经口内镜下肌切开术对贲门失弛缓症患者食管动力的影响

Effects of peroral endoscopic myotomy on esophageal motility in patients with achalasia

摘要:

目的 探讨经口内镜下肌切开术（peroral endoscopic myotomy, POEM）初次治疗对贲门失弛缓症（achalasia，AC）患者术后食管动力的影响。 方法 纳入2012年1月至2016年6月期间于首都医科大学附属北京友谊医院就诊并行POEM治疗的AC患者，按研究设计完成各项检查、POEM治疗及随访观察，比较各型AC患者的POEM治疗成功率以及POEM治疗前后食管动力的改变。 结果 POEM术后6个月随访时，Ⅰ型AC患者的症状缓解率为100.0%（13/13），Ⅱ型为95.5%（42/44），Ⅲ型为90.1%（10/11）。与术前比较，术后1～6个月内下食管括约肌静息压[10.5（6.9，15.8）mmHg比24.6（18.3，35.1）mmHg，1 mmHg=0.133 kPa]、4 s整合松弛压[6.0（3.7，8.8）mmHg比21.8（15.3，28.0）mmHg]、上食管括约肌静息压[43.4（33.7，57.3）mmHg比45.3（33.2，71.1）mmHg]、上食管括约肌残余压[1.5（0.0,4.6）mmHg比3.9（1.1,6.9）mmHg]均明显改善（P均＜0.05）。术后6个月，食管腔扩张的最宽直径较术前明显减小[（3.0±0.7）cm比（3.9±1.1）cm，P＜0.001]，总Eckardt评分较术前明显降低[1（0，2）分比6（5，8）分，P＜0.001]。POEM术后，Ⅰ型AC患者食管体部均未出现蠕动恢复，Ⅱ型AC患者中有4例（9.1%，4/44）较术前恢复弱蠕动或期前收缩，Ⅲ型AC患者中10例（90.9%，10/11）较术前出现正常蠕动波、期前收缩或弱蠕动的比例增加。 结论 POEM术后不仅食管胃交界部流出道梗阻得到改善，而且食管体部动力也一定程度上发生改变，其中部分患者体部动力有一定恢复；但是这种变化在3个AC亚型表现不同，Ⅲ型最明显，其次是Ⅱ型，Ⅰ型则无明显改变。

Abstract:

Objective To evaluate the effects of peroral endoscopic myotomy (POEM) on esophageal motility in patients with achalasia（AC） after POEM. Methods Demographics, clinical and manometric data, and outcomes were collected from the medical records of patients who received POEM as the primary therapy for AC in Beijing Friendship Hospital from January 2012 to June 2016. The rate of treatment success and change in esophageal dynamics before and after treatment were compared in different types of AC. Results At 6 months′ follow-up of POEM, the symptom remission rate of AC patients with type Ⅰ, type Ⅱ,and type Ⅲ was 100.0% (13/13), 95.5% (42/44) and 90.1% (10/11), respectively. Within 6 months after POEM, lower esophageal sphincter resting pressure [10.5 (6.9, 15.8) mmHg VS 24.6 (18.3, 35.1) mmHg, 1 mmHg=0.133 kPa], 4 s integrated relaxation pressure [6.0 (3.7, 8.8) mmHg VS 21.8 (15.3, 28.0) mmHg], upper esophageal sphincter (UES)resting pressure [43.4 (33.7, 57.3) mmHg VS 45.3 (33.2, 71.1) mmHg] and UES residual pressure [1.5 (0.0, 4.6) mmHg VS 3.9 (1.1, 6.9) mmHg] were significantly improved compared with those of pre-operation (all P<0.05). At 6 months after POEM, esophageal dilatation diameter (3.0±0.7 cm VS 3.9±1.1 cm) and Eckardt scores [1 (0, 2) VS 6 (5, 8)] were also significantly improved compared with those of pre-operation (all P<0.001). After POEM, the esophageal body peristalsis did not recover in type Ⅰ AC patients. Four patients (9.1%, 4/44) of type Ⅱ AC recovered weak peristalsis or premature contraction, and 10 patients (90.9%, 10/11) of type Ⅲ AC recovered with more normal peristaltic wave, and the rate of pre-systolic contraction or weak peristalsis increased. Conclusion POEM can improve the esophagogastric junction outflow tract obstruction and change the esophageal body motility.After POEM, part patients have recovery of esophageal body motility, which is most obvious in type Ⅲ AC, followed by type Ⅱ, and type Ⅰ AC patients have no significant change.