经口内镜肌切开术治疗既往行 Heller 肌切开术的病例：中位随访 5 年后的结果。
Per-oral endoscopic myotomy in cases with prior Heller's myotomy: Outcomes at a median follow-up of 5 years.
机构信息
Interventional Endoscopy Asian Institute of Gastroenterology, Hyderabad, India.
Asian Institute of Gastroenterology, Hyderabad, India.
出版信息
J Gastroenterol Hepatol. 2023 Nov;38(11):2035-2039. doi: 10.1111/jgh.16320. Epub 2023 Aug 12.
BACKGROUND AND AIM
Per-oral endoscopic myotomy (POEM) is an established treatment for achalasia cardia. However, data on the long-term efficacy of POEM in patients with failed Heller's myotomy (HM) are limited. The purpose of this study was to evaluate the long-term outcomes of POEM in patients with persistent or recurrent symptoms following HM.
METHODS
Data of patients with recurrence of symptoms after HM who underwent POEM (September 2013 to December 2022) were analyzed, retrospectively. Primary outcome was clinical success [Eckardt score (ES) ≤ 3]. Secondary outcomes included improvement of manometry parameters, barium emptying at 5 min and gastroesophageal reflux (esophagitis and increased esophageal acid exposure) after POEM.
RESULTS
Seventy-two cases (45.9 ± 13.4 years, 43 men) with history of HM were included in the study. The subtypes of achalasia were type 1 (40.3%), type 2 (37.5%), and unknown (19.4%). Prior treatment included HM in 48 (66.7%), HM plus pneumatic dilatation in 20 (27.8%), and HM plus pneumatic dilatation and Botox in 4 (5.5%). Technical success was achieved in all cases. Mean length of myotomy was 10.7 ± 3.3 cm, and mean procedure duration was 59.2 ± 25.9 min. There was significant improvement in ES (pre-POEM 6.5 ± 1.8 vs post-POEM 0.7 ± 0.7), lower esophageal sphincter pressure pressures (31.7 ± 12.5 vs 13.3 ± 5.7 mmHg) and barium emptying (14.2 ± 4.2 vs 2.4 ± 3.1 cm) after POEM. At a median follow-up of 63 months (IQR 40-95), clinical success (ES ≤ 3) was documented in 58 (80.6%) patients. Reflux esophagitis and increased esophageal acid exposure were recorded in 28 of 49 (57.1%) and 11 of 20 (55%) patients, respectively.
CONCLUSION
POEM is a durable treatment modality in cases with relapse of symptoms after HM.
背景与目的
经口内镜下肌切开术（POEM）是治疗贲门失弛缓症的一种成熟的治疗方法。然而，关于 POEM 在 Heller 肌切开术（HM）失败后的患者中的长期疗效的数据有限。本研究的目的是评估 POEM 在 HM 后症状持续或复发的患者中的长期疗效。
方法
回顾性分析了 2013 年 9 月至 2022 年 12 月期间因 HM 后症状复发而行 POEM 治疗的患者的数据。主要结局为临床成功[Eckardt 评分（ES）≤3]。次要结局包括 POEM 后测压参数、5 分钟钡排空和胃食管反流（食管炎和食管酸暴露增加）的改善。
结果
本研究纳入了 72 例（45.9±13.4 岁，43 名男性）有 HM 病史的患者。贲门失弛缓症的亚型为 1 型（40.3%）、2 型（37.5%）和未知（19.4%）。既往治疗包括 HM 48 例（66.7%）、HM 联合气动扩张 20 例（27.8%）和 HM 联合气动扩张和肉毒毒素注射 4 例（5.5%）。所有病例均达到技术成功。平均肌切开长度为 10.7±3.3cm，平均手术时间为 59.2±25.9min。POEM 后 ES（术前 6.5±1.8 与术后 0.7±0.7）、食管下括约肌压力（31.7±12.5 与 13.3±5.7mmHg）和钡排空（14.2±4.2 与 2.4±3.1cm）均有显著改善。在中位随访 63 个月（IQR 40-95）时，58 例（80.6%）患者记录到临床成功（ES≤3）。28 例（57.1%）和 11 例（55%）患者分别记录到反流性食管炎和食管酸暴露增加。
结论
POEM 是 HM 后症状复发患者的一种持久的治疗方法。
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