Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, 7-45-1, Nanakuma, Jyounan-ku, Fukuoka, 814-0180, Japan.
Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan.
Surg Endosc. 2022 Jun;36(6):4255-4264. doi: 10.1007/s00464-021-08763-w. Epub 2021 Oct 29.
Peroral endoscopic myotomy (POEM) is standard treatment for achalasia. Gastroesophageal reflux disease (GERD) after POEM has been an important challenge since the early days of POEM implementation. The esophagogastric junction anti-reflux barrier consists of internal lower esophageal sphincter (LES) (i.e., intrinsic muscles of distal esophagus with sling fibers) and external LES (crural diaphragm and phrenoesophageal ligament anchors the distal esophagus to the crural diaphragm). During conventional POEM, the entire internal LES is unintentionally dissected. Preservation of the sling fiber may reduce post-POEM GERD, but its safety and effectiveness have been unclear. In this study, we investigated the safety and effectiveness of sling fiber preservation POEM (SP-POEM) for reducing severe post-procedural erosive esophagitis.
We analyzed data of 236 patients who underwent POEM; of these, 203 patients underwent posterior myotomy without (Group 1) or with attempted (Group 2) sling fiber preservation. Group 1 (N = 79; sling fiber excision, N = 68) and Group 2 (N = 90; sling fiber preservation, N = 81) were compared. Post-procedural erosive esophagitis (Los Angeles classification) were assessed and the area (direction and length) of mucosal break was also investigated. The gastroesophageal flap valve was evaluated by Hill's classification.
Severe erosive esophagitis exceeding grade C (Los Angeles classification) occurred in 44.1% of patients (30/68) in Group 1 and in 18.5% of patients (15/81) in Group 2. In mapping of erosive esophagitis, mucosal breaks appeared widely in all directions in Group 1; they tended to be limited in Group 2 (especially in the 2 o'clock direction). Assessment using the Hill's classification showed that the gastroesophageal flap valve was preserved after SP-POEM.
SP-POEM is safe and effective, with a success rate of 90%. The rate of severe erosive esophagitis can be decreased by preserving sling fibers.
经口内镜下肌切开术（POEM）是治疗贲门失弛缓症的标准治疗方法。自 POEM 实施早期以来，POEM 后胃食管反流病（GERD）一直是一个重要挑战。食管胃交界处抗反流屏障由内部下食管括约肌（LES）（即远端食管的固有肌肉和吊带纤维）和外部 LES（膈脚和膈食管韧带将远端食管固定在膈脚上）组成。在传统的 POEM 中，整个内部 LES 被无意中切开。保留吊带纤维可能会减少 POEM 后的 GERD，但它的安全性和有效性尚不清楚。在这项研究中，我们研究了保留吊带纤维的 POEM（SP-POEM）在减少严重术后糜烂性食管炎中的安全性和有效性。
我们分析了 236 例接受 POEM 的患者的数据；其中，203 例患者行后肌切开术，其中 1 组（无吊带纤维保留，n=79）和 2 组（试图保留吊带纤维，n=90）。比较组 1（n=79；吊带纤维切除，n=68）和组 2（n=90；保留吊带纤维，n=81）。评估术后糜烂性食管炎（洛杉矶分类），并研究黏膜破裂的面积（方向和长度）。胃食管瓣阀采用 Hill 分类进行评估。
组 1 中 44.1%（30/68）的患者发生超过 C 级（洛杉矶分类）的严重糜烂性食管炎，而组 2 中仅 18.5%（15/81）的患者发生这种情况。在糜烂性食管炎的定位图中，组 1 中黏膜破裂广泛出现在各个方向；而在组 2 中，黏膜破裂倾向于局限（特别是在 2 点钟方向）。使用 Hill 分类进行评估显示，SP-POEM 后保留了胃食管瓣阀。
SP-POEM 是安全有效的，成功率为 90%。保留吊带纤维可降低严重糜烂性食管炎的发生率。
