困难经口内镜下括约肌切开术的临床研究及危险因素分析

Clinical research and risk factors analysis of difficult Peroral endoscopic myotomy

目的通过分析困难经口内镜下括约肌切开术(POEM)发生率及危险因素,系统性地对困难POEM进行临床研究。方法回顾性收集2015年5月至2021年5月于中国人民解放军西部战区总医院行POEM的贲门失弛缓症患者资料,分析困难POEM的危险因素。临床结局包括手术时间≥90 min、手术中止及主要不良事件发生。结果共纳入132例患者,共计29例(21.97%)困难POEM;128例(96.97%)手术成功,4例(3.03%)因严重黏膜下纤维化、隧道建立失败导致手术中止;手术时间≥90 min有23例(17.42%);8例(6.06%)出现主要并发症;二元Logistic回归分析显示年龄≥50岁(OR 3.681;95%CI 1.491~9.650;P=0.008)、既往有球囊扩张或手术史(OR 4.979;95%CI 1.359~18.246;P=0.015);SMF-2/3级(OR 5.205;95%CI 1.973~13.731;P=0.001)与困难POEM的发生有关。结论年龄≥50岁、既往有球囊扩张或手术史及SMF-2/3级为困难POEM的独立预测因素,对于这部分患者,建议在行POEM手术时需小心谨慎,尽量由经验丰富的内镜医师带领进行。

Objective Through analyzing of the incidence and risk,the clinical research of difficult POEM is systematically evaluated.Methods By retrospectively collecting the data from May 2015 to May 2021 of patients with achalasia who underwent POEM at the General Hospital of the Western Theater Command PLA,the risk factors of difficult POEM were analyzed.The clinical outcomes included operation time≥90 minutes,operation suspension,and major adverse events.Results A total of 132 patients were included,of which 29(21.97%)had difficult POEM.Among the cases,128 cases(96.97%)were successfully operated,and 4 cases(3.03%)were aborted due to severe submucosal fibrosis and failure of tunnel creation;the operation time was≥90 minutes in 23 cases(17.42%);8 cases(6.06%)had major complications;binary logistic regression analysis showed that age≥50 years old(OR value:3.681;95%CI:1.491-9650;P=0.008),a history of balloon dilation or surgery(OR value:4.979;95%CI:1.359-18.246;P=0.015);SMF-2/3 grade(OR:5.205.95%CI:1.973-13.731;P=0.001)was associated with the occurrence of difficult POEM.Conclusion Age≥50 years,previous history of balloon dilation or surgery and SMF grade 2/3 are independent predictors of difficult POEM,and for this group of patients,caution is recommended when performing POEM procedures,which should be operated by an experienced endoscopist as much as possible.