Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.
Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, USA.
Dig Endosc. 2022 Jul;34(5):965-973. doi: 10.1111/den.14197. Epub 2021 Dec 12.
Indications for peroral endoscopic myotomy (POEM) and endoscopic submucosal dissection (ESD) in patients with achalasia concomitant with esophageal carcinoma (EC) are unclear. This study aimed to clarify the role of POEM in cases of achalasia concomitant with EC and to elucidate the indications for ESD and efficient surveillance for EC.
We conducted a multicenter cohort study at 14 hospitals in Japan, including 3707 cases of achalasia-related esophageal motility disorders (EMDs). Factors contributing to EC risk, the characteristics of EC, and clinical outcomes of POEM/ESD were analyzed.
In patients undergoing POEM, screening and surveillance endoscopy throughout a 1-year period resulted in diagnosis of 72.1% new EC cases. Of 62 patients with 123 ECs, 40.3% had multiple or metachronous lesions within 37.5 months. EC was predominantly observed in the middle thoracic esophagus (58.5%) and posteriorly (73.2%). POEM had comparable safety and efficacy in cases of concomitant EC even after ESD. Endoscopic en bloc resection was performed in 95.8% and 89.3% of ECs diagnosed before and after POEM, respectively (P = 0.351); however, ESD on the POEM-line was impaired by fibrosis. Multivariate analysis revealed risk factors for EC, including regular alcohol consumption, a history of smoking, advanced age, and extended disease duration. Alcohol intake and smoking had a synergistic effect on EC development.
Screening and surveillance of POEM help in detecting EC. ESD is feasible in achalasia, although on the POEM-line is challenging. Surveillance endoscopy for EC is recommended for cases with specific risks and a history of ECs.
贲门失弛缓症（achalasia）合并食管癌（EC）患者行经口内镜下肌切开术（POEM）和内镜黏膜下剥离术（ESD）的适应证尚不明确。本研究旨在阐明 POEM 在贲门失弛缓症合并 EC 患者中的作用，并阐明 ESD 的适应证和对 EC 的有效监测。
我们在日本的 14 家医院进行了一项多中心队列研究，纳入了 3707 例贲门失弛缓症相关食管动力障碍（EMD）患者。分析了 EC 风险相关因素、EC 的特征以及 POEM/ESD 的临床结局。
在接受 POEM 的患者中，通过 1 年的筛查和监测内镜检查，诊断出 72.1%的新 EC 病例。在 62 例 123 例 EC 患者中，40.3%的患者在 37.5 个月内存在多发或异时性病变。EC 主要位于中胸段食管（58.5%）和后位（73.2%）。即使在 POEM 后行 ESD，POEM 治疗合并 EC 患者的安全性和疗效相当。在 POEM 前和 POEM 后诊断的 EC 中，分别有 95.8%和 89.3%的患者行内镜整块切除（P=0.351）；然而，POEM 线上的 ESD 因纤维化而受到影响。多因素分析显示，EC 的危险因素包括规律饮酒、吸烟史、年龄较大和疾病持续时间延长。饮酒和吸烟对 EC 的发生有协同作用。
POEM 的筛查和监测有助于发现 EC。ESD 在贲门失弛缓症中是可行的，尽管在 POEM 线上具有挑战性。对于具有特定风险和 EC 病史的患者，建议进行 EC 监测。
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