confidence interval [CI] 93-100%) and did not differ between anterior and posterior myotomy (Relative risk [RR] 0.98, 95%CI: 0.96-1.01; I2: 0%). Incidence of GERD after POEM based on 24-hour pH monitoring (RR 0.98, 95%CI: 0.75-1.28), endoscopy (RR 1.04, 95%CI: 0.78-1.38), and symptoms (RR 0.89, 95%CI: 0.55-1.42) was similar. Posterior myotomy was associated with fewer AEs (RR 0.63, 95%CI: 0.42-0.94), lower risk of mucosotomy (RR 0.42, 95%CI: 0.27-0.66) and shorter incision closure time (mean difference: -2.28 minutes, 95%CI: -3.46 to -1.10). Anterior myotomy was associated with a shorter length of hospitalization (mean difference: 0.31 days, 95%CI: 0.05-0.57), although the clinical relevance of this finding is negligible. No significant differences were found regarding manometric outcomes, total operation and myotomy time.
Anterior and posterior myotomy are equally effective for the treatment of achalasia, without significant differences in postprocedural GERD. Posterior POEM was associated with fewer AEs and a shorter incision closure time.
经口内镜下肌切开术（POEM）中肌切开的最佳方向尚不清楚。本荟萃分析旨在比较前入路和后入路肌切开术在治疗贲门失弛缓症方面的临床疗效和安全性。
检索PubMed、Embase、Cochrane 图书馆、WOK 和 clinicaltrials.gov，以确定比较 POEM 期间前入路和后入路肌切开术治疗贲门失弛缓症的随机临床试验（RCT）。主要结局是临床成功率。次要结局包括术后胃食管反流病（GERD）、不良事件（AEs）、测压结果和与手术相关的参数。主要分析采用随机效应模型。
纳入了 4 项 RCT 共 488 例患者。POEM 后 3-12 个月的总体临床成功率为 97%（95%置信区间[CI] 93-100%），前入路和后入路肌切开术之间无差异（相对风险[RR] 0.98，95%CI：0.96-1.01；I2：0%）。基于 24 小时 pH 监测（RR 0.98，95%CI：0.75-1.28）、内镜（RR 1.04，95%CI：0.78-1.38）和症状（RR 0.89，95%CI：0.55-1.42）的 POEM 后 GERD 发生率相似。后入路肌切开术相关不良事件（RR 0.63，95%CI：0.42-0.94）、黏膜切开（RR 0.42，95%CI：0.27-0.66）和切口闭合时间（平均差值：-2.28 分钟，95%CI：-3.46 至-1.10）较少。前入路肌切开术与较短的住院时间（平均差值：0.31 天，95%CI：0.05-0.57）相关，尽管这一发现的临床相关性可以忽略不计。在测压结果、总手术和肌切开时间方面无显著差异。
前入路和后入路肌切开术治疗贲门失弛缓症同样有效，术后胃食管反流病无显著差异。后入路 POEM 相关不良事件较少，切口闭合时间较短。
