Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
Division of Minimally Invasive Surgery, Department of Surgery, University of Wisconsin-Madison, 4602 Eastpark Blvd, Suite 3525, Madison, WI, 53718, USA.
Surg Endosc. 2023 Jun;37(6):4812-4817. doi: 10.1007/s00464-022-09556-5. Epub 2022 Sep 19.
Myotomy is the gold standard treatment for achalasia, yet long-term failure rates approach 15%. Treatment options for recurrent dysphagia include pneumatic dilation (PD), laparoscopic redo myotomy, per oral endoscopic myotomy (POEM), or esophagectomy. We employ both PD and POEM as first-line treatment for these patients. We evaluated operative success and patient reported outcomes for patients who underwent PD or POEM for recurrent dysphagia after myotomy.
We identified patients with achalasia who underwent PD or POEM for recurrent dysphagia after previous myotomy within a foregut database at our institution between 2013 and 2021. Gastroesophageal Reflux Disease-Health-Related quality of Life (GERD-HRQL) and Eckardt scores, and overall change in each were compared across PD and POEM groups. Successful treatment of dysphagia was defined by Eckardt scores ≤ 3.
103 patients underwent myotomy for achalasia. Of these, 19 (18%) had either PD or POEM for recurrent dysphagia. Nine were treated with PD and 10 with POEM. The mean change in Eckardt and GERD-HRQL scores did not differ between groups. 50% of the PD group and 67% of the POEM group had resolution of their dysphagia symptoms (p = 0.65). Mean procedure length was greater in the POEM group (267 vs 72 min, p < 0.01) as was mean length of stay (1.56 vs 0.3 days, p < 0.01). There was one adverse event after PD and three adverse events after POEM. After PD, 7 patients (70%) required additional procedures compared to four patients (44%) in the POEM group, consisting mostly of repeat PD.
Patients undergoing PD or POEM for recurrent dysphagia after myotomy have similar rates of dysphagia resolution and reflux symptoms. Patients undergoing PD enjoy a shorter length of stay and shorter procedure time but may require more subsequent procedures.
肌切开术是治疗贲门失弛缓症的金标准，但长期失败率接近 15%。对于复发性吞咽困难的治疗选择包括气囊扩张术（PD）、腹腔镜再次肌切开术、经口内镜肌切开术（POEM）或食管切除术。我们将 PD 和 POEM 均作为这些患者的一线治疗方法。我们评估了在我们机构的一个前肠数据库中，在先前的肌切开术后因复发性吞咽困难而行 PD 或 POEM 的患者的手术成功率和患者报告的结果。
我们在 2013 年至 2021 年期间，在我们机构的前肠数据库中，确定了因先前肌切开术后复发性吞咽困难而行 PD 或 POEM 的贲门失弛缓症患者。比较 PD 和 POEM 组之间的胃食管反流病相关生活质量（GERD-HRQL）和 Eckardt 评分以及每个评分的总体变化。吞咽困难的成功治疗定义为 Eckardt 评分≤3。
103 例患者因贲门失弛缓症而行肌切开术。其中 19 例（18%）因复发性吞咽困难而行 PD 或 POEM。9 例行 PD 治疗，10 例行 POEM 治疗。两组间 Eckardt 和 GERD-HRQL 评分的变化无差异。PD 组 50%和 POEM 组 67%的患者吞咽困难症状缓解（p=0.65）。POEM 组的手术时间（267 分钟 vs. 72 分钟，p<0.01）和平均住院时间（1.56 天 vs. 0.3 天，p<0.01）均较长。PD 后发生 1 例不良事件，POEM 后发生 3 例不良事件。PD 组有 7 例（70%）患者需要进行额外的手术，而 POEM 组有 4 例（44%）患者需要进行额外的手术，主要是重复 PD。
在行肌切开术后因复发性吞咽困难而行 PD 或 POEM 的患者，其吞咽困难缓解率和反流症状相似。PD 组患者的住院时间和手术时间较短，但可能需要更多后续手术。
