Background and Aims

Heller myotomy (HM) is considered the standard surgical treatment for patients with achalasia. However, approximately 10% to 20% of patients with achalasia have persistent or recurrent symptoms after HM that require further therapy. Several studies have reported the outcomes of peroral endoscopic myotomy (POEM) in these patients. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of POEM in patients with achalasia with previous HM.

Methods

An electronic literature search of PubMed, Embase, and the Cochrane Library was conducted up to January 31, 2020. Studies evaluating the outcomes of POEM in patients with achalasia with previous HM were eligible for inclusion. The primary outcomes were the pooled rates of clinical success (defined as post-POEM Eckardt score ≤3), mean change in Eckardt score, lower esophageal sphincter pressure, and integrated relaxation pressure (IRP). The secondary outcomes were procedure-related adverse events (AEs) and incidence of postoperative GERD.

Results

A total of 9 studies involving 272 patients with achalasia were recruited in this review. POEM was successfully performed in 270 (99.3%) patients after previous HM. Clinical success was achieved in 90.0% (95% confidence interval [CI], 83.1%-96.8%) of patients. Eckardt score, lower esophageal sphincter pressure, and IRP were significantly lowered by 5.14 (95% CI, 4.19-6.09), 12.01 mm Hg (95% CI, 6.74–17.27), and 10.02 mm Hg (95% CI, 4.95-15.09), respectively. The pooled rates of postoperative symptomatic reflux, esophagitis, and abnormal pH monitoring were 36.9% (95% CI, 20.7%-53.1%), 33.0% (95% CI, 9.6%-56.4%), and 47.8% (95% CI, 33.4%-62.2%), respectively. Substantial heterogeneity was detected across all outcome measurements. Most of the AEs were self-limiting or managed conservatively.

Conclusions

POEM is a safe and effective treatment for patients with achalasia with previous HM. Further data from prospective, controlled studies with long-term follow-up are needed to confirm these findings.

中文翻译：

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经先前Heller肌切开术治疗的al门失弛缓患者的经口内镜下肌切开术：系统评价和荟萃分析。

背景和目标

eller肌切开术（HM）被认为是门失弛缓症患者的标准手术治疗方法。但是，大约10％至20％的门失弛缓症患者在HM后出现持续性或复发性症状，需要进一步治疗。几项研究报告了这些患者经口内镜下肌切开术（POEM）的结果。我们进行了系统的回顾和荟萃分析，以评估POEM在既往患有HM的门失弛缓患者中的疗效和安全性。

方法

截至2020年1月31日，进行了PubMed，Embase和Cochrane图书馆的电子文献搜索。对先前患有HM的门失弛缓患者的POEM结果进行评估的研究符合纳入条件。主要结果是合并的临床成功率（定义为POEM后Eckardt评分≤3），Eckardt评分的平均变化，食管括约肌压力降低和综合舒张压（IRP）。次要结果是与手术相关的不良事件（AE）和术后GERD发生率。

结果

这项研究共招募了9项研究，涉及272名门失弛缓患者。在先前的HM之后，成功对270例（99.3％）患者进行了POEM。90.0％（95％置信区间[CI]，83.1％-96.8％）的患者获得了临床成功。Eckardt评分，食管括约肌降低和IRP分别降低了5.14（95％CI，4.19-6.09），12.01 mm Hg（95％CI，6.74-17.27）和10.02 mm Hg（95％CI，4.95-15.09） ）， 分别。术后症状性反流，食管炎和pH值异常监测的合并率为36.9％（95％CI，20.7％-53.1％），33.0％（95％CI，9.6％-56.4％）和47.8％（95％CI） ，33.4％-62.2％）。在所有结果测量中都检测到了很大的异质性。大多数不良事件是自我限制或保守管理的。

结论

POEM对于既往患有HM的门失弛缓患者是一种安全有效的治疗方法。需要前瞻性，对照研究和长期随访的进一步数据，以证实这些发现。