Nabi Zaheer, Chandran Vinci, Basha Jahangeer, Ramchandani Mohan, Inavolu Pradev, Kalpala Rakesh, Goud Rajesh, Jagtap Nitin, Darisetty Santosh, Gupta Rajesh, Tandan Manu, Lakhtakia Sundeep, Kotla Rama, Devarasetty Rangarao, Rao Guduru Venkat, Reddy D Nageshwar
Asian Institute of Gastroenterology, Hyderabad, India.
Gastrointest Endosc. 2024 Jan;99(1):1-9. doi: 10.1016/j.gie.2023.08.007. Epub 2023 Aug 19.
GERD is common after peroral endoscopic myotomy (POEM). Selective sparing of oblique fibers may reduce the incidence of reflux esophagitis after POEM. In this study, we compared the incidence of GERD between conventional myotomy (CM) versus oblique fiber-sparing (OFS) myotomy in patients with achalasia.
Eligible patients with type I and II achalasia who underwent POEM from January 2020 to October 2020 were randomized into 2 groups (CM and OFS myotomy). Exclusion criteria were type III achalasia, sigmoid esophagus, and history of Heller's myotomy. The primary study outcome was incidence of reflux esophagitis (at least grade B) in the 2 groups. Secondary outcomes were reflux symptoms, esophageal acid exposure, clinical success, and adverse events.
One hundred fifteen patients were randomized into CM (n = 58) and OFS myotomy (n = 57) groups. POEM was technically successful in all patients. Overall, reflux esophagitis was found in 56 patients (48.7%). The incidence of at least grade B esophagitis was similar in both groups (CM vs OFS myotomy: 25.9% vs 31.6%, P = .541). The mean number of reflux episodes (48.2 ± 36.6 vs 48.9 ± 40.3, P = .933), increased esophageal acid exposure >6% (45.5% vs 31.7%, P = .266), and high DeMeester scores (38.6% vs 41.5%, P = .827) were similar in both groups. There was no difference in the rate of symptomatic reflux (GERD questionnaire score >7) or use of proton pump inhibitors at 1 year.
Sparing of sling fibers has no significant impact on the incidence of significant reflux esophagitis after POEM. Novel strategies need to be explored to prevent reflux after POEM. (Clinical trial registration number: NCT04229342.).
经口内镜下肌切开术（POEM）后胃食管反流病（GERD）很常见。选择性保留斜行肌纤维可能会降低POEM术后反流性食管炎的发生率。在本研究中，我们比较了贲门失弛缓症患者常规肌切开术（CM）与保留斜行肌纤维（OFS）肌切开术的GERD发生率。
将2020年1月至2020年10月接受POEM的I型和II型贲门失弛缓症合格患者随机分为两组（CM和OFS肌切开术）。排除标准为III型贲门失弛缓症、乙状结肠食管和海勒肌切开术病史。主要研究结局是两组反流性食管炎（至少B级）的发生率。次要结局是反流症状、食管酸暴露、临床成功率和不良事件。
115例患者被随机分为CM组（n = 58）和OFS肌切开术组（n = 57）。所有患者的POEM技术均成功。总体而言，56例患者（48.7%）发现有反流性食管炎。两组至少B级食管炎的发生率相似（CM组与OFS肌切开术组：25.9%对31.6%，P = 0.541）。两组的平均反流发作次数（48.2±36.6对48.9±40.3，P = 0.933）、食管酸暴露增加>6%（45.5%对31.7%，P = 0.266）和高DeMeester评分（38.6%对41.5%，P = 0.827）相似。1年时症状性反流率（GERD问卷评分>7）或质子泵抑制剂的使用情况无差异。
保留吊带肌纤维对POEM术后严重反流性食管炎的发生率无显著影响。需要探索新的策略来预防POEM术后的反流。（临床试验注册号：NCT04229342。）
