Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA.
Esophagus. 2021 Oct;18(4):932-940. doi: 10.1007/s10388-021-00840-2. Epub 2021 Apr 13.
The American Society of Anesthesiologists (ASA) physical status classification system was developed as a simple categorization of patients' physiological status that predicts the operative risk. Peroral endoscopic myotomy (POEM) is a less invasive alternative to surgical myotomy in achalasia. As such, POEM seems to be an appealing option for high-risk patients with achalasia. However, there are no studies which systematically analyzed the outcomes of POEM among patients with different ASA classes. Hence, we aimed to compare the safety and efficacy of POEM in patients with lower and higher ASA classes.
Medical records of all achalasia patients who underwent POEM at our institution between April 2014 and May 2019 were reviewed. Patients were categorized arbitrarily into two groups, lower ASA class (ASA I and II combined) and higher ASA class (ASA class III and IV combined). Demographic and procedural details, timed barium swallow (TBE), high-resolution esophageal manometry (HREM), pH study findings and Eckardt scores were compared between the two groups. Baseline characteristics were compared using Chi-square test and two-sample t-test for categorical and continuous variables, respectively.
A total of 144 patients met our study criteria (lower ASA class, n = 44; and higher ASA class, n = 100). Patients in higher ASA class were significantly more obese and older. More patients in lower ASA class had prior Heller myotomy and more patients in higher ASA Class had prior botulinum toxin injections. Procedural parameters were similar in both groups. Procedural complications were infrequent and were also similar in the two groups. The length of stay, 30-day readmission rate, reflux symptoms and esophageal pH study findings were also comparable between the two groups. Treatment success was similar in both groups, 97.7% in lower ASA class versus 92% in higher ASA class (p = 0.19). At 2-month follow-up, both groups had significant improvement in HREM and TBE parameters.
POEM is a very safe and highly effective treatment option for achalasia patients with advanced ASA class similar to lower ASA class patients. POEM may be considered as the preferred choice for myotomy in these high-risk achalasia patients due to its low morbidity and high efficacy.
美国麻醉医师协会（ASA）身体状况分类系统是一种简单的患者生理状况分类方法，用于预测手术风险。经口内镜下肌切开术（POEM）是治疗贲门失弛缓症的一种微创替代手术。因此，POEM 似乎是一种对伴有贲门失弛缓症的高危患者有吸引力的选择。然而，目前尚无研究系统分析不同 ASA 分级患者 POEM 的结果。因此，我们旨在比较 POEM 在低危和高危 ASA 分级患者中的安全性和疗效。
回顾了 2014 年 4 月至 2019 年 5 月在我院接受 POEM 治疗的所有贲门失弛缓症患者的病历。患者被任意分为两组，低 ASA 分级（ASA I 和 II 级合并）和高 ASA 分级（ASA III 和 IV 级合并）。比较两组间的人口统计学和手术细节、 timed barium swallow（TBE）、高分辨率食管测压（HREM）、pH 研究结果和 Eckardt 评分。使用卡方检验和两样本 t 检验分别比较两组间的基线特征。
共有 144 例患者符合本研究标准（低 ASA 分级组，n=44；高 ASA 分级组，n=100）。高 ASA 分级组患者明显更肥胖且年龄更大。低 ASA 分级组中更多患者有既往 Heller 肌切开术，高 ASA 分级组中更多患者有既往肉毒毒素注射。两组手术参数相似。手术并发症均少见，两组间也相似。两组间住院时间、30 天再入院率、反流症状和食管 pH 研究结果也相似。两组治疗成功率相似，低 ASA 分级组为 97.7%，高 ASA 分级组为 92%（p=0.19）。在 2 个月随访时，两组 HREM 和 TBE 参数均有显著改善。
POEM 是一种非常安全且高度有效的贲门失弛缓症治疗选择，适用于 ASA 分级较高的患者，与 ASA 分级较低的患者相似。由于 POEM 具有较低的发病率和较高的疗效，因此对于这些高危贲门失弛缓症患者，可考虑将其作为肌切开术的首选。
