Background and Aims

Mucosal injury (MI) is one of the most common perioperative adverse events of per-oral endoscopic myotomy (POEM). Severe undertreated MI may lead to contamination of the tunnel and even mediastinitis. This study explored the characteristics, predictors, and management approaches of intraoperative MI.

Methods

A retrospective review of the prospectively collected database at a large tertiary referral endoscopy unit was conducted for all patients undergoing POEM between August 2010 and March 2016. MI was graded according to the difficulty of repair (I, easy to repair; II, difficult to repair). The primary outcomes were the incidence and predictors of intraoperative MI. Secondary outcomes were MI details and the corresponding treatment.

Results

POEM was successfully performed in 1912 patients. A total of 338 patients experienced 387 MIs, for an overall frequency of 17.7% (338/1912). Type II MI was rare, with a frequency of 1.7% (39/1912). Major adverse events were more common in patients with MI than in those without MI (6.2% vs 2.5%, P < .001). On multivariable analysis, MI was independently associated with previous Heller myotomy (odds ratio [OR], 2.094; P = .026), previous POEM (OR, 2.441; P = .033), submucosal fibrosis (OR, 4.530; P < .001), mucosal edema (OR, 1.834; P = .001), and tunnel length ≥13 cm (OR, 2.699; P < .001). Previous POEM (OR, 5.005; P = .030) and submucosal fibrosis (OR, 12.074; P < .001) were significant predictors of type II MI. POEM experience >1 year was a protective factor for MI (OR, .614; P = .042) and type II MI (OR, .297; P = .042).

Conclusions

MI during POEM is common, but type II injury is rare. Previous POEM and submucosal fibrosis were significant predictors of type II mucosal injury. POEM experience after the learning curve reduces the risk of MI.

中文翻译：

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经口内镜下肌切开术过程中粘膜内损伤的临床和内镜预测因子

背景和目标

粘膜损伤（MI）是经口内镜下肌切开术（POEM）最常见的围手术期不良事件之一。严重未充分治疗的心肌梗塞可能导致隧道污染，甚至纵隔炎。这项研究探讨了术中心肌梗死的特征，预测因素和管理方法。

方法

在2010年8月至2016年3月期间，对所有接受POEM的所有患者在大型三级转诊内窥镜检查单元中对前瞻性收集的数据库进行了回顾性评估。MI根据修复的难度进行分级（I，易于修复； II，难以修复） ）。主要结果是术中MI的发生率和预测指标。次要结果是MI细节和相应的治疗方法。

结果

POEM在1912例患者中成功进行。总共338名患者经历了387例MI，总发生率为17.7％（338/1912）。II型MI很少见，发生率为1.7％（39/1912）。发生心梗的患者的主要不良事件比没有心梗的患者更为常见（6.2％vs 2.5％，P  <.001）。在多变量分析中，MI独立与先前的Heller肌切开术（比值[OR]为2.094；P  = .026），先前的POEM（OR 为2.441 ；P = .033），粘膜下纤维化（OR为4.530；P  <。 001），粘膜水肿（OR，1.834; P  = .001）和隧道长度≥13cm（OR，2.699; P  <.001）。以前的POEM（OR，5.005; P = .030）和粘膜下纤维化（OR，12.074; P  <.001）是II型MI的重要预测指标。POEM经验> 1年是MI（OR，.614; P  = .042）和II型MI（OR，.297; P  = .042）的保护因素。

结论

POEM期间的心梗很常见，但II型损伤很少见。先前的POEM和粘膜下纤维化是II型粘膜损伤的重要预测指标。学习曲线后的POEM经验可降低发生MI的风险。