Department of Evidence-Based Medicine, Centro Universitário Lusíada, Santos, Brazil.
Department of Evidence-Based Medicine, Universidade de São Paulo, São Paulo, Brazil.
Dis Esophagus. 2021 Oct 11;34(10). doi: 10.1093/dote/doab053.
Achalasia may evolve to sigmoid megaesophagus in 10-15% of patients and is usually treated with esophagectomy, which has high morbi-mortality. Many surgeons debate the applicability of the Heller myotomy for treating sigmoid megaesophagus. This study intents to analyze the effectiveness of myotomy for treating patients with sigmoid megaesophagus.
A systematic review and meta-analysis was conducted in PubMed, Cochrane, Lilacs and Embase alongside manual search of references. The inclusion criteria were clinical trials, cohort, case-series; patients with sigmoid megaesophagus and esophageal diameter ≥ 6 cm; and patients undergoing primary myotomy. The exclusion criteria were reviews, case reports, cross-sectional studies, editorials, letters, congress abstracts, full-text unavailability; previous surgical treatment for achalasia; and pediatric or animal model studies. No restrictions on language and date of publication, and no filters were applied. Subgroups analyses were performed to assess the laparoscopic myotomy perioperative outcomes. Besides, subgroup analyses were performed to assess the long-term outcomes of the studies with a follow-up time > 24 months. To verify heterogeneity, the I2 test was used. The random effects were applied, and the fixed model was evaluated as sensitivity analysis. To assess risk of bias and certainty of evidence, the tools ROBINS-I and GRADE were used, respectively. Registration number: CRD42020199667.
Sixteen articles were selected, encompassing 350 patients. The mean age ranged from 36 to 61 years old, and the mean follow-up ranged from 16 to 109 months. Complications rate was 0.08 (CI: 0.040-0.153; P = 0.01). Need for retreatment rate was 0.128 (CI: 0.031-0.409; P = 0.01). The probability of good or excellent outcomes after myotomy was 0.762 (CI: 0.703-0.812; P < 0.01). Postoperative mortality rate was 0.008 (CI: 0.004-0.015; P < 0.01).
Surgical myotomy is an option for avoiding esophagectomy in achalasia, with a low morbi-mortality rate and good results. It is effective for most patients and only a minority will demand retreatment.
10-15%的贲门失弛缓症患者可能会发展为乙状结肠巨食管，通常采用食管切除术治疗，但其死亡率和发病率较高。许多外科医生对 Heller 肌切开术治疗乙状结肠巨食管的适用性存在争议。本研究旨在分析肌切开术治疗乙状结肠巨食管患者的效果。
对 PubMed、Cochrane、Lilacs 和 Embase 进行系统评价和荟萃分析，并手动搜索参考文献。纳入标准为临床试验、队列研究、病例系列研究；乙状结肠巨食管患者，食管直径≥6cm；行原发性肌切开术的患者。排除标准为综述、病例报告、横断面研究、社论、信件、会议摘要、全文不可用；先前针对贲门失弛缓症的手术治疗；以及儿科或动物模型研究。不限制语言和出版日期，也不应用过滤器。进行亚组分析以评估腹腔镜肌切开术的围手术期结果。此外，还进行了亚组分析，以评估随访时间超过 24 个月的研究的长期结果。为了检验异质性，使用了 I2 检验。应用随机效应，固定模型作为敏感性分析。使用 ROBINS-I 和 GRADE 工具分别评估风险偏倚和证据确定性。注册号：CRD42020199667。
选择了 16 篇文章，共纳入 350 名患者。平均年龄为 36-61 岁，平均随访时间为 16-109 个月。并发症发生率为 0.08（95%CI：0.040-0.153；P=0.01）。需要再次治疗的发生率为 0.128（95%CI：0.031-0.409；P=0.01）。肌切开术后良好或优秀结局的概率为 0.762（95%CI：0.703-0.812；P<0.01）。术后死亡率为 0.008（95%CI：0.004-0.015；P<0.01）。
手术肌切开术是避免贲门失弛缓症行食管切除术的一种选择，其死亡率和发病率较低，效果良好。它对大多数患者有效，只有少数患者需要再次治疗。
