经口内镜下肌切开术治疗贲门失弛缓症216例分析

Peroral Endoscopic Myotomy for Esophageal Achalasia: Analysis of 216 Cases

背景：经口内镜下肌切开术（ POEM）是治疗贲门失弛缓症（ EA）的新技术，已有研究证实该法治疗EA可行、安全、有效，但关于术中全层肌切开与环肌切开疗效差异的报道尚少。目的：探讨POEM治疗EA的疗效和安全性。方法：2011年8月至2013年11月中南大学湘雅二医院收治EA患者216例，行POEM治疗，其中全层肌切开133例，环肌切开83例。术后对患者进行定期随访和复查，观察手术前后Eckardt评分和食管直径改变、术中、术后并发症发生情况和复发率，并比较全层肌切开与环肌切开疗效有无差异。结果：216例患者均成功实施POEM，操作时间平均为59.1 min，隧道长度平均为13.3 cm，肌切开长度平均为10.1 cm。术后患者症状均得到缓解，Eckardt评分较术前显著改善，术后6个月食管直径较术前显著缩小（53.7 mm对30.8 mm，P＜0.001），并发症发生率为13.0%（28/216）。患者术后随访3～30个月（平均13.8个月），有效率为99.1%（214/216），随访期内无一例复发病例。全层肌切开与环肌切开相比，操作时间、有效率和并发症发生率差异均无统计学意义（ P＞0.05）。结论：POEM可作为EA安全、有效的治疗手段；全层肌切开并不增加手术操作时间和手术相关并发症，但其远期疗效和并发症仍有待进一步随访评估。

Background：There have been several studies about peroral endoscopic myotomy（ POEM）for treating esophageal achalasia（ EA）. Although the feasibility,safety and effectiveness of POEM have been demonstrated,comparative studies of full-thickness and circular muscle myotomy were rare. Aims：To evaluate the efficacy and safety of POEM for treating patients with EA. Methods：A total of 216 patients with EA admitted from Aug. 2011 to Nov. 2013 at the Second Xiangya Hospital of Central South University were treated with POEM,of whom 133 received full-thickness myotomy and 83 received circular muscle myotomy. Data about Eckardt ’s score, diameter of esophageal lumen, intra- and post-operative complications and recurrence before and/or during periodical follow-up were collected,and the efficacy of full-thickness and circular muscle myotomy was compared. Results：All the 216 patients successfully underwent POEM with an average operation time of 59. 1 minutes. Average length of tunnel and myotomy were 13. 3 cm and 10. 1 cm,respectively. Symptoms remitted in all of the 216 patients,Eckardt’s score decreased significantly,diameter of esophageal lumen was reduced（pre-treatment vs. 6 months after treatment,53. 7 mm vs. 30. 8 mm,P〈0. 001）,and complications occurred in 13. 0%（28/216）of the cases. Success treatment was achieved in 99. 1%（214/216）of the cases with a follow-up of 3-30 months（ mean 13. 8 months）,no recurrence was noted. The operation time,efficacy and complications were comparable between full-thickness and circular muscle myotomy（P〉0. 05）. Conclusions：POEM is an effective and safe method for treating EA. Full-thickness myotomy did not increase the operation time and procedure-related complications, however,its long-term efficacy and complications need to be further assessed.