改良球囊扩张术对脑干卒中后吞咽障碍患者食管上括约肌功能的影响

Effect of balloon dilatation on upper esophageal sphincter in brainstem stroke patients with dysphagia ： an investigation using high-resolution solid-state manometry

目的使用高分辨率固态测压方法观察改良球囊扩张治疗对脑干卒中后吞咽障碍患者上食管括约肌（UES）功能的影响，并探讨其作用的生物力学机制。方法选取中山大学附属第三医院康复科2011年9月至2012年3月30例脑干卒中后经吞咽造影确诊为咽期吞咽障碍的住院患者，分为球囊扩张治疗组与吞咽常规治疗组。球囊扩张组给予球囊扩张治疗及常规吞咽康复治疗；吞咽常规治疗组仅给予常规吞咽康复训练。在治疗前、拔除鼻饲管或治疗已达3周后，进行吞咽功能评估及UES测压检查。评估的指标包括：UES松弛残余压，UES松弛持续时间及UES静息压。结果球囊扩张组15例患者治疗后12例拔除了鼻饲管，吞咽水（P=0．008）、浓流质（P=0．004）及糊状食物时（P=0．001）UES松弛残余压较治疗前明显下降，治疗后吞咽水（P=0．006）、浓流质（P=0．002）及糊状食物（P〈0．001）时UES松弛持续时间也较治疗前明显延长，差异均有统计学意义。UES静息压也有所恢复[治疗前（30±3）mmHg治疗后（59±6）mmHg，P〈0．001]。球囊扩张组患者治疗后FOIS评分均值较治疗前增加3．5分，差异有统计学意义（P=0．001）。常规治疗组15例患者治疗后2位拔除了鼻饲管，吞咽3种食物时UES松弛残余压与持续时间改善不明显（P〉0．05）。常规治疗组患者治疗后FOIS评分均值较治疗前增加0．63分，差异有统计学意义（P=0．026）。结论UES松弛功能受损是脑干卒中患者吞咽障碍的重要表现。改良球囊扩张术对UES松弛功能有益处；对恢复UES的静息压也有帮助。

Objective To explore the effects of balloon dilation intervention on function of upper esophageal sphincter （UES） in brainstem stroke patients with dysphagia before and after treatment by high- resolution solid-state manometry. Methods Thirty brainstem stroke patients with pharyngeal dysphagia were recruited. The dilatation treatment group （ n = 15 ） completed a 3-week regimen of modified balloon dilatation and traditional swallowing including E-stim, Mendelsohn Maneuver and supraglottic swallowing. And the control group （n = 15 ） only completed 3 weeks of traditional swallowing therapy. Before, and after dilatation, the nadir of UES and its duration were measured during swallowing of thin liquid, thick liquid and pasty material in 3-ml volumes. The results of both groups were compared for identical parameters. Results In the experimental group, post-treatment UES residual pressure （ for water, P = 0. 008 ; for thick liquid, P = 0. 004 ; for paste, P = 0. 001 ） and relaxation duration （ for water, P = 0. 006 ; for thick liquid, P = 0.002; for paste, P 〈 0. 001 ） both significantly improved for all three materials. UES resting pressure approximated normal（ Pre-treatment 30 ±3 mm Hg; post-treatment 59 ＋ 6 mm Hg, P 〈 0. 001 ）. In the control group, there was no improvement in post-treatment UES residual pressure and relaxation duration for all three materials （ P 〉 0.05 ）. In the experimental group, feeding tube was removed in 12/15 versus 2/15 patients in the control group. The experimental group had 3.5 points improvement （ P = 0. 001 ） while the control group improved by a mere 0.63 point （ P = 0.026） in FOIS scores. Conclusion Failed UES is a major cause of dysphagia in brainstem stroke patients. Dysphagia therapy with dilatation improves relaxation of UES. Moreover, it is helpful for restoring UES resting pressure. Traditional swallowing therapy has no positive effect on UES.