背景:食管胃交界处流出道梗阻(EGJOO)是一种食管运动性障碍,其特征是食管下括约肌(LES)松弛失败,蠕动保留。研究表明,Heller肌切开术联合Dor胃底折叠术(HMD)和经口内镜肌切开术(POEM)是EGJOO的有效治疗方法。然而,缺乏比较这两种手术的疗效和影响的数据。因此,本研究的目的是比较原发性EGJOO接受HMD或POEM的患者的结局和对食管生理学的影响.
方法:这是对2013年至2021年在我们机构接受HMD或POEM进行原发性EGJOO的患者的回顾性研究。良好的结局定义为术后1年Eckardt评分≤3。GERD-HRQL问卷,内窥镜检查,pH监测,比较手术前和术后以及组间基线和术后1年的高分辨率测压(HRM)结果.目的GERD定义为DeMeester评分>14.7或LAC/D级食管炎。
结果:最终研究人群包括52例接受过HMD(n=35)或POEM(n=17)的EGJOO患者。在平均(SD)随访24.6(15.3)个月时,30例(85.7%)患者接受HMD治疗,14例(82.4%)患者接受POEM治疗(p=0.753).在HMD之后,GERD-HRQL总分下降(31(22-45)至4(0-19);p<0.001),和客观反流(54.2%至25.9%;p=0.033)。在测压上,LES静息压(48(34-59)至13(8-17);p<0.001)和IRP(22(17-28)至8(3-11);p<0.001),但食管体部特征没有改变(p>0.05)。不完全推注清除改善(70%(10-90)至10%(0-40);p=0.010)。在POEM之后,GERD-HRQL总分无变化(p=0.854),但客观反流显着增加(0至62%;p<0.001)。在测压上,LES静息压力(43(30-68)至31(5-34);p=0.042)和IRP(23(18-33)至12(10-32);p=0.048),DCI(1920(1600-5500)至0(0-814);p=0.035),失败的吞咽增加(0%(0-30)至100%(10-100);p=0.032)。Bolusclearancedidnotimproved(p=0.539).与HMD相比,POEM的食管肌切开术长度较长(11(7-15)-5(5-6);p=0.001),更客观的反流(p=0.041),较低的DCI(0(0-814)-vs-1695(929-3101);p=0.004),和完整的燕子(90(70-100)-vs-0(0-40);p=0.006),但更多的失败吞咽(100(10-100);p=0.018)和不完全的推注间隙(90(90-100)-vs-10(0-40);p=0.004)。
结论:经口内镜下肌切开术和Heller肌切开术联合Dor胃底折叠术在缓解EGJOO症状方面同样有效。然而,POEM导致更严重的反流和几乎完全的食道身体功能丧失。
Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by failure of lower esophageal sphincter (LES) relaxation with preserved peristalsis. Studies have shown that Heller myotomy with Dor fundoplication (HMD) and per oral endoscopic myotomy (POEM) are effective treatments for EGJOO. However, there is paucity of data comparing the efficacy and impact of these two procedures. Therefore, the aim of this study was to compare outcomes and impact on esophageal physiology in patients undergoing HMD or POEM for primary EGJOO.
This was a retrospective review of patients who underwent either HMD or POEM for primary EGJOO at our institution between 2013 and 2021. Favorable outcome was defined as an Eckardt score ≤ 3 at 1 year after surgery. GERD-HRQL questionnaire, endoscopy, pH monitoring, and high-resolution manometry (HRM) results at baseline and 1 year after surgery were compared pre- and post-surgery and between groups. Objective GERD was defined as DeMeester score > 14.7 or LA grade C/D esophagitis.
The final study population consisted of 52 patients who underwent HMD (n = 35) or POEM (n = 17) for EGJOO. At a mean (SD) follow-up of 24.6 (15.3) months, favorable outcome was achieved by 30 (85.7%) patients after HMD and 14 (82.4%) after POEM (p = 0.753). After HMD, there was a decrease GERD-HRQL total score (31 (22-45) to 4 (0-19); p < 0.001), and objective reflux (54.2 to 25.9%; p = 0.033). On manometry, there was a decrease in LES resting pressure (48 (34-59) to 13 (8-17); p < 0.001) and IRP (22 (17-28) to 8 (3-11); p < 0.001), but esophageal body characteristics did not change (p > 0.05). Incomplete bolus clearance improved (70% (10-90) to 10% (0-40); p = 0.010). After POEM, there was no change in the GERD-HRQL total score (p = 0.854), but objective reflux significantly increased (0 to 62%; p < 0.001). On manometry, there was a decrease in LES resting pressure (43 (30-68) to 31 (5-34); p = 0.042) and IRP (23 (18-33) to 12 (10-32); p = 0.048), DCI (1920 (1600-5500) to 0 (0-814); p = 0.035), with increased failed swallows (0% (0-30) to 100% (10-100); p = 0.032). Bolus clearance did not improve (p = 0.539). Compared to HMD, POEM had a longer esophageal myotomy length (11 (7-15)-vs-5 (5-6); p = 0.001), more objective reflux (p = 0.041), lower DCI (0 (0-814)-vs-1695 (929-3101); p = 0.004), and intact swallows (90 (70-100)-vs-0 (0-40); p = 0.006), but more failed swallows (100 (10-100); p = 0.018) and incomplete bolus clearance (90 (90-100)-vs-10 (0-40); p = 0.004).
Peroral endoscopic myotomy and Heller myotomy with Dor fundoplication are equally effective at relieving EGJOO symptoms. However, POEM causes worse reflux and near complete loss of esophageal body function.