Department of Gastroenterology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
Gastrointest Endosc. 2021 Jan;93(1):47-56.e5. doi: 10.1016/j.gie.2020.05.056. Epub 2020 Jun 11.
Heller myotomy (HM) is considered the standard surgical treatment for patients with achalasia. However, approximately 10% to 20% of patients with achalasia have persistent or recurrent symptoms after HM that require further therapy. Several studies have reported the outcomes of peroral endoscopic myotomy (POEM) in these patients. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of POEM in patients with achalasia with previous HM.
An electronic literature search of PubMed, Embase, and the Cochrane Library was conducted up to January 31, 2020. Studies evaluating the outcomes of POEM in patients with achalasia with previous HM were eligible for inclusion. The primary outcomes were the pooled rates of clinical success (defined as post-POEM Eckardt score ≤3), mean change in Eckardt score, lower esophageal sphincter pressure, and integrated relaxation pressure (IRP). The secondary outcomes were procedure-related adverse events (AEs) and incidence of postoperative GERD.
A total of 9 studies involving 272 patients with achalasia were recruited in this review. POEM was successfully performed in 270 (99.3%) patients after previous HM. Clinical success was achieved in 90.0% (95% confidence interval [CI], 83.1%-96.8%) of patients. Eckardt score, lower esophageal sphincter pressure, and IRP were significantly lowered by 5.14 (95% CI, 4.19-6.09), 12.01 mm Hg (95% CI, 6.74-17.27), and 10.02 mm Hg (95% CI, 4.95-15.09), respectively. The pooled rates of postoperative symptomatic reflux, esophagitis, and abnormal pH monitoring were 36.9% (95% CI, 20.7%-53.1%), 33.0% (95% CI, 9.6%-56.4%), and 47.8% (95% CI, 33.4%-62.2%), respectively. Substantial heterogeneity was detected across all outcome measurements. Most of the AEs were self-limiting or managed conservatively.
POEM is a safe and effective treatment for patients with achalasia with previous HM. Further data from prospective, controlled studies with long-term follow-up are needed to confirm these findings.
Heller 肌切开术（HM）被认为是贲门失弛缓症患者的标准手术治疗方法。然而，约 10%至 20%的贲门失弛缓症患者在 HM 后仍存在持续性或复发性症状，需要进一步治疗。几项研究报道了经口内镜肌切开术（POEM）在这些患者中的治疗效果。我们进行了一项系统评价和荟萃分析，以评估 POEM 在既往 HM 治疗后的贲门失弛缓症患者中的疗效和安全性。
对 PubMed、Embase 和 Cochrane 图书馆进行了电子文献检索，检索时间截至 2020 年 1 月 31 日。评估 POEM 在既往 HM 治疗后的贲门失弛缓症患者中的疗效和安全性的研究符合纳入标准。主要结局是临床成功率（定义为 POEM 后 Eckardt 评分≤3）、Eckardt 评分的平均变化、食管下括约肌压力和整合松弛压力（IRP）。次要结局是与手术相关的不良事件（AE）和术后胃食管反流病（GERD）的发生率。
本综述共纳入 9 项研究，共 272 例既往 HM 治疗后的贲门失弛缓症患者。在 270 例（99.3%）患者中成功完成了 POEM。90.0%（95%可信区间[CI]，83.1%-96.8%）的患者达到了临床成功。Eckardt 评分、食管下括约肌压力和 IRP 分别显著降低了 5.14（95%CI，4.19-6.09）、12.01mmHg（95%CI，6.74-17.27）和 10.02mmHg（95%CI，4.95-15.09）。术后症状性反流、食管炎和异常 pH 监测的累积发生率分别为 36.9%（95%CI，20.7%-53.1%）、33.0%（95%CI，9.6%-56.4%）和 47.8%（95%CI，33.4%-62.2%）。所有结局指标均存在显著异质性。大多数 AE 是自限性的或保守治疗的。
POEM 是既往 HM 治疗后的贲门失弛缓症患者的一种安全有效的治疗方法。需要前瞻性、对照研究的长期随访数据来证实这些发现。
