Martins Rafael Krieger, Ribeiro Igor Braga, DE Moura Diogo Turiani Hourneaux, Hathorn Kelly E, Bernardo Wanderley Marques, DE Moura Eduardo Guimarães Hourneaux
Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Unidade de Endoscopia, Departamento de Gastroenterologia, São Paulo, SP, Brasil.
Harvard Medical School, Brigham and Women's Hospital, Division of Gastroenterology, Hepatology and Endoscopy, MA, USA.
Arq Gastroenterol. 2020 Jan-Mar;57(1):79-86. doi: 10.1590/S0004-2803.202000000-14.
Achalasia is a neurodegenerative motility esophageal disorder characterized by failure of lower esophageal sphincter relaxation. The conventional treatment option for achalasia has been laparoscopic Heller myotomy (LHM). However, in 2010, Inoue et al. described peroral endoscopic myotomy (POEM), a minimally invasive procedure, as an alternative therapy. To date, some studies with small sample sizes have aimed to compare outcomes of LHM vs POEM.
Thus, the aim of this study is to perform a systematic review and meta-analysis to better evaluate the efficacy and safety of these two techniques.
Individualized search strategies were developed from inception through April 2019 in accordance with PRISMA guidelines. Variables analyzed included operative time, overall adverse events rate, post-procedure gastroesophageal reflux disease (GERD), hospitalization length, post-procedure pain score, and Eckardt Score reduction.
Twelve cohort trials were selected, consisting of 893 patients (359 in POEM group and 534 in LHM.) No randomized clinical trials were available. There was no difference in operative time (MD= -10,26, 95% CI (-5,6 to 8,2), P<0.001) or Post-Operative Gastroesophageal Reflux (RD: -0.00, 95%CI: (-0.09, 0.09), I2: 0%). There was decreased length of hospital stay for POEM (MD: -0.6, 95% CI (-1.11, -0.09), P=0.02), and an increased mean reduction in Eckardt score in POEM patients (MD = -0.257, 95% CI: (-0.512 to -0.002), P=0.048), with similar rates of adverse events.
POEM demonstrated similar results compared to laparoscopic Heller myotomy with regards to improvement of dysphagia, post-procedure reflux, and surgical time, with the benefit of shorter length of hospital stay. Therefore, POEM can be considered an option for patients with achalasia.
贲门失弛缓症是一种神经退行性动力性食管疾病，其特征为食管下括约肌松弛功能障碍。贲门失弛缓症的传统治疗方法是腹腔镜下Heller肌切开术（LHM）。然而，2010年，井上等人将经口内镜下肌切开术（POEM）这种微创手术描述为一种替代疗法。迄今为止，一些小样本研究旨在比较LHM与POEM的治疗效果。
因此，本研究的目的是进行系统评价和荟萃分析，以更好地评估这两种技术的疗效和安全性。
根据PRISMA指南，制定了从研究开始到2019年4月的个性化检索策略。分析的变量包括手术时间、总体不良事件发生率、术后胃食管反流病（GERD）、住院时间、术后疼痛评分以及埃卡德特评分降低情况。
选择了12项队列试验，共893例患者（POEM组359例，LHM组534例）。没有可用的随机临床试验。手术时间（MD = -10.26，95%CI（-5.6至8.2），P<0.001）或术后胃食管反流（RD：-0.00，95%CI：（-0.09，0.09），I²：0%）没有差异。POEM组的住院时间缩短（MD：-0.6，95%CI（-1.11，-0.09），P = 0.02），POEM患者的埃卡德特评分平均降低幅度增加（MD = -0.257，95%CI：（-0.512至-0.002），P = 0.048），不良事件发生率相似。
在改善吞咽困难、术后反流和手术时间方面，POEM与腹腔镜下Heller肌切开术的结果相似，且具有住院时间较短的优势。因此，POEM可被视为贲门失弛缓症患者的一种治疗选择。
