Upper Gastro-Intestinal Surgery Unit, Department of Surgery, Faculty of Medicine, University of Malaya, Professor Diraja Ungku Aziz Road, 50603, Kuala Lumpur, Malaysia.
Department of Internal Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
Surg Endosc. 2023 Mar;37(3):1735-1741. doi: 10.1007/s00464-022-09680-2. Epub 2022 Oct 10.
Per-Oral Endoscopic Myotomy (POEM) is an effective treatment for Esophageal Achalasia Cardia (EAC) but the endoscopic technique required is complex. As competency is crucial for patient safety, we believe that its' competency can be demonstrated when the complication rate equals that of an established procedure such as Laparoscopic Heller's Myotomy with Fundoplication (LHM + F).
A multicentre, ambi-directional, non-randomized comparison of intra-procedural complications during the learning curve of POEM was performed against a historical cohort of LHM + F. Demographic, clinicopathological, procedural data and complications were collected. A direct head-to-head comparison was performed, followed by a population pyramid of complication frequency. Case sequence was then divided into blocks of 5, and the complication rates during each block was compared to the historical cohort.
From January 2010 to April 2021, 60 patients underwent LHM + F and 63 underwent POEM. Mean age was lower for the POEM group (41.7 years vs 48.1 years, p = 0.03), but there was no difference in gender nor type of Achalasia. The POEM group recorded a shorter overall procedural time (125.9 min vs 144.1 min, p = 0.023) and longer myotomies (10.1 cm vs 6.2 cm, p = 0.023). The overall complication rate of POEM was 20.6%, whereas the historical cohort of LHM + F had a rate of 10.0%. On visual inspection of the population pyramid, complications were more frequent in the earlier procedures. On block sequencing, complication frequency could be seen tapering off dramatically after the 25th case, and subsequently equalled that of LHM + F.
POEM is challenging even for experienced endoscopists. From our data, complication rates between POEM and LHM + F equalize after approximately 25 POEMs.
经口内镜下肌切开术（POEM）是治疗食管贲门失弛缓症（EAC）的有效方法，但需要的内镜技术非常复杂。由于手术的安全性至关重要，我们认为当并发症发生率与已确立的手术（如腹腔镜 Heller 肌切开术加胃底折叠术（LHM+F））相当时，就可以证明其具有胜任力。
我们进行了一项多中心、双向、非随机的比较研究，即在 POEM 的学习曲线期间，将术中并发症与历史队列中的 LHM+F 进行比较。收集了人口统计学、临床病理学、手术过程数据和并发症。进行了直接的头对头比较，然后对并发症频率进行了人口金字塔分析。然后将病例序列分为 5 个块，比较每个块的并发症发生率与历史队列。
从 2010 年 1 月至 2021 年 4 月，60 例患者接受了 LHM+F 手术，63 例患者接受了 POEM 手术。POEM 组的平均年龄较低（41.7 岁比 48.1 岁，p=0.03），但性别和贲门失弛缓症类型无差异。POEM 组的总手术时间较短（125.9 分钟比 144.1 分钟，p=0.023），肌切开术较长（10.1 厘米比 6.2 厘米，p=0.023）。POEM 的总并发症发生率为 20.6%，而 LHM+F 的历史队列发生率为 10.0%。通过观察人口金字塔，在早期手术中并发症更为常见。通过块序列分析，在第 25 例之后，可以看到并发症频率显著减少，随后与 LHM+F 相等。
即使对于经验丰富的内镜医生来说，POEM 也具有挑战性。根据我们的数据，POEM 和 LHM+F 之间的并发症发生率在大约 25 例 POEM 后趋于一致。
