经口内镜肌切开术(POEM)与腹腔镜肌切开术(LHM)对75例III型贲门失弛缓症的治疗：一项多中心比较研究

经口内镜肌切开术（POEM）与腹腔镜Heller肌切开术（LHM）

对75例III型贲门失弛缓症的治疗一项多中心比较研究KumbhariViveketal.POEMvsLHMtreatmentforachalasia…EndoscIntOpen2015;03:E195–E201Peroralendoscopicmyotomy(POEM)vslaparoscopicHellermyotomy(LHM)forthetreatmentofTypeIIIachalasiain75patients:amulticentercomparativestudy

KumbhariViveketal.POEMvsLHMtreatmentforachalasia…EndoscIntOpen2015;03:E195–E2012023/2/1laparoscopicHellermyotomy(LHM)2023/2/1

goldstandard内镜下球囊扩张法2023/2/1Peroralendoscopicmyotomy(POEM)Firstdescribedinaporcinemodelin2007morethan5000clinicalprocedureshavebeenperformedinseveralcentersacrosstheworld

InitialclinicaldatafromEurope,Asia,andUnitedStateshasdemonstratedtheeffectivenessandsafetyofthisprocedurewhenperformedbyexperiencedendoscopists2023/2/1复旦大学附属中山医院在国内率先成功开展POEM微创手术治疗贲门失弛缓症，至今完成2000多例，约占世界总量一半2023/2/1周平红（2010）姚礼庆POEM2023/2/1BACKGROUNDAND

STUDY

AIMSTheoutcomesoftransabdominallaparoscopicHellermyotomy(LHM)fortypeIIIachalasiahasbeenreportedinsubgroupanalysisofachalasiastudieswithclinicalresponseratesof69.3%to86%。TheseoutcomesareinferiortoLHMforotherachalasiasubtypesasevidencedbyresponseratesfortypeIIof95%2023/2/1BACKGROUNDAND

STUDY

AIMSType

III

achalasia

ischaracterizedbyrapidlypropagatingpressurizationattributabletospasticcontractions.Although

laparoscopic

Heller

myotomy

(LHM)isthecurrentgoldstandardmanagementfor

type

III

achalasia,

Peroral

endoscopic

myotomy

(POEM)isconceivablysuperiorbecauseitallowsforalonger

myotomy.Ouraimsweretocomparetheefficacyandsafetyof

POEM

with

LHM

for

type

IIIachalasia

patients2023/2/1PATIENTS

ANDMETHODSAretrospective

study

of49

patients

whounderwent

POEM

for

type

III

achalasia

acrosseightcenterswerecomparedto26

patients

whounderwent

LHM

atasingleinstitution.(4US,3Asian,and1European)betweenJanuary2011andNovember2013wereincludedAugust2000andDecember2013atasingletertiaryUnitedStatesinstitution(JohnsHopkinsHospital)2023/2/1Flowdiagramdepictingthecriteria

usedtoincludepatientssuitableforanalysis2023/2/1Table2Baselinecharacteristicsofpatients

whounderwentperoralendoscopicmyotomyandlaparoscopicHellermyotomy2023/2/1PATIENTS

ANDMETHODS

Proceduraldatawereabstractedandpre-andpost-proceduralsymptomswererecorded.ClinicalresponsewasdefinedbyimprovementofsymptomsanddecreaseinEckardtstageto≤ 1. Secondaryoutcomesincludedlengthof

myotomy,procedureduration,lengthofhospitalstay,andrateofadverseevents.2023/2/12023/2/1Table1EckardtsymptomscoringandstagingRESULTS

Clinicalresponsewassignificantlymorefrequentinthe

POEM

cohort(98.0 %

vs

80.8 %;P = 0.01).

POEM

patients

hadsignificantlyshortermeanproceduretimethan

LHM

patients

(102 min

vs

264min;P < 0.01)despitelongerlengthof

myotomy

(16 cm

vs

8cm;P < 0.01).2023/2/1RESULTS

Therewasnosignificantdifferencebetween

POEM

and

LHM

inthelengthofhospitalstay(3.3days

vs

3.2days;P = 0.68),respectively.Rateofadverseeventswassignificantlylessinthe

POEM

group(6 %

vs

27 %;P < 0.01).2023/2/1CONCLUSIONS

POEM

allowsforalonger

myotomy

than

LHM,whichmayresultinimprovedclinicaloutcomes.

POEM

appearstobeaneffectiveandsafealternativeto

LHM

in

patients

with

type

III

achalasia.2023/2/1limitationsofthisstudy2023/2/1limitationsofthisstudy2023/2/1themeanlengthoffollow-upintheLHMcohortwassubstantiallylongerat21.5monthscomparedto8.6monthsinthePOEMcohort,whichmayhavebiasedtheclinicalresponseinfavorofPOEM.I型被定义为在10次吞咽中，≥8次吞咽时远端食管内压力≤30mmHg；Ⅱ型的定义是在10次吞咽中，至少2次吞咽时食管内压力≥30mmHg；Ⅲ型定义为有2次或以上吞咽伴有痉挛性收缩