贲门失弛缓症的四种介入治疗成形术的选择和中远期疗效比较

Follow-up and methods selection of the four types of interventional procedure for achalasia

目的探讨贲门失弛缓症有效的介入治疗方法,并分析4种介入治疗方法的中、远期疗效。方法238例贲门失弛缓症患者。其中球囊导管成形术组(A组)80例;永久性贲门支架成形组(B组)8例;暂时性贲门支架成形术组(C组)135例;直径递增组合成形术组(暂时性贲门支架加增加直径的球囊导管成形术8例;直径递增暂时性贲门支架成形术7例)15例(D组)。C、D组术后3～5d由胃镜取出支架。4种介入治疗方法随访时间6～138个月。结果A组80例共进行152次扩张,平均每例1.9次。并发症发生率为疼痛43.8%、反流27.5%、出血10.0%;随访半年、1、3、5、8年和10年以上患者吞咽困难复发率分别为32.5%、56.3%、85.5%、89.1%、92.6%、100%。B组8例,安放裸支架5枚和部分覆膜抗反流支架3枚,支架置入成功率100%。并发症发生率为疼痛5/8、反流5/8、出血3/8、肉芽组织增生3/8;随访半年、1、3年和5年以上患者吞咽困难复发率分别为3/8、4/8、5/8、4/8。C组135例,安放部分覆膜支架135枚。并发症发生率为疼痛39.3%、反流21.5%、出血17.0%;随访半年、1、3、5、8年和10年以上患者吞咽困难复发率分别为7.4%、8.7%、12.9%、23.9%、42.1%、66.7%。D组15例,并发症发生率为疼痛73.3%、反流40.0%、出血40.0%;随访半年、1、3年和5年以上患者吞咽困难复发率分别为12.5%、20.0%、27.3%、28.6%。4种介入治疗方法治疗前后贲门管腔直径、吞咽困难评分等差异均有显著性(P<0.01)。结论暂时性贲门支架成形术是贲门失弛缓症介入治疗中的首选方法;直径递增组合成形术为贲门失弛缓症介入治疗的补充方法。

Objective To determine the best method out of the four types of interventional procedure for achalasia based on a middle and long-term follow-up. Methods The study cohort comprised 238 patients of achalasia. Among them, 80 patients were treated under fluoroscopy with balloon dilation （group A）, 8 patients with permanent uncovered or anti-reflux metal covered stent dilation （group B）, 135 patients with temporary partially metal covered stent dilation （group C）, 15 patients with temporary partially metal covered stent dilation and ballon dilation by stepping increarse of their diameters （group D）. Stents in group C-D were withdrawn after 3 - 5 days via gastroscopy. The follow-up for groups A-D lasted 6 months - 138 months. Results One hundred and fifty-two balloon dilations were performed in the 80 patients of group A （mean 1.9 times per case）. Complications were chest pain（n = 30）, reflux（n = 35）, and bleeding （n = 22）. Twenty-six patients （32.5% ）out of 80, 45 patients （56.25% ）out of 80, 53 patients （85.48%） out of 62 and 41 patients （89.13%） out of d6, 25 patients （92.59%） out of 27, 9 patients （100%）out of 9 in group A exhibited dysphagia relapse during 6 months, 1 year, 3 years, 5 years, 8 years, 10 years follow-up, respectively. Five uncovered and 3 anti-reflux metal covered expandable stents were permanently placed in the 8 patients of group B. Complications in group B were chest pain（n = 5）, reflux（n = 5）, bleeding（n = 3）, and hyperplasia of granulation tissue（n = 3）. Three patients（37.50%）out of 8, 4 patients （50.00%）out of 8, 2 patients （66.70%） out of 3, 1 patients（50.00%）out of 2 in group B exhibited dysphagia relapse during 6 months, 1 year, 3 years and 5 years follow-up, respectively. One hundred and thirty-five partially metal covered expandable stents were temporarily placed in the 135 patients of group C with complications of chest pain （n = 53）, reflux （n = 29）, and bleeding （n = 23）. Ten patients（7.41%）out of 135, 11 patients（8.73%）out of 126, 12 patients （12.90%） out of 93, 16 patients（23.88%）out of 67, 16 patients（42.11%） out of 38 and 8 patients （66.67%） out of 12 in group C exhibited dysphagia relapse during 6 months, 1 year, 3 years, 5 years, 8 years, 10 years follow-up, respectively. Eight partially covered expandable metal stents and seven balloon dilations by stepping increase diameters were performed in the 15 patients of group D with complications of chest pain （n = 11 ）, reflux （n = 6） and bleeding （n = 6）. One patients （12.50%）out of 15, 3 patients （20.00%） out of 15, 3 patients （27.27%） out of 11, 2 patients （28.57%） out of 7 in group D exhibited dysphagia relapse during 6 months, 1 year, 3 years, and 5 years follow-up, respectively. All the stents were inserted and withdrawn successfully. Conclusion Temporary partially covered metal stent dilation is first method of choice in interventional procedure for achalasia. Combination with stepping increase of diameters should be an important adjunct. （J Intervent Radiol, 2006, 15： 413-417）