经口内镜下肌切开术对Ⅱ型贲门失弛症食管动力学影响
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摘要
目的应用高分辨率食管测压(HRM)探讨经口内镜下肌切开术(POEM)对Ⅱ型贲门失弛症(AC)病人的食管动力学影响,评估POEM治疗Ⅱ型AC的近期疗效。方法选取2015年6月至2017年6月在安徽医科大学附属安庆医院经食管钡餐造影及胃镜检查确诊为AC病人连续入组,并进行HRM,根据2014年芝加哥分类标准选取Ⅱ型AC病人20例,其中12例入组行POEM手术。所有入组者分别于术前及术后1个月行HRM检查,比较手术前后食管动力学指标的变化。结果 12Ⅱ型AC病人POEM术治疗前后临床症状评分系统(Eckardt评分)差异有统计学意义(t=4.325,P<0.001);所有入组者食管下括约肌松弛参数及食管体部蠕动性参数均有明显改善,食管下括约肌静息压(LESP)术前(37.5±18.6)mmHg(1 mmHg=0.133 kPa)高于术后(16.4±6.4)mmHg(t=3.935,P<0.001);4 s完整松弛压力(4 s IRP)术前(31.4±14.8)mmHg与术后(11.5±6.5)mmHg比较,差异有统计学意义(t=5.815,P<0.001);食管下括约肌松弛率(LESRR)术前(23.1±18.6)%与术后(45.6±21.7)%比较,差异有统计学意义(t=-5.482,P<0.05)。12例病人术前食管运动以无传导性同步收缩波为主,术后有2例病人出现食管近端蠕动波,但仍达不到正常水平;其余10例在压力测定中同步收缩及无效吞咽显著减少,但食管体部均无完整的蠕动性收缩波。结论 POEM能有效改善Ⅱ型AC病人的LES松弛障碍和降低LESP,但对恢复食管体部蠕动功能有限,近期效果显著,远期疗效及并发症有待进一步随访研究。
Objective To investigate the effects of peroral endoscopic myotomy(POEM) on esophageal dynamics in type Ⅱachalasia patients by using high resolution manometry(HRM), and to evaluate the short-term efficacy of POEM on type Ⅱ achalasia.Methods Consecutive patients with achalasia diagnosed by endoscopy and barium meal X-ray examination in Anqing Municipal Hospital Affiliated to Anhui Medical University from June 2015 to June 2017 were enrolled for high resolution manometry.Twenty type Ⅱ achalasia patients were selected according to 2012 Chicago classification criteria, with 12 patients in the study group who underwent POEM and received pre-and postoperative high-resolution manometry within 1 month after POEM.The characteristics of esophageal motility of the two groups were compared.Results Eckardt scoring indicated that POEM treatment led to significant improvement of type II achalasia related symptom(t = 4.325,P < 0.001).The relaxation parameters of the lower esophageal sphincter and the peristalsis parameters of the esophagus were improved in all patients, and the preoperative lower esophageal sphincter pressure(37.5± 18.6) mmHg was higher than that after surgery(t=3.935,P < 0.001).The 4 s integrated relaxation pressure(31.4± 14.8) mmHg decreased significantly after POEM treatment(t = 5.815,P< 0.001).Lower esophageal sphincter relaxation rate increased significantly after POEM.The esophageal motility of the 12 patients was dominated by the non conductive synchronous contraction wave.There were 2 patients with esophageal proximal peristalsis after operation, but it still failed to reach the normal level; the other 10 cases showed significant decrease in synchronous contractions and ineffective swallowing, but there was still no complete peristaltic contraction in the esophageal body. Conclusions POEM can significantly reduce LESP and4 sIRP in patients with type Ⅱ achalasia,However, the recovery of esophageal peristalsis is limited.The short-term effect is remarkable,and the long-term efficacy and complications need further follow-up study.
Objective To investigate the effects of peroral endoscopic myotomy(POEM) on esophageal dynamics in type Ⅱachalasia patients by using high resolution manometry(HRM), and to evaluate the short-term efficacy of POEM on type Ⅱ achalasia.Methods Consecutive patients with achalasia diagnosed by endoscopy and barium meal X-ray examination in Anqing Municipal Hospital Affiliated to Anhui Medical University from June 2015 to June 2017 were enrolled for high resolution manometry.Twenty type Ⅱ achalasia patients were selected according to 2012 Chicago classification criteria, with 12 patients in the study group who underwent POEM and received pre-and postoperative high-resolution manometry within 1 month after POEM.The characteristics of esophageal motility of the two groups were compared.Results Eckardt scoring indicated that POEM treatment led to significant improvement of type II achalasia related symptom(t = 4.325,P < 0.001).The relaxation parameters of the lower esophageal sphincter and the peristalsis parameters of the esophagus were improved in all patients, and the preoperative lower esophageal sphincter pressure(37.5± 18.6) mmHg was higher than that after surgery(t=3.935,P < 0.001).The 4 s integrated relaxation pressure(31.4± 14.8) mmHg decreased significantly after POEM treatment(t = 5.815,P< 0.001).Lower esophageal sphincter relaxation rate increased significantly after POEM.The esophageal motility of the 12 patients was dominated by the non conductive synchronous contraction wave.There were 2 patients with esophageal proximal peristalsis after operation, but it still failed to reach the normal level; the other 10 cases showed significant decrease in synchronous contractions and ineffective swallowing, but there was still no complete peristaltic contraction in the esophageal body. Conclusions POEM can significantly reduce LESP and4 sIRP in patients with type Ⅱ achalasia,However, the recovery of esophageal peristalsis is limited.The short-term effect is remarkable,and the long-term efficacy and complications need further follow-up study.
引文
[1]FRANCIS DL,KATZKA DA.Achalasia:update on the disease and its treatment[J].Gastroenterology,2010,139(2):369-374.
[2]KAHRILAS PJ,BREDENOORD AJ,Fox M,et al.The Chicago Classification of esophageal motility disorders,v3.0[J].Neurogastroenterol Motil,2015,27(2):160-174.
[3]MIN M,PENG LH,YANG YS,et al.Characteristics of achalasia subtypes in untreated Chinese patients:a high-resolution manometry study[J].J Dig Dis,2012,13(10):504-509.
[4]IACOB D,FUFEZAN O,FARCAU D,et al.Clinical and ultrasound approach to achalasia in a child.Case report[J].Med Ultrason,2010,12(1):66-70.
[5]内镜治疗专家协作组.经口内镜下肌切开术治疗贲门失弛缓症专家共识[J].中华胃肠外科杂志,2012,15(11):1197-1200.
[6]李莉,彭丽华.高分辨率测压法在食管动力检测中的临床应用[J].胃肠病学和肝病学杂志,2011,20(3):279-282.
[7]郑晓敏,李仁君,李敏.Ⅱ型贲门失弛缓症患者食管动力学特征的高分辨率测压分析[J].中华消化内镜杂志,2014,31(5):249-252.
[8]YAGHOOBI M,MIKAELI J,MONTAZERI G,et a1.Correlation between clinical severity score and the lower esophageal sphincter relaxation pressure in idiopathic achalasia[J].Am J Gastroenterol,2003,98(2):278-283.
[9]PARK H,CONKLIN JL.Neuromuscular control of esophageal peristalsis[J].Curr Gastroenterol Rep,1999,1(3):186-197.
[10]ECKARDT AJ,ECKARDT VF.Treatment and surveillance strategies in achalasia:an update[J].Nat Rev Gastroenterol Hepatol,2011,8(6):311-319.
[11]ECKARDT VF,AIGNHERR C,BERNHARD G.Predictors of outcome in patients with achalasia treated by pneumatic dilation[J].Gastroenterology,1992,103(6):1732-1738.
[12]令狐恩强,李惠凯,彭丽华,等.经口内镜肌切开术对贲门失弛缓症患者食管动力的影响[J].中华消化内镜杂志,2011,28(11):611-614.
[13]钟芸诗,李亮,周平红,等.经口内镜下肌切开术对贲门失弛缓症患者的食管动力学影响[J].中华胃肠外科杂志,2012,15(7):668-670.
[14]BREDENOORD AJ,FOX M,KAHRILAS PJ,et al.Chicago classification criteria of esophageal motility disorders defined in high resolution esophageal pressure topography[J].Neurogastroenterol Motil,2012,24 Suppl 1:57-65.
[15]俞汀,汤玉蓉,林琳.食管高分辨率测压对贲门失弛缓症诊断和治疗的指导意义[J].中华消化杂志,2015,35(5):353-355.2017-08-312019-01-15
[2]KAHRILAS PJ,BREDENOORD AJ,Fox M,et al.The Chicago Classification of esophageal motility disorders,v3.0[J].Neurogastroenterol Motil,2015,27(2):160-174.
[3]MIN M,PENG LH,YANG YS,et al.Characteristics of achalasia subtypes in untreated Chinese patients:a high-resolution manometry study[J].J Dig Dis,2012,13(10):504-509.
[4]IACOB D,FUFEZAN O,FARCAU D,et al.Clinical and ultrasound approach to achalasia in a child.Case report[J].Med Ultrason,2010,12(1):66-70.
[5]内镜治疗专家协作组.经口内镜下肌切开术治疗贲门失弛缓症专家共识[J].中华胃肠外科杂志,2012,15(11):1197-1200.
[6]李莉,彭丽华.高分辨率测压法在食管动力检测中的临床应用[J].胃肠病学和肝病学杂志,2011,20(3):279-282.
[7]郑晓敏,李仁君,李敏.Ⅱ型贲门失弛缓症患者食管动力学特征的高分辨率测压分析[J].中华消化内镜杂志,2014,31(5):249-252.
[8]YAGHOOBI M,MIKAELI J,MONTAZERI G,et a1.Correlation between clinical severity score and the lower esophageal sphincter relaxation pressure in idiopathic achalasia[J].Am J Gastroenterol,2003,98(2):278-283.
[9]PARK H,CONKLIN JL.Neuromuscular control of esophageal peristalsis[J].Curr Gastroenterol Rep,1999,1(3):186-197.
[10]ECKARDT AJ,ECKARDT VF.Treatment and surveillance strategies in achalasia:an update[J].Nat Rev Gastroenterol Hepatol,2011,8(6):311-319.
[11]ECKARDT VF,AIGNHERR C,BERNHARD G.Predictors of outcome in patients with achalasia treated by pneumatic dilation[J].Gastroenterology,1992,103(6):1732-1738.
[12]令狐恩强,李惠凯,彭丽华,等.经口内镜肌切开术对贲门失弛缓症患者食管动力的影响[J].中华消化内镜杂志,2011,28(11):611-614.
[13]钟芸诗,李亮,周平红,等.经口内镜下肌切开术对贲门失弛缓症患者的食管动力学影响[J].中华胃肠外科杂志,2012,15(7):668-670.
[14]BREDENOORD AJ,FOX M,KAHRILAS PJ,et al.Chicago classification criteria of esophageal motility disorders defined in high resolution esophageal pressure topography[J].Neurogastroenterol Motil,2012,24 Suppl 1:57-65.
[15]俞汀,汤玉蓉,林琳.食管高分辨率测压对贲门失弛缓症诊断和治疗的指导意义[J].中华消化杂志,2015,35(5):353-355.2017-08-312019-01-15