背景:腹腔镜和内镜下两种方法对贲门失弛缓症的手术治疗已被认为是儿童的明确治疗方法。尽管许多中心的报道量很低,在全球范围内,内镜治疗小儿贲门失弛缓症的经验越来越多.这项研究的目的是报告我们通过口腔内镜下肌切开术(POEM)作为贲门失弛缓症的一线或修正治疗的机构经验。
方法:IRB批准对所有因门失弛缓症接受手术治疗的患者进行回顾性研究,特别是使用POEM技术,从2015年7月到2021年9月。数据包括人口统计,术中细节,手术前后的Eckardt评分,并发症,结果,并取得了随访。
结果:在研究期间,共有43名儿童接受了46例贲门失弛缓症手术,包括POEM和腹腔镜Heller肌切开术(LHM).操作包括37个POEMS(33个主要POEMS;LHM失败后3个POEMS;POEM失败后1个POEM)。此外,9LHM操作,包括,4个主LHM;3个尝试POEMS转换为LHM;1个失败的LHM转换为重做LHM后尝试POEM;1个失败的POEM后LHM。在POEM组(n=37)中,根据高分辨率食管测压结果,Chicago诊断时的分类类型如下:9例患者为I型(24.3%);25例患者为II型(67.6%);2例患者为III型(5.9%),1例患者为未知类型(2.7%).16名儿童(43.2%)在POEM[气动球囊扩张术(PBD)之前曾接受过贲门失弛缓症的内镜治疗,和/或肉毒杆菌注射液(BTI)],),而先前的手术干预发生在4例(10.8%),3LHM和1POEM。手术年龄为2-18岁(平均±SD年龄:11.6±4.5岁)。手术时的体重11.8-100.7kg(平均值±SDkg;39±19.9kg)。基线Eckardt评分范围为4-10分(平均值±SD:6.73±1.5)。手术时间为64-359分钟(平均±SD分钟:138.1±62.2分钟)。术中并发症16例(43.2%),但在入院时不需要再次手术,包括:4例粘膜切开术(11.8%);9例气胸(24.3%);2例纵隔气肿(5.4%);10例气腹(27%);0例粘膜下隧道出血(0%);0例开放转换/死亡(0%)。术后并发症包括:5例反复吞咽困难(13.5%);0例食管漏(0%);3例GERD(8.1%);1例POEM失败(2.7%)。中位住院时间为2天(平均±SD天:2.4±0.9天)。随访时间为1~74个月,中位数为15个月,平均随访22.6个月±20个月。POEM后Eckardt评分为0.6±0.9。5例患者在POEM后需要一次PBD(13.5%),1例患者在POEM后需要重复肌切开术(LHM)(2.7%),再干预率为16.2%。随后Eckardt评分正常化(≤3),所有患者(100%)均达到症状缓解。
结论:POEM作为小儿门失弛缓症的一线治疗,或作为先前肌切开术或POEM失败后的二次手术,在我们的经验是安全有效的。我们已经展示了与我们自己先前使用LHM的经验相当的结果。将进行长期随访以监测复发症状,足够的身体生长,和一般发展。
方法:II.
BACKGROUND: The surgical treatment of achalasia by both laparoscopic and endoscopic approaches has been recognized as the definitive management in children. Despite reported low volumes in many centers, there has been an increasing worldwide experience with endoscopic approaches to pediatric achalasia. The aim of this study is to report our institutional experience with per oral endoscopic myotomy (POEM) as first-line or revisional therapy for achalasia.
METHODS: An IRB approved retrospective review of all patients who underwent operative procedures for achalasia, specifically with the POEM technique, from July 2015 to September 2021. Data including demographics, intra-operative details, pre and post operative Eckardt scores, complications, outcomes, and follow-up were obtained.
RESULTS: During the study period, a total of 43 children underwent 46 operations for achalasia including POEM and laparoscopic Heller myotomy (LHM). Operations included 37 POEMS (33 primary POEMS; 3 POEMS after failed LHM; and 1 POEM after failed POEM). Additionally, 9 LHM operations including, 4 primary LHM; 3 attempted POEMS converted to LHM; 1 attempted POEM after failed LHM converted to redo LHM; and 1 LHM after failed POEM. In the POEM group (n = 37), based on the high resolution esophageal manometry findings Chicago Classification types at diagnosis were as follows: 9 patients were type I (24.3%); 25 patients were type II (67.6%); 2 patients were type III (5.9%) and 1 patient was unknown type (2.7%). Sixteen children (43.2%) had prior endoscopic treatment of achalasia prior to POEM [Pneumatic Balloon Dilatation (PBD), and/or Botox injection (BTI)],), while prior operative intervention occurred in 4 patients (10.8%), 3 LHM and 1 POEM. Age at operation was 2-18 years (mean ± SD age: 11.6 ± 4.5 years). Weight at operation 11.8-100.7 kg (mean ± SD kg; 39 ± 19.9 kg). Range of baseline Eckardt score was 4-10 (mean ± SD: 6.73 ± 1.5). Operative time was 64-359 min (mean ± SD minutes: 138.1 ± 62.2 min). Intraoperative complications occurred in 16 patients (43.2%) but did not require reoperation during index admission including: 4 mucosotomy (11.8%); 9 pneumothoraces (24.3%); 2 pneumomediastinum (5.4%); 10 pneumoperitoneum (27%); 0 sub-mucosal tunnel bleeding (0%); 0 open conversion/death (0%). Post operative complications included: 5 recurrent dysphagia (13.5%); 0 esophageal leak (0%); 3 GERD (8.1%); 1 failed POEM (2.7%). Median length of stay was 2 days (mean ± SD days: 2.4 ± 0.9 day). Follow-up ranged from 1 to 74 months (median 15 months), mean follow-up 22.6 months ± 20 months. Post POEM Eckardt score was 0.6 ± 0.9. Five patients required a single PBD post POEM (13.5%) and 1 patient required a repeat myotomy (LHM) after POEM (2.7%) for a 16.2% reintervention rate. Subsequent normalization of Eckardt scores (≤ 3) and symptomatic relief was achieved in all patients (100%).
CONCLUSIONS: POEM as first-line therapy for pediatric achalasia, or as a secondary procedure after failed prior myotomy or POEM, in our experience is safe and effective. We have shown equivalent results to our own prior experience with LHM. Long-term follow-up will be performed to monitor for recurrent symptoms, adequate physical growth, and general development.
METHODS: II.