经口内镜下肌切开术治疗贲门失弛缓症的初探

Peroral endoscopic myotomy for achalasia

目的探讨经口内镜下肌切开术（POEM）治疗贲门失弛缓症（AC）的疗效和可行性。方法研究2010年8月至2010年12月确诊为AC并接受POEM治疗的8例患者的临床资料。患者年龄16～62岁，平均43岁，病程2-20年，平均8．4年。POEM的主要步骤包括：食管黏膜层切开；分离黏膜下层，建立黏膜下“隧道”；胃镜直视下切开环形肌；金属夹关闭黏膜层切口。结果8例患者均成功接受POEM术，手术时间45-115min，平均68．5min，黏膜下隧道长度8～13cm，平均9．5cm，环形肌切开长度7～11cm，平均8．5cm，无1例出现与POEM相关的严重并发症。术后随访1～4个月，平均2．5个月，7例吞咽困难明显得到解除；1例术后15d出现进食困难及呕吐，胃镜检查发现黏膜下窦道形成，行内镜下窦道切开。结论作为一种新的微创治疗方法，POEM治疗AC短期疗效肯定，可以迅速解除AC患者吞咽困难，但其长期疗效及远期并发症仍有待随访观察。

Objective To evaluate the efficacy and the feasibility of peroral endoscopic myotomy （POEM） for aehalasia （AC）. Methods The clinical data of 8 patients diagnosed as having AC and receiving POEM at our center from August 2010 to December 2010 were reviewed. The patients were 16-62 years old, mean 43yr, whose disease courses lasted for 2-20 years, mean 8.4 years. The key procedures of POEM were as the following, esophageal mucosal incision, submucosal tunneling by endoscopic submueosal dissection （ESD） , endoscopic myotomy of the circular muscle and closure of mucosal entry by hemostatic clips. Results All the 8 patients underwent POEM successfully. The mean operation time was 68.5 min （ ranging 45-115 min）. The mean submucosal tunneling length was 9.5 cm （ ranging 8-13 cm）. The average length of endoscopic myotomy of inner circular muscle was 8.5cm （ ranging 7-11 cm）. No severe complications related to POEM occurred. Patients were followed up for 1-4 months （ mean 2.5 months）. Dysphagia was relieved significantly during the follow-up in 7 patients. But dysphagia and vomiting re-occurred in one patient 15 days after the operation. Endoscopy revealed a submucosal fistula, which was managed by incision. Conclusion As a new minimally invasive therapy for AC, POEM is very effective to relieve dysphagia in a short term. However, further observation is needed to evaluate long-term efficacy and complications.