内镜下扩张结合肉毒杆菌毒素注射治疗贲门失弛缓症术后随访分析

Endoscopic dilatation combined with botulismotoxin injection for cardiac achalasia

目的研究内镜下贲门扩张结合肉毒杆菌毒素注射术治疗贲门失弛缓的临床疗效、术后的食管动力学变化。方法选择29例贲门失弛缓患者，经临床评估、内镜及食管动力学检测后，在内镜下对贲门进行水囊扩张，再于贲门四壁分4点注射A型肉毒杆菌毒素。分别于术后1周、1个月、6个月、12个月对患者密切随访，评估临床表现，检测相关的食管动力学指标，然后对结果进行统计学处理，再比较分析。结果患者在内镜术前出现不同程度的吞咽困难、胸痛和呕吐，内镜术后1周、6个月、12个月吞咽困难、胸痛及呕吐发生率较术前显著降低。术后12个月吞咽困难、胸痛发生率较术后1周、6个月组显著升高，呈现明显升高趋势。内镜术后下段食管的平均压力较术前显著降低，术后6个月较1个月显著升高。内镜术后1个月开始，与术前相比，下段食管的平均收缩间期显著缩短，下段食管的顺行性则显著改善。内镜治疗术后食管下括约肌静息压较术前显著降低，术后6个月食管下括约肌（LES）静息压较术后1个月则明显升高。内镜术后LES松弛率较术前显著升高，术后6个月食管下括约肌松弛率较术后1个月则明显降低。内镜术后1个月开始食管顺行性收缩比例较术前显著升高，而非协调性收缩的比例则显著降低。内镜治疗术后食管体部收缩幅度较术前显著降低。结论内镜下贲门扩张及肉毒杆菌毒素注射术能显著改善贲门失弛缓症患者的临床表现及食管动力学状况，但术后1个月开始临床复发率逐步升高、食管动力学异常逐渐加重。

Objective To evaluate the effect of endoscopic dilatation combined with botulismotoxin injection for cardiac achalasia and to study the post-operative changes in esophageal manometry. Methods Endoscopic water balloon dilatation combined with botulismotoxin 4-point injection at cardiac wall was applied in 29 patients with cardiac achalasia after detailed clinical assessments including endoscopy and esophageal manometry. Patients were followed up postoperatively at 1 week, 1 month, 6 months, and 12 months, respectively. Results ,Different degrees of dysphagia, chest pain and vomiting were presented in all patients, and were significantly relieved after the endoscopic procedure during the follow-up period, although the incidences of dysphagia and chest pain at 12 months post operation were significantly higher than those at 1 week and 6 months. The parameters of esophageal manometry including the mean pressure of lower part esophagus, the mean intersystolic period of lower esophagus, the compliance of lower esophagus, the rest pressure of lower esophagus sphincter （LES） , the LES relaxing rate, the rate of esophageal compliant con- traction and the rate of non-concordant contraction, were all significandy improved after the endoscopic procedure, although these variables were showing a tendency of deterioration during the follow-up period. Con- clusion The combination of endoscopic dilation with botulismotoxin injection can relief clinical symptoms and improve esophageal kinetics of cardiac achalasia, but from 1 month after the procedure, the clinical recurrence rate increases, and the abnormality of esophageal kinetics aggravates.