腹腔镜Heller肌切开术与经口内镜下肌切开术治疗贲门失弛缓症疗效及安全性的meta分析

doi:10.3969/j.issn.1004-583X.2024.08.002

摘要/Abstract

摘要：

目的系统评价腹腔镜Heller肌切开术(LHM)与经口内镜下肌切开术(POEM)治疗贲门失弛缓症的疗效及安全性。方法计算机检索PubMed、EMbase、The Cochrane Library、Web of Science 及万方数据库、维普数据库、中国知网数据库(CNKI),搜索建库至2023年11月公开发表的相关文献,采用RevMan 5.0软件进行meta 分析。结果共纳入15篇文献,其中1篇是随机对照试验,8篇是回顾性队列研究,6篇是前瞻性非随机对照试验。共1 439例患者,LHM组696例,POEM组743例。Meta分析结果显示,与LHM组相比,POEM组术后吞咽困难复发率更低[OR=2.01, 95%CI(1.17, 3.44), P=0.01]、手术时间更短[MD=22.66,95%CI(5.57, 39.75),P=0.009]、住院时间更短[MD=0.55, 95%CI(0.38, 0.71), P<0.01]、术后恢复正常生活天数更少[MD=4.49, 95%CI(4.00, 4.97), P<0.01],在胃食管反流病发生率和术后皮下气肿发生率上LHM低于POEM[OR=0.64, 95%CI(0.45, 0.90), P=0.009;OR=0.33, 95%CI(0.11,0.99), P=0.05];而在术后总并发症发生率、术后质子泵抑制剂使用率、术后6个月Eckardt评分等方面,两个术式差异无统计学意义(P>0.05)。结论与LHM相比,POEM术后吞咽困难复发率、手术时间、住院时间、术后恢复正常生活天数更具优势。

关键词: 贲门失弛缓症, 腹腔镜Heller肌切开术, 经口内镜下肌切开术, Meta分析

Abstract:

Objective To systematically evaluate the efficacy and safety of laparoscopic Heller myotomy (LHM) versus peroral endoscopic myotomy (POEM) on esophageal achalasia. Methods Relevant articles reporting the efficacy and safety of LHM versus POEM on esophageal achalasia published up to November 2023 were searched in the PubMed, EMbase, The Cochrane Library, Web of Science, Wanfang database, VIP and China Knowledge Network database (CNKI). Meta-analysis was performed using RevMan 5.0 software. Results A total of 15 articles were included, including 1 randomized controlled trial, 8 retrospective cohort studies, and 6 prospective non-randomized controlled trials. A total of 1, 439 patients were included, with 696 patients in the LHM group and 743 in the POEM group. Meta-analysis showed that POEM resulted in a significantly lower recurrent rate of postoperative dysphagia (OR=2.01, 95%CI 1.17, 3.44, P=0.01), shorter operative time (MD=22.66, 95%CI 5.57, 39.75, P=0.009), shorter length of stay (MD=0.55, 95%CI 0.38, 0.71, P<0.01), fewer days to return to normal life after surgery (MD=4.49, 95%CI 4.00, 4.97, P<0.01) than those in the LHM group, LHM resulted in a significantly lower incidences of gastroesophageal reflux disease (OR=0.64, 95%CI 0.45, 0.90, P=0.009) and postoperative subcutaneous emphysema (OR=0.33, 95%CI 0.11, 0.99, P=0.05) than those in the POEM group. The incidence of total postoperative complications, postoperative proton pump inhibitors utilization, and postoperative Eckardt score at 6 months were comparable between groups (P>0.05). Conclusion Compared with LHM, POEM has more advantages in lowering the recurrence of postoperative dysphagia, operative time, length of stay, and duration to return to normal life after surgery.

Key words: achalasia, laparoscopic Heller myotomy, peroral endoscopic myotomy, meta-analysis

中图分类号:

R571

叶智博, 李可勇, 阙昌浩, 王亚平, 苟云久. 腹腔镜Heller肌切开术与经口内镜下肌切开术治疗贲门失弛缓症疗效及安全性的meta分析[J]. 临床荟萃, 2024, 39(8): 684-692.

Ye Zhibo, Li Keyong, Que Changhao, Wang Yaping, Gou Yunjiu. Efficacy and safety of laparoscopic Heller myotomy versus peroral endoscopic myotomy on esophageal achalasia: A meta-analysis[J]. Clinical Focus, 2024, 39(8): 684-692.

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链接本文: https://huicui.hebmu.edu.cn/CN/10.3969/j.issn.1004-583X.2024.08.002

https://huicui.hebmu.edu.cn/CN/Y2024/V39/I8/684

图/表 15

图1 文献筛选流程及结果

Fig.1 Literature screening process and results

表1 纳入研究的基本信息

Tab.1 Baseline information of included studies

纳入研究	研究方法	国家	BMI		手术方式		例数	年龄(岁)		男/女(例)
纳入研究	研究方法	国家	LHM组	POEM组	LHM组	POEM组	例数	LHM组	POEM组	LHM组	POEM组
蒋彬^[8]2019	R	中国	NA	NA	LHM	POEM	61	44.1±14.8	45.4±14.6	14/16	18/13
Hungness^[9] 2013	R	美国	25	27	LHM	POEM	73	49	38	29/26	13/5
Ujiki^[10] 2013	PNC	美国	26.5±1.3	25.3±1.1	LHM	POEM	39	60.2±4.7	64.1±4.8	12/9	13/5
Bhayani^[11] 2014	R	美国	NA	NA	LHM	POEM	101	57 56	31/33	19/18
Kumagai^[12] 2014	PNC	瑞典	22.9±3.6	23.3±3.7	LHM	POEM	83	45	45.5	19/22	27/15
Chan^[13] 2016	R	中国	NA	NA	LHM	POEM	56	38.4	48.2	11/12	12/21
Leeds^[14] 2017	PNC	美国	28.8±5.2	25.7±4.0	LHM	POEM	23	52.7±12.4	52.0±16.9	6/5	4/8
Peng^[15] 2017	R	中国	NA	NA	LHM	POEM	31	44.7±21.6	37.5±13.0	8/10	8/5
Werner^[16] 2019	RCT	美国	24.5±4.5	24.8±4.6	LHM	POEM	221	48.6±14.6	41.7±14.8	60/49	68/44
Wirsching^[17] 2019	PNC	美国	27	30	LHM	POEM	51	56.6	58	12/16	11/12
Ali^[18] 2020	R	巴西	NA	NA	LHM	POEM	40	44.2±13.2	44.9±14.6	14/6	12/8
Costantini^[19] 2020	PNC	意大利	22	23	LHM	POEM	280	48	47	73/67	70/70
Attaar^[20] 2021	R	美国	26.8±5.7	27.1±6.7	LHM	POEM	159	58.0±19.0	64.0±16.0	19/14	62/64
Podboy^[21] 2021	R	美国	NA	NA	LHM	POEM	98	58.0±2.4	59.2±2.4	10/33	22/33
Wong^[22] 2023	PNC	马来西亚	NA	NA	LHM	POEM	123	48.1±17.3	41.7±14.8	31/29	29/34

图2 2组术后吞咽困难复发率meta分析森林图

Fig.2 Forest plot of meta-analysis of the recurrent rate of postoperative dysphagia in the two groups

表2 2组术后并发症发生率比较

Tab.2 Incidence of postoperative complications between the LHM group and the POEM group

并发症	纳入研究数量	样本量(例)		$I 2$ (%)	$O R$ 值	分析模型	95% $C I$	$P$ 值
并发症	纳入研究数量	LHM组	POEM组	$I 2$ (%)	$O R$ 值	分析模型	95% $C I$	$P$ 值
总体并发症	12^{[8⇓-10,12⇓⇓⇓ -16,18⇓ -20,22]}	561	628	27	0.82	固定效应模型	(0.55, 1.23)	0.33
胃食管反流病	10^{[8,10⇓⇓ -13,15,17,19,21,22]}	387	407	48	0.64	固定效应模型	(0.45, 0.90)	<0.05
皮下气肿	5^{[8⇓-10,13,15]}	147	113	16	0.33	固定效应模型	(0.11, 0.99)	0.05
食管穿孔	7^{[9- 10,12,14,16,19,22]}	437	405	0	0.86	固定效应模型	(0.39, 1.90)	0.7
黏膜损伤	4^[8,14,17,22]	129	129	67	0.86	随机效应模型	(0.11, 6.61)	0.89

表2 2组术后并发症发生率比较

Tab.2 Incidence of postoperative complications between the LHM group and the POEM group

并发症	纳入研究数量	样本量(例)		$I 2$ (%)	$O R$ 值	分析模型	95% $C I$	$P$ 值
并发症	纳入研究数量	LHM组	POEM组	$I 2$ (%)	$O R$ 值	分析模型	95% $C I$	$P$ 值
总体并发症	12^{[8⇓-10,12⇓⇓⇓ -16,18⇓ -20,22]}	561	628	27	0.82	固定效应模型	(0.55, 1.23)	0.33
胃食管反流病	10^{[8,10⇓⇓ -13,15,17,19,21,22]}	387	407	48	0.64	固定效应模型	(0.45, 0.90)	<0.05
皮下气肿	5^{[8⇓-10,13,15]}	147	113	16	0.33	固定效应模型	(0.11, 0.99)	0.05
食管穿孔	7^{[9- 10,12,14,16,19,22]}	437	405	0	0.86	固定效应模型	(0.39, 1.90)	0.7
黏膜损伤	4^[8,14,17,22]	129	129	67	0.86	随机效应模型	(0.11, 6.61)	0.89

图3 2组术后并发症meta分析森林图

Fig.3 Forest plot of meta-analysis of postoperative complications in the two groups

图4 2组术后胃食管反流病发生率meta分析森林图

Fig.4 Forest plot of meta-analysis of the incidence of postoperative gastroesophageal reflux disease in the two groups

图5 2组手术时间meta分析森林图

Fig.5 Forest plot of meta-analysis of operative time in the two groups

图6 2组住院时间meta分析森林图

Fig.6 Forest plot of meta-analysis of length of stay in the two groups

图7 2组住院时间亚洲组meta分析森林图

Fig.7 Forest plot of meta-analysis for length of stay in the Asian group

图8 2组住院时间非亚洲组meta分析森林图

Fig.8 Forest plot of meta-analysis for length of stay in non-Asian group

图9 2组术后PPI使用率meta分析森林图

Fig.9 Forest plot of meta-analysis of postoperative PPI utilization in the two groups

图10 2组术后6个月Eckardt评分meta分析森林图

Fig.10 Forest plot of meta-analysis of Eckardt score at moth 6 in the two groups

图11 2组术后恢复正常生活天数meta分析森林图

Fig.11 Forest plot of meta-analysis of the days to return to normal life after surgery in the two groups

图12 手术时间的漏斗图

Fig.12 Funnel plot of operation time

图13 术后胃食管反流病发生率的漏斗图

Fig.13 Funnel plot of the incidence of gastroesophageal reflux disease after surgery

参考文献 34

[1]	Vaezi MF, Pandolfino JE, Yadlapati RH, et al. ACG Clinical Guidelines: Diagnosis and management of achalasia[J]. Am J Gastroenterol, 2020, 115(9): 1393-1411. doi: 10.14309/ajg.0000000000000731 pmid: 32773454
[2]	刘瑛, 金世柱, 徐婉莹. 贲门失弛缓症发病机制的研究进展[J]. 中国比较医学杂志, 2020, 30(10): 138-142.
[3]	Schlottmann F, Herbella FAM, Patti MG. The evolution of the treatment of esophageal achalasia: From the open to the minimally invasive approach[J]. World J Surg, 2022, 46(7): 1522-1526.
[4]	Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia[J]. Endoscopy, 2010, 42(4): 265-271. doi: 10.1055/s-0029-1244080 pmid: 20354937
[5]	Rolland S, Paterson W, Bechara R. Achalasia: Current therapeutic options[J]. Neurogastroenterol Motil, 2023, 35(1): e14459.
[6]	Pesce M, Sweis R. Advances and caveats in modern achalasia management[J]. Ther Adv Chronic Dis, 2021, 12: 2040622321993437.
[7]	中华医学会消化内镜学分会超级微创协作组, 中国医师协会内镜医师分会, 北京医学会消化内镜学分会. 中国贲门失弛缓症诊治专家共识(2020, 北京)[J]. 中华消化内镜杂志, 2021, 38(4):256-275.
[8]	蒋彬, 张灵敏, 孙天宇, 等. 腹腔镜Heller手术与经口内镜下肌切开术治疗贲门失弛缓症的临床效果比较[J]. 第三军医大学学报, 2019, 41(22):2199-2204.
[9]	Hungness ES, Teitelbaum EN, Santos BF, et al. Comparison of perioperative outcomes between peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy[J]. J Gastrointest Surg, 2013, 17(2): 228-235. doi: 10.1007/s11605-012-2030-3 pmid: 23054897
[10]	Ujiki MB, Yetasook AK, Zapf M, et al. Peroral endoscopic myotomy: A short-term comparison with the standard laparoscopic approach[J]. Surgery, 2013, 154(4): 893-897.
[11]	Bhayani NH, Kurian AA, Dunst CM, et al. A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia[J]. Ann Surg, 2014, 259(6): 1098-1103. doi: 10.1097/SLA.0000000000000268 pmid: 24169175
[12]	Kumagai K, Tsai JA, Thorell A, et al. Per-oral endoscopic myotomy for achalasia. Are results comparable to laparoscopic Heller myotomy?[J]. Scandinavian journal of gastroenterology, 2015, 50(5): 505-512. doi: 10.3109/00365521.2014.934915 pmid: 25712228
[13]	Chan SM, Wu JC, Teoh AY, et al. Comparison of early outcomes and quality of life after laparoscopic Heller's cardiomyotomy to peroral endoscopic myotomy for treatment of achalasia[J]. Dig Endosc, 2016, 28(1): 27-32. doi: 10.1111/den.12507 pmid: 26108140
[14]	Leeds SG, Burdick JS, Ogola GO, et al. Comparison of outcomes of laparoscopic Heller myotomy versus per-oral endoscopic myotomy for management of achalasia[J]. Proc (Bayl Univ Med Cent), 2017, 30(4): 419-423. pmid: 28966450
[15]	Peng L, Tian S, Du C, et al. Outcome of peroral endoscopic myotomy (POEM) for treating achalasia compared with laparoscopic heller myotomy (LHM)[J]. Surg Laparosc Endosc Percutan Tech, 2017, 27(1): 60-64. doi: 10.1097/SLE.0000000000000368 pmid: 28145968
[16]	Werner YB, Hakanson B, Martinek J, et al. Endoscopic or surgical myotomy in patients with idiopathic achalasia[J]. N Engl J Med, 2019, 381(23): 2219-2229.
[17]	Wirsching A, Boshier PR, Klevebro F, et al. Comparison of costs and short-term clinical outcomes of per-oral endoscopic myotomy and laparoscopic Heller myotomy[J]. Am J Surg, 2019, 218(4): 706-711. doi: S0002-9610(19)30160-6 pmid: 31353034
[18]	Ali AB, Khan NA, Nguyen DT, et al. Robotic and per-oral endoscopic myotomy have fewer technical complications compared to laparoscopic Heller myotomy[J]. Surg Endosc, 2020, 34(7): 3191-3196. doi: 10.1007/s00464-019-07093-2 pmid: 31482358
[19]	Costantini A, Familiari P, Costantini M, et al. Poem versus laparoscopic heller myotomy in the treatment of esophageal achalasia: A case-control study from two high volume centers using the propensity score[J]. J Gastrointest Surg, 2020, 24(3): 505-515. doi: 10.1007/s11605-019-04465-w pmid: 31848870
[20]	Attaar M, Su B, Wong HJ, et al. Comparing cost and outcomes between peroral endoscopic myotomy and laparoscopic heller myotomy[J]. Am J Surg, 2021, 222(1): 208-213. doi: 10.1016/j.amjsurg.2020.10.037 pmid: 33162014
[21]	Podboy AJ, Hwang JH, Rivas H, et al. Long-term outcomes of per-oral endoscopic myotomy compared to laparoscopic Heller myotomy for achalasia: A single-center experience[J]. Surg Endosc, 2021, 35(2): 792-801.
[22]	Wong WJ, Affendi N, Siow SL, et al. When is POEM truly equivalent to LHM? A comparison of complication rates during the learning curve[J]. Surg Endosc, 2023, 37(3): 1735-1741.
[23]	李泽宇, 黄留业. 高分辨率食管测压在经口内镜下肌切开术治疗贲门失弛缓症中的应用价值[J]. 中国内镜杂志, 2021, 27(2): 55-60.
[24]	Swanström LL. Achalasia: Treatment, current status and future advances[J]. Korean J Intern Med, 2019, 34(6): 1173-1180. doi: 10.3904/kjim.2018.439 pmid: 30866609
[25]	Olson MT, Triantafyllou T, Singhal S. A Decade of investigation: peroral endoscopic myotomy versus laparoscopic heller myotomy for achalasia[J]. J Laparoendosc Adv Surg Tech A, 2019, 29(9): 1093-1104. doi: 10.1089/lap.2019.0242 pmid: 31313957
[26]	Haisley KR, Swanström LL. The modern age of POEM: The past, present and future of per-oral endoscopic myotomy[J]. J Gastrointest Surg, 2021, 25(2): 551-557. doi: 10.1007/s11605-020-04815-z pmid: 33140317
[27]	马晓冰, 王瑞玲, 李雪, 等. 经口内镜下肌切开术治疗贲门失弛缓症的研究进展[J]. 中华胃肠内镜电子杂志, 2015, 2(3): 108-112.
[28]	Costantini M, Salvador R, Costantini A. Esophageal achalasia: Pros and cons of the treatment options[J]. World J Surg, 2022, 46(7): 1554-1560. doi: 10.1007/s00268-022-06495-z pmid: 35238987
[29]	Schlottmann F, Luckett DJ, Fine J, et al. Laparoscopic heller myotomy versus peroral endoscopic myotomy (POEM) for achalasia: A systematic review and meta-analysis[J]. Ann Surg, 2018, 267(3): 451-460. doi: 10.1097/SLA.0000000000002311 pmid: 28549006
[30]	Khashab MA, Vela MF, Thosani N, et al. ASGE guideline on the management of achalasia[J]. Gastrointest Endosc, 2020, 91(2): 213-227.e6. doi: S0016-5107(19)31658-X pmid: 31839408
[31]	Talukdar R, Inoue H, Nageshwar Reddy D. Efficacy of peroral endoscopic myotomy (POEM) in the treatment of achalasia: A systematic review and meta-analysis[J]. Surg Endosc, 2015, 29(11): 3030-3046. doi: 10.1007/s00464-014-4040-6 pmid: 25539695
[32]	Gong F, Li Y, Ye S. Effectiveness and complication of achalasia treatment: A systematic review and network meta-analysis of randomized controlled trials[J]. Asian J Surg, 2023, 46(1): 24-34.
[33]	Du C, Ma L, Chai N, et al. Factors affecting the effectiveness and safety of submucosal tunneling endoscopic resection for esophageal submucosal tumors originating from the muscularis propria layer[J]. Surg Endosc, 2018, 32(3): 1255-1264. doi: 10.1007/s00464-017-5800-x pmid: 28842802
[34]	Inoue H, Sato H, Ikeda H, et al. Per-oral endoscopic myotomy: A series of 500 patients[J]. J Am Coll Surg, 2015, 221(2): 256-264.