Khoraki Jad, Campos Guilherme M, Alwatari Yahya, Mazzini Guilherme S, Mangino Martin J, Wolfe Luke G
Department of Surgery, Division of Bariatric and Gastrointestinal Surgery, Virginia Commonwealth University, Richmond, VA.
Department of Surgery, Division of Bariatric and Gastrointestinal Surgery, Virginia Commonwealth University, Richmond, VA.
Surgery. 2022 May;171(5):1263-1272. doi: 10.1016/j.surg.2021.10.019. Epub 2021 Nov 10.
Per-oral endoscopic myotomy is an alternative to pneumatic dilation and laparoscopic Heller myotomy to treat lower esophageal sphincter diseases. Laparoscopic Heller myotomy and per-oral endoscopic myotomy perioperative outcomes data come from relatively small retrospective series and 1 randomized trial. We aimed to estimate the number of inpatient procedures performed in the United States and compare perioperative outcomes and costs of laparoscopic Heller myotomy and per-oral endoscopic myotomy using a nationally representative database.
Cross-sectional retrospective analysis of hospital admissions for laparoscopic Heller myotomy or per-oral endoscopic myotomy from October 2015 through December 2018 in the National Inpatient Sample. Patient and hospital characteristics, concurrent antireflux procedures, perioperative adverse events (any adverse event and those associated with extended length of stay ≥3 days), mortality, length of stay, and costs were compared. Logistic regression evaluated factors independently associated with adverse events.
An estimated 11,270 patients had laparoscopic Heller myotomy (n = 9,555) or per-oral endoscopic myotomy (n = 1,715) without significant differences in demographics and comorbidities. A concurrent anti-reflux procedure was more frequent with laparoscopic Heller myotomy (72.8% vs 15.5%, P < .001). Overall adverse event rate was higher with per-oral endoscopic myotomy (13.3% vs 24.8%, P < .001), and mortality was similar. Per-oral endoscopic myotomy had higher rates of adverse events associated with extended length of stay (9.3% vs 16.6%, P < .001), infectious adverse events (3.5% vs 8.2%, P < .001), gastrointestinal bleeding (3.4% vs 5.8%, P = .04), accidental injuries (3% vs 5.5%, P = .03), and thoracic adverse events (4.5% vs 9%, P < .01). Rates of adverse events of both procedures remained similar during the years of the study. Per-oral endoscopic myotomy was independently associated with adverse events. Length of stay (laparoscopic Heller myotomy: 3.2 ± 0.1 vs per-oral endoscopic myotomy: 3.7 ± 0.3 days, P = .17) and costs (laparoscopic Heller myotomy: $15,471 ± 406 vs per-oral endoscopic myotomy: $15,146 ± 1,308, P = .82) were similar.
In this national database review, laparoscopic Heller myotomy had a lower rate of perioperative adverse events at similar length of stay and costs than per-oral endoscopic myotomy. Laparoscopic Heller myotomy remains a safer procedure than per-oral endoscopic myotomy for a myotomy of the distal esophagus and lower esophageal sphincter in the United States.
经口内镜下肌切开术是治疗食管下括约肌疾病的一种替代气囊扩张术和腹腔镜下Heller肌切开术的方法。腹腔镜下Heller肌切开术和经口内镜下肌切开术的围手术期结果数据来自相对较小的回顾性系列研究和1项随机试验。我们旨在估计美国住院手术的数量，并使用全国代表性数据库比较腹腔镜下Heller肌切开术和经口内镜下肌切开术的围手术期结果及成本。
对2015年10月至2018年12月期间全国住院患者样本中接受腹腔镜下Heller肌切开术或经口内镜下肌切开术的医院入院病例进行横断面回顾性分析。比较患者和医院特征、同期抗反流手术、围手术期不良事件（任何不良事件以及与延长住院时间≥3天相关的不良事件）、死亡率、住院时间和成本。逻辑回归评估与不良事件独立相关的因素。
估计有11270例患者接受了腹腔镜下Heller肌切开术（n = 9555）或经口内镜下肌切开术（n = 1715），在人口统计学和合并症方面无显著差异。腹腔镜下Heller肌切开术同期进行抗反流手术的频率更高（72.8%对15.5%，P <.001）。经口内镜下肌切开术的总体不良事件发生率更高（13.3%对24.8%，P <.001），死亡率相似。经口内镜下肌切开术与延长住院时间相关的不良事件发生率更高（9.3%对16.6%，P <.001）、感染性不良事件发生率更高（3.5%对8.2%，P <.001）、胃肠道出血发生率更高（3.4%对5.8%，P =.04）、意外伤害发生率更高（3%对5.5%，P =.03）以及胸部不良事件发生率更高（4.5%对9%，P <.01）。在研究期间，两种手术的不良事件发生率保持相似。经口内镜下肌切开术与不良事件独立相关。住院时间（腹腔镜下Heller肌切开术：3.2±0.1天对经口内镜下肌切开术：3.7±0.3天，P =.17）和成本（腹腔镜下Heller肌切开术：15471±406美元对经口内镜下肌切开术：15146±1308美元，P =.82）相似。
在这项全国性数据库回顾中，腹腔镜下Heller肌切开术在住院时间和成本相似的情况下，围手术期不良事件发生率低于经口内镜下肌切开术。在美国，对于远端食管和食管下括约肌的肌切开术，腹腔镜下Heller肌切开术仍然是比经口内镜下肌切开术更安全的手术。
