POEM最近有了广泛的传播,旨在成为食道门失弛缓症的首选治疗方法。正在进行的针对腹腔镜肌切开术的RCT结果不可用,yet.我们,因此,设计了此倾向评分(PS)病例对照研究,目的是评估POEM与长期腹腔镜Heller肌切开术Dor胃底折叠术(LHD)的比较,并验证它是否真的可以取代后者作为门失弛缓症的一线治疗。
两组2014年1月至2017年11月接受原发性贲门失弛缓症治疗的连续患者在两个高容量中心招募。一个拥有丰富的POEM经验,一个拥有LHD经验。包括以前接受过内镜治疗的患者,而既往有LHD或POEM的患者被排除在外.因此,两个中心共有140名患者匹配。LHD和POEM按照已建立的技术进行。对患者进行临床随访(Eckardt评分),内窥镜,和pH压力测定评估。
所有患者均顺利完成手术。与LHD相比,POEM需要更短的手术时间和术后住院时间(p<0.001)。两组均无死亡记录。POEM组记录了7例并发症(5例粘膜穿孔),LHD组记录了3例并发症(3例粘膜穿孔)(p=0.33)。POEM组的两名患者和LHD的一名患者失去了随访。两组中的一名患者在随访期间因无关原因死亡。POEM的中位随访时间为24个月[15-30],LHD的中位随访时间为31个月[15-41](p<0.05),99.3%的POEM患者和97.7%的LHD患者显示Eckardt评分≤3(p<0.12)。治疗四年后,两组患者症状得到充分控制的概率均>90%(p=0.2,Log-rank检验).HR测压显示LES压力和4sIRP的降低相似;24小时pH监测显示38.4%的POEM患者异常暴露于酸,与17.1%的LHD患者相比(p<0.01),在37.4%的POEM患者和15.2%的LHD患者中发现食管炎(p<0.05)。
POEM提供与LHD相同的中期结果。这项研究证实,然而,前者术后GERD发生率较高,即使它的真正意义需要进一步评估。
POEM has recently had a widespread diffusion, aiming at being the treatment of choice for esophageal achalasia. The results of ongoing RCTs against laparoscopic myotomy are not available, yet. We, therefore, designed this propensity score (PS)
case-control study with the aim of evaluating how POEM compares to the long-standing laparoscopic Heller myotomy + Dor fundoplication (LHD) and verifying if it may really replace the latter as the first-line treatment for achalasia.
Two groups of consecutive patients undergoing treatment for primary achalasia from January 2014 to November 2017 were recruited in two high-volume centers, one with extensive experience with POEM and one with LHD. Patients with previous endoscopic treatment were included, whereas patients with previous LHD or POEM were excluded. A total of 140 patients in both centers were thus matched. LHD and
POEM were performed following established techniques. The patients were followed with clinical (Eckardt score), endoscopic, and pH-manometry evaluations.
The procedure was successfully completed in all the patients. POEM required a shorter operation time and postoperative stay compared to LHD (p < 0.001). No mortality was recorded in either group. Seven complications were recorded in the POEM group (five mucosal perforations) and 3 in the LHD group (3 mucosal perforations)(p = 0.33). Two patients in the
POEM group and one in the LHD were lost to follow-up. One patient in both groups died during the follow-up for unrelated causes. At a median follow-up of 24 months [15-30] for POEM and 31 months [15-41] for LHD (p < 0.05), 99.3% of the POEM patients and 97.7% of the LHD patients showed an Eckardt score ≤ 3 (p < 0.12). Four years after the treatment, the probability to have symptoms adequately controlled was > 90% for both groups (p = 0.2, Log-rank test). HR-Manometry showed a similar reduction in the LES pressure and 4sIRP; 24-h pH-monitoring showed however an abnormal exposure to acid in 38.4% of POEM patients, as compared to 17.1% of LHD patients (p < 0.01) and esophagitis was found in 37.4% of the POEM and 15.2% of LHD patients (p < 0.05).
POEM provides the same midterm results as LHD. This study confirms, however, a higher incidence of postoperative GERD with the former, even if its real significance needs to be further evaluated.