Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.
Department of Endoscopy, Kobe University Hospital, Kobe, Japan.
J Gastroenterol Hepatol. 2019 Dec;34(12):2158-2163. doi: 10.1111/jgh.14814. Epub 2019 Aug 23.
One of the main concerns related to peroral endoscopic myotomy (POEM) is postoperative gastroesophageal reflux (GER). The two penetrating vessels (TPVs) that are found at the boundary between the circular and oblique muscles in the posterior cardia wall have been suggested to be a good indicator of the optimal distal extent of POEM. However, the effect of performing myotomy using the TPVs as an anatomical reference on the frequency of post-POEM GER has not been studied.
This study involved consecutive patients who underwent POEM for the treatment of achalasia between April 2015 and June 2017. All enrolled patients underwent POEM in the 5 o'clock position and were divided into two groups: the conventional line group (CL group, n = 31), in which the TPVs were not exposed during submucosal tunnel dissection in the cardia, and the TPVs line group (TPVs group, n = 83), in which the TPVs were exposed and gastric myotomy was performed along the right side of the TPVs to preserve the oblique muscle. Examinations for post-POEM GER were conducted 3 months after the POEM.
The frequency of grade B or higher reflex esophagitis was 26/83 (31.3%) in the TPVs group and 18/31 (58.1%) in the CL group (P = 0.017). Nine of 83 patients (10.8%) had GER symptoms in the TPVs group, and six of 31 (19.4%) had GER symptoms in the CL group (P = 0.23).
The novel myotomy method preserving oblique muscle using TPVs as anatomical landmarks significantly reduced the frequency of post-POEM GER.
经口内镜下肌切开术（POEM）相关的主要关注点之一是术后胃食管反流（GER）。在后贲门壁环肌和斜肌交界处发现的两个穿透血管（TPV）被认为是 POEM 最佳远端范围的良好指标。然而，使用 TPV 作为解剖参考进行肌切开术对 POEM 后 GER 频率的影响尚未研究。
本研究纳入了 2015 年 4 月至 2017 年 6 月期间因贲门失弛缓症而行 POEM 的连续患者。所有入组患者均在 5 点钟位置行 POEM，分为两组：常规线组（CL 组，n=31），在贲门黏膜下隧道分离过程中不暴露 TPV；TPV 线组（TPVs 组，n=83），暴露 TPV 并沿 TPV 右侧行胃肌切开术以保留斜肌。POEM 后 3 个月进行 POEM 后 GER 检查。
TPVs 组中 26/83（31.3%）出现 B 级或更高级别的反流性食管炎，CL 组中 18/31（58.1%）出现（P=0.017）。TPVs 组 83 例患者中有 9 例（10.8%）出现 GER 症状，CL 组中有 31 例（19.4%）出现 GER 症状（P=0.23）。
使用 TPV 作为解剖标志保留斜肌的新型肌切开术显著降低了 POEM 后 GER 的频率。
