Aiolfi Alberto, Bona Davide, Riva Carlo Galdino, Micheletto Giancarlo, Rausa Emanuele, Campanelli Giampiero, Olmo Giorgia, Bonitta Gianluca, Bonavina Luigi
Department of Biomedical Science for Health, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy.
J Laparoendosc Adv Surg Tech A. 2020 Feb;30(2):147-155. doi: 10.1089/lap.2019.0432. Epub 2019 Jul 31.
Laparoscopic Heller myotomy (LHM), pneumatic dilatation (PD), and peroral endoscopic myotomy (POEM) are common treatments for esophageal achalasia. Literature evidence is restricted to pairwise analysis and PD versus POEM comparison is missing. The aim of this network meta-analysis (NMA) was to comprehensively compare outcomes within these three surgical approaches with those of esophageal achalasia. PubMed, EMBASE, and Web of Science databases were consulted. A systematic review and a fully Bayesian study level arm-based random effect NMA were performed. Nineteen studies (14 observational and 5 randomized controlled trial) and 4407 patients were included. Overall, 50.4% underwent LHM, 42.8% PD, and 6.8% POEM. The postoperative dysphagia remission was statistically significantly improved in POEM compared with LHM and PD (risk ratio [RR] = 1.21; 95% credible intervals [CIs] = 1.04-1.47 and RR = 1.40; 95% CIs = 1.14-1.79, respectively). Postoperative gastroesophageal reflux disease (GERD) rate was higher in POEM than in LHM and PD (RR = 1.75; 95% CIs = 1.35-2.03 and RR = 1.36; 95% CIs = 1.18-1.68, respectively). Postoperative Eckardt score was significantly lower in POEM than in LHM and PD (standardized mean difference (smd) = -0.6; 95% CIs = -1.4 to -0.2 and smd = -1.2; 95% CIs = -2.3 to -0.2, respectively). No statistically significant differences were found comparing LHM and PD in any of the analyzed outcomes. In the short-term follow-up, POEM seems to be associated with better dysphagia improvement and higher postoperative GERD than LHM and PD. The choice of the ideal initial management should be left to multidisciplinary team discussion and personalized on each patient basis.
腹腔镜下贲门肌切开术（LHM）、气囊扩张术（PD）和经口内镜肌切开术（POEM）是治疗食管贲门失弛缓症的常用方法。文献证据仅限于两两分析，缺少PD与POEM的比较。本网状Meta分析（NMA）的目的是全面比较这三种手术方法与食管贲门失弛缓症治疗效果。检索了PubMed、EMBASE和Web of Science数据库。进行了系统评价和基于全贝叶斯研究水平组的随机效应NMA。纳入了19项研究（14项观察性研究和5项随机对照试验），共4407例患者。总体而言，50.4%的患者接受了LHM，42.8%接受了PD，6.8%接受了POEM。与LHM和PD相比，POEM术后吞咽困难缓解在统计学上有显著改善（风险比[RR]=1.21；95%可信区间[CIs]=1.04 - 1.47和RR = 1.40；95% CIs = 1.14 - 1.79）。POEM术后胃食管反流病（GERD）发生率高于LHM和PD（RR = 1.75；95% CIs = 1.35 - 2.03和RR = 1.36；95% CIs = 1.18 - 1.68）。POEM术后埃卡特评分显著低于LHM和PD（标准化均值差（smd）=-0.6；95% CIs=-1.4至-0.2和smd=-1.2；95% CIs=-2.3至-0.2）。在任何分析结果中，比较LHM和PD均未发现统计学上的显著差异。在短期随访中，与LHM和PD相比，POEM似乎与更好的吞咽困难改善和更高的术后GERD发生率相关。理想的初始治疗选择应留待多学科团队讨论，并根据每位患者的情况进行个性化处理。
