经口内镜下肌切开术治疗老年贲门失弛缓症的疗效和安全性及其影响因素分析

Analysis of Efficacy,Safety and Influential Factors of Peroral Endoscopic Myotomy in Geriatric Patients With Achalasia

背景:经口内镜下肌切开术(POEM)治疗贲门失弛缓症(AC)安全有效。但POEM在老年人中的应用报道较少,且受限于较小的样本量和较短的随访时间。目的:探讨POEM治疗老年AC患者的有效性和安全性及其影响因素。方法:纳入2012年11月-2018年12月南京医科大学第一附属医院接受POEM治疗的AC患者共215例,分为老年组(≥60岁)和非老年组(<60岁),比较两组的临床资料、POEM手术情况、疗效和安全性并进行随访,分析影响疗效的因素。结果:老年组患者病程显著长于非老年组(P=0.002),但下食管括约肌完整松弛压(IRP)显著低于非老年患者组(P=0.013),而两组一般情况、芝加哥分型、POEM手术情况、术后Eckardt评分相比无明显差异(P> 0.05)。中位随访时间为42 (29,60)个月,老年组治疗失败或复发的发生率明显高于非老年组(17.5%对7.4%,P=0.047),两组患者临床反流发生率差异无统计学意义(P> 0.05)。老年组患者术后疗效与术前IRP具有相关性(P=0.033)。倾向性评分结果显示,两组患者预后无明显差异。结论:POEM治疗老年AC患者安全有效,但因老年患者病程较长、术前IRP较低,疗效相对非老年患者较差。

Background: Peroral endoscopic myotomy( POEM) is safe and effective in the treatment of achalasia( AC).However,there are few reports on application of POEM in the elderly,and is limited by small sample size and short followup. Aims: To evaluate the efficacy and safety of POEM and its influential factors on AC in geriatric patients. Methods: A total of 215 AC patients received POEM from November 2012 to December 2018 at the First Affiliated Hospital of Nanjing Medical University were enrolled,and were divided into elderly group( ≥60 years old) and non-elderly group( < 60 years old). The clinical information,POEM procedure,efficacy and safety were compared,follow-up was performed,and influential factors were analyzed. Results: The disease course in elderly group was significantly longer than that in nonelderly group( P = 0. 002);the integrated relaxation pressure( IRP) of lower esophageal sphincter in elderly group was significantly decreased than that in non-elderly group( P = 0. 013). No significant differences in basic information,Chicago classification,POEM procedure,postoperative Eckardt score between the two groups were found( P > 0. 05). The median follow-up was 42( 29,60) months. The rate of treatment failure or recurrence in elderly group was significantly increased than that in non-elderly group( 17. 5% vs. 7. 4%,P = 0. 047). However,there was no statistical difference in incidence of clinical reflux between the two groups( P > 0. 05). The postoperative efficacy was correlated with preoperative IRP in elderly patients( P = 0. 033). The propensity score matching results showed that no significant difference in prognosis was found between the two groups. Conclusions: POEM is safe and effective for elderly patients with AC. However,the efficacy is lower in elderly patients than that in non-elderly patients due to the long course of disease and lower preoperative IRP.