内镜黏膜下剥离术治疗巨大滑动型食管裂孔疝合并难治性胃食管反流病的初步探索（含视频）

Feasibility of endoscopic submucosal dissection for the treatment of large hiatal hernia combined with refractory gastroesophageal reflux disease (with video)

摘要:

目的 初步探讨食管裂孔疝内镜黏膜下剥离术（hiatal hernia‑endoscopic submucosal dissection，HH‑ESD）治疗巨大食管裂孔疝（长径>3 cm）合并难治性胃食管反流病的安全性和疗效。方法 2018年4月—2020年3月，因巨大食管裂孔疝合并难治性胃食管反流病自愿在内蒙古医科大学附属人民医院消化内镜中心接受HH‑ESD治疗患者纳入临床试验，观察手术完成情况和并发症发生情况，并随访观察治疗前后各项指标的变化情况，包括胃食管反流病健康相关生活质量评价（gastroesophageal reflux disease‑health related quality of life，GERD‑HRQL）评分、胃食管反流病问卷量表（gastroesophageal reflux disease‑questionnaire，GERD‑Q）评分、胃镜检查结果、24 h食管pH值监测结果、食管高分辨率测压结果和质子泵抑制剂使用情况。结果 研究期间共收集到10例患者，病史2～10年，均顺利完成HH‑ESD治疗，术中无穿孔、大出血等不良事件，住院时间6～12 d。术后3例出现吞咽困难，分别于3或6个月内自行缓解。术前GERD‑HRQL评分19～29分，术后3和12个月分别为0～14分和0～8分，较术前均有较大幅度下降；术前GERD‑Q评分9～17分，术后3和12个月均为6～9分，较术前均有较大幅度下降。胃镜随访提示，10例患者的食管炎较术前均有不同程度好转，疝囊较术前均有不同程度缩小，Hill分级较术前均有不同程度降低。术前DeMeester评分30.3～247.1分，术后12个月时为0.2～29.9分，较术前有较大幅度下降；术前食管裂孔疝长径3.0～6.0 cm，术后12个月时为0～5.0 cm，较术前均有不同程度缩小。随访12个月时，7例已停用质子泵抑制剂，其余3例已改为间断口服。结论 初步结果显示，HH‑ESD治疗巨大食管裂孔疝合并难治性胃食管反流病安全、有效。

Abstract:

Objective To study the safety and efficacy of hiatal hernia‑endoscopic submucosal dissection (HH‑ESD) for the treatment of giant hiatal hernia (>3 cm in length) complicated with refractory gastroesophageal reflux disease (GERD). Methods Patients with giant hiatal hernia complicated with refractory GERD who voluntarily received HH‑ESD at the Digestive Endoscopy Center of the Affiliated People''s Hospital of Inner Mongolia Medical University from April 2018 to March 2020 were included in the clinical study. The completion of HH‑ESD and the occurrence of complications were observed, and the changes of indicators before and after the treatment were observed, including gastroesophageal reflux disease‑health related quality of life (GERD‑HRQL) score, gastroesophageal reflux disease questionnaire (GERD‑Q) score, endoscopy results, 24 h esophageal pH monitoring results, esophageal high‑resolution manometry results and proton pump inhibitor (PPI) usage. Results Data of 10 patients were collected during the study, with a medical history of 2‑10 years. All patients successfully underwent HH‑ESD treatment. No adverse events such as perforation and massive bleeding occurred during the operation, and the hospital stay was 6‑12 days. Dysphagia occurred in 3 cases after the operation, which was relieved spontaneously within 3 or 6 months. The preoperative GERD‑HRQL scores ranged from 19 to 29, which were reduced to 0‑14 and 0‑8 at 3 and 12 months after the operation, respectively. The preoperative GERD‑Q score was 9‑17, and the scores at 3 and 12 months after the operation were all 6‑9, which were significantly lower than those before. Gastroscopy showed that esophagitis was improved in all patients, hernia sac was reduced, and Hill grade was reduced compared with that before. The preoperative DeMeester score was 30.3‑247.1, and the postoperative 12‑month score was 0.2‑29.9, which was significantly lower than that before. The long diameter of hiatal hernia was 3.0‑6.0 cm before the operation and 0‑5.0 cm at 12 months after, which was smaller than that before. At 12 months of the follow‑up, 7 patients had stopped PPI, and the remaining 3 had changed to intermittent oral PPI. Conclusion Preliminary results show that HH‑ESD is safe and effective for the treatment of giant hiatal hernia complicated with refractory GERD.