Liao Ye, Xiao Ting-Yue, Wu Yu-Fan, Zhang Jing-Jing, Zhang Bao-Zhen, Wang Yi-Dan, Wang Sheng, Liu Xiang, Sun Si-Yu, Guo Jin-Tao
Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China.
Department of Science and Education, Shenyang Sixth People's Hospital, Shenyang 110006, Liaoning Province, China.
World J Gastroenterol. 2020 Oct 14;26(38):5863-5873. doi: 10.3748/wjg.v26.i38.5863.
People with achalasia typically have a thick lower esophageal muscularis propria (LEMP), and peroral endoscopic myotomy (POEM) has been effective in treating most patients. LEMP thickness may be associated with the outcomes and prognosis after POEM. However, more evidence is needed regarding the relationship between LEMP thickness and patient prognosis after POEM.
To assess the association between LEMP thickness, measured using endoscopic ultrasound (EUS), and long-term prognosis, especially relapse, after POEM for achalasia.
All medical records, including EUS data, of patients who underwent POEM to treat achalasia at Shengjing Hospital of China Medical University from January 2012 to September 2018 were retrospectively reviewed. LEMP thickness was measured by EUS, and a thickness of ≥ 3 mm was defined as thickened. The severity of patient symptoms was evaluated using the Eckardt score. Relapse was defined as a 3-point rise in the Eckardt score after a period of clinical remission. The relationship between patient characteristics, muscle thickness, and recurrence was analyzed.
Eighty-two patients (32 males and 50 females, aged 17-78 years) and 85 POEM procedures were included. In total, 76.8% (63/82 patients) of patients had a thickened muscularis propria. Older age and longer disease course were associated with muscularis propria thickening ( < 0.05). The mean postoperative follow-up time was 35.4 ± 17.2 mo (range, 8-87.5 mo) in 60 patients. Five patients with Eckardt scores > 3 refused further management after their symptoms were relieved. The relapse rate was 12.73% (7/55 cases). Five patients, four of whom had muscularis propria thickening, had disease recurrence within 12 mo after the procedure. Achalasia relapsed in one patient who had a thickened muscularis propria after 24 mo and in another patient who did not have a thickened muscularis propria after 30 mo. Patients with recurrence were typically younger and had a shorter disease course ( < 0.05). The relapse rate in patients with a non-thickened muscularis propria tended to be higher (18.2%, 2/11 patients) than that in patients with a thickened muscularis propria (11.4%, 5/44 patients), although no significant difference was found. Age (hazard ratio = 0.92; 95% confidence interval: 0.865-0.979; < 0.05) and being male (hazard ratio = 7.173; 95% confidence interval: 1.277-40.286; < 0.05) were identified as risk factors for symptomatic recurrence by multivariable analysis using the Cox model.
Patients with a thickened muscularis are typically older and have a longer disease course. Younger age and the male sex are associated with increased recurrence. Patients with a thin muscularis propria may be prone to relapse, although further validation is needed.
贲门失弛缓症患者通常食管下段固有肌层（LEMP）增厚，经口内镜下肌切开术（POEM）已被证明对大多数患者有效。LEMP厚度可能与POEM术后的疗效和预后相关。然而，关于LEMP厚度与POEM术后患者预后之间的关系，仍需要更多证据。
评估使用内镜超声（EUS）测量的LEMP厚度与贲门失弛缓症POEM术后长期预后，尤其是复发之间的关联。
回顾性分析2012年1月至2018年9月在中国医科大学附属盛京医院接受POEM治疗贲门失弛缓症患者的所有病历，包括EUS数据。通过EUS测量LEMP厚度，≥3mm定义为增厚。使用 Eckardt评分评估患者症状的严重程度。复发定义为临床缓解一段时间后Eckardt评分升高3分。分析患者特征、肌层厚度与复发之间的关系。
纳入82例患者（男性32例，女性50例，年龄17 - 78岁），共进行85次POEM手术。总计76.8%（63/82例）的患者固有肌层增厚。年龄较大和病程较长与固有肌层增厚相关（P < 0.05）。60例患者术后平均随访时间为35.4±17.2个月（范围8 - 87.5个月）。5例Eckardt评分>3分的患者症状缓解后拒绝进一步治疗。复发率为12.73%（7/55例）。5例患者在术后12个月内疾病复发，其中4例固有肌层增厚。1例固有肌层增厚的患者在术后24个月复发，另1例固有肌层未增厚的患者在术后30个月复发。复发患者通常年龄较小且病程较短（P < 0.05）。固有肌层未增厚患者的复发率（18.2%，2/11例）虽高于固有肌层增厚患者（11.4%，5/44例），但差异无统计学意义。年龄（风险比 = 0.92；95%置信区间：0.865 - 0.979；P < 0.05）和男性（风险比 = 7.173；95%置信区间：1.277 - 40.286；P < 0.05）经Cox模型多变量分析被确定为症状复发的风险因素。
固有肌层增厚的患者通常年龄较大且病程较长。年龄较小和男性与复发增加相关。固有肌层较薄的患者可能易于复发，尽管需要进一步验证。
