Abstract：
BACKGROUND: Long-term outcome data are limited for non-achalasia esophageal motility disorders treated by peroral endoscopy myotomy (POEM) as a separate group. We investigated a subset of symptomatic patients with hypercontractile esophagus (Jackhammer esophagus).
METHODS: Forty two patients (mean age 60.9 years; 57% female, mean Eckardt score 6.2 ± 2.1) treated by primary peroral myotomy for symptomatic Jackhammer esophagus 2012-2018 in seven European centers were retrospectively analyzed; myotomy included the lower esophageal sphincter but did not extend more than 1 cm into the cardia in contrast to POEM for achalasia. Manometry data were re-reviewed by an independent expert. The main outcome was the failure rate defined by retreatment or an Eckardt score >3 after at least two years following POEM.
RESULTS: Despite 100% technical success (mean intervention time 107 ± 48.9 min, mean myotomy length 16.2 ± 3.7 cm), the 2-year success rate was 64.3% in the entire group. In a subgroup analysis, POEM failure rates were significantly different between Jackhammer-patients without (n = 22), and with esophagogastric junction outflow obstruction (EGJOO, n = 20) (13.6% % vs. 60%, p = 0.003) at a follow-up of 46.5 ± 19.0 months. Adverse events occurred in nine cases (21.4%). 14 (33.3%) patients were retreated, two with surgical fundoplication due to reflux. Including retreatments, an improvement in symptom severity was found in 33 (78.6%) at the end of follow-up (Eckardt score ≤3, mean Eckardt change 4.34, p < 0.001). EGJOO (p = 0.01) and frequency of hypercontractile swallows (p = 0.02) were predictors of POEM failure. The development of a pseudodiverticulum was observed in four cases within the subgroup of EGJOO.
CONCLUSIONS: Patients with symptomatic Jackhammer without EGJOO benefit from POEM in long-term follow-up. Treatment of Jackhammer with EGJOO, however, remains challenging and probably requires full sphincter myotomy and future studies which should address the pathogenesis of this variant and alternative strategies.
METHODS: Forty two patients (mean age 60.9 years; 57% female, mean Eckardt score 6.2 ± 2.1) treated by primary peroral myotomy for symptomatic Jackhammer esophagus 2012-2018 in seven European centers were retrospectively analyzed; myotomy included the lower esophageal sphincter but did not extend more than 1 cm into the cardia in contrast to POEM for achalasia. Manometry data were re-reviewed by an independent expert. The main outcome was the failure rate defined by retreatment or an Eckardt score >3 after at least two years following POEM.
RESULTS: Despite 100% technical success (mean intervention time 107 ± 48.9 min, mean myotomy length 16.2 ± 3.7 cm), the 2-year success rate was 64.3% in the entire group. In a subgroup analysis, POEM failure rates were significantly different between Jackhammer-patients without (n = 22), and with esophagogastric junction outflow obstruction (EGJOO, n = 20) (13.6% % vs. 60%, p = 0.003) at a follow-up of 46.5 ± 19.0 months. Adverse events occurred in nine cases (21.4%). 14 (33.3%) patients were retreated, two with surgical fundoplication due to reflux. Including retreatments, an improvement in symptom severity was found in 33 (78.6%) at the end of follow-up (Eckardt score ≤3, mean Eckardt change 4.34, p < 0.001). EGJOO (p = 0.01) and frequency of hypercontractile swallows (p = 0.02) were predictors of POEM failure. The development of a pseudodiverticulum was observed in four cases within the subgroup of EGJOO.
CONCLUSIONS: Patients with symptomatic Jackhammer without EGJOO benefit from POEM in long-term follow-up. Treatment of Jackhammer with EGJOO, however, remains challenging and probably requires full sphincter myotomy and future studies which should address the pathogenesis of this variant and alternative strategies.
摘要：
背景：经口内镜肌切开术（POEM）治疗的非贲门失弛缓性食管运动障碍的长期结果数据有限。我们调查了一部分有症状的食管过度收缩（Jachammer食管）患者。
方法：42例患者（平均年龄60.9岁；57％为女性，回顾性分析2012-2018年在7个欧洲中心对有症状的Jackhammer食管行原发性经口肌切开术治疗的平均Eckardt评分6.2±2.1);肌切开术包括食管下括约肌,但延伸进贲门不超过1cm,而POEM用于贲门失弛缓症.独立专家重新审查了测压数据。主要结果是在POEM后至少两年后，由再治疗或Eckardt评分>3定义的失败率。
结果：尽管技术上取得了100％的成功（平均干预时间107±48.9分钟，平均肌切开术长度16.2±3.7cm），全组2年成功率为64.3%。在亚组分析中，POEM失败率在无创手的患者(n=22)之间有显著差异，以及食管胃结合部流出道梗阻(EGJOO，n=20）（13.6%与60%,p=0.003），随访46.5±19.0个月。不良事件发生在9例(21.4%)。14例(33.3%)患者接受复治,两个由于反流导致的胃底折叠术。包括再治疗，随访结束时,33例(78.6%)患者症状严重程度改善(Eckardt评分≤3分,平均Eckardt变化4.34,p<0.001).EGJOO（p=0.01）和吞下过度收缩的频率（p=0.02）是POEM失败的预测因子。在EGJOO亚组的4例中观察到假憩室的发展。
结论：在长期随访中，没有EGJOO的有症状的手提钻患者受益于POEM。EGJOO治疗手提钻,然而,仍然具有挑战性，可能需要完整的括约肌切开术和未来的研究，这些研究应解决这种变异和替代策略的发病机制。
方法：42例患者（平均年龄60.9岁；57％为女性，回顾性分析2012-2018年在7个欧洲中心对有症状的Jackhammer食管行原发性经口肌切开术治疗的平均Eckardt评分6.2±2.1);肌切开术包括食管下括约肌,但延伸进贲门不超过1cm,而POEM用于贲门失弛缓症.独立专家重新审查了测压数据。主要结果是在POEM后至少两年后，由再治疗或Eckardt评分>3定义的失败率。
结果：尽管技术上取得了100％的成功（平均干预时间107±48.9分钟，平均肌切开术长度16.2±3.7cm），全组2年成功率为64.3%。在亚组分析中，POEM失败率在无创手的患者(n=22)之间有显著差异，以及食管胃结合部流出道梗阻(EGJOO，n=20）（13.6%与60%,p=0.003），随访46.5±19.0个月。不良事件发生在9例(21.4%)。14例(33.3%)患者接受复治,两个由于反流导致的胃底折叠术。包括再治疗，随访结束时,33例(78.6%)患者症状严重程度改善(Eckardt评分≤3分,平均Eckardt变化4.34,p<0.001).EGJOO（p=0.01）和吞下过度收缩的频率（p=0.02）是POEM失败的预测因子。在EGJOO亚组的4例中观察到假憩室的发展。
结论：在长期随访中，没有EGJOO的有症状的手提钻患者受益于POEM。EGJOO治疗手提钻,然而,仍然具有挑战性，可能需要完整的括约肌切开术和未来的研究，这些研究应解决这种变异和替代策略的发病机制。
