全身麻醉下上消化道不同部位病变行内镜黏膜下剥离术术中消化道蠕动情况的比较和处理

Comparison and treatment of vigorous peristalsis in different parts of upper gastrointestinal tract in the process of endoscopic submucosal dissection under general anesthesia

目的比较气管插管全身麻醉下上消化道不同部位病变行内镜黏膜下剥离术(ESD)术中消化道蠕动情况并探讨处理方法。方法序贯收入浙江大学医学院附属第一医院2014年2—7月在全身麻醉下行上消化道病变ESD的患者76例,依据病变部位不同分为胃窦胃角组(25例)、胃体胃底组(21例)、食管和食管胃交界组(30例)。患者快速静脉麻醉诱导后行气管插管,术中以持续静脉泵注丙泊酚、间断静脉注射芬太尼维持麻醉深度。应用内镜影像系统记录ESD操作过程,对胃食管蠕动情况进行胃蠕动评分(食管和食管胃交界组无该项评分)和操作评分,胃蠕动评分>2分定义为剧烈蠕动,操作评分>2分定义为影响操作。当操作评分>2分时即刻静脉注射消旋山莨菪碱10mg作为补救措施。记录手术结束至拔除气管导管的时间(拔管时间)和拔除气管导管至被准许返回病房的时间[麻醉后监测治疗室(PACU)时间]。记录在PACU和术后24h的药物不良反应和患者情况。结果胃体胃底组、食管和食管胃交界组的手术时间和麻醉时间均显著长于胃窦胃角组(P值均<0.05),3组间拔管时间、PACU时间、丙泊酚用量的差异均无统计学意义(P值均>0.05)。在胃蠕动评分方面,胃窦胃角组剧烈蠕动的发生率为68.0%(17/25),显著高于胃体胃底组的9.5%(2/21,P<0.05);胃窦胃角组的胃蠕动评分亦显著高于胃体胃底组(P<0.01)。在操作评分方面,胃窦胃角组影响操作的发生率为68.0%(17/25),显著高于胃体胃底组的4.8%(1/21)、食管和食管胃交界组的3.3%(1/30,P值均<0.05);胃窦胃角组的操作评分亦显著高于胃体胃底组、食管和食管胃交界组(P值均<0.01)。因剧烈蠕动影响操作的患者在给予消旋山莨菪碱后蠕动均得到明显抑制(操作评分≤2分),顺利完成手术。3组间患者在PACU中视力模糊和腹痛发生率,以及术后24h咽痛、腹痛、发热、排尿困难和恶心呕吐发生率的差异均无统计学意义(P值均>0.05)。结论气管插管全身麻醉下上消化道病变行ESD术中消化道剧烈蠕动易发生于胃窦胃角处病变的手术过程中,术中静脉注射消旋山莨菪碱10mg能有效抑制蠕动,有利于手术操作。

Objective To compare the incidence of vigorous peristalsis in different parts of upper gastrointestinal tract during endoscopic submucosal dissection （ESD） under tracheal intubation general anesthesia. Methods A total of 76 patients scheduled for ESD of upper gastrointestinal tract under general anesthesia in our hospital from February to July in 2014 were sequentially enrolled in this study. The patients were assigned to three groups based on the foci location： gastric antrum and angle group （n = 25）, gastric body and fundus group （n = 21） and esophagus and esophagogastric junction group （n = 30）. Tracheal intubation was facilitated with rapid intravenous induction. The anesthesia was maintained with continuous intravenous injection of propofol and intermittent intravenous injection of fentanyl. The process of ESD was recorded by endoscopic video system, and the score of peristalsis of esophagus and stomach （no in the esophagus and esophagogastric junction group） and operation score were recorded. Gastric peristalsis score〉2 was defined as vigorous peristalsis. When operation score 〉2, racanisodamine 10 mg had to be intravenously injected to proceed smoothly ESD. Extubation time （the interval between the end of ESD and tracheal extubation） and PACU time （the interval between tracheal extubation and permission to general ward） were recorded. Drug adverse reaction and condition of patients in PACU and 24 h after operation were also recorded. Results Operation time and anesthesia time in the gastric antrum and angle group were significantly shorter than those in the other two groups （all P〈 0.05）. There were no significant differences in extubation time, postanesthesia care unit （PACU） time or dosage of propofol between groups （all P 〉0.05）. The incidence of vigorous peristalsis was 68.0 % （17/25） in the gastric antrum and angle group, which was significantly higher than that in the gastric body and fundus group （9.5%, 2/21, P〈0. 05）. The score of gastric peristalsis in the gastric antrum and angle group was also significantly higher than that in the gastric body and fundus group （P〈0.01）. The patient proportion of operation score 〉2 in the gastric antrum and angle group was 68.0 % （17/25）, which was significantly higher than that in the gastric body and fundus group （4.8 %, 1/21 ） and esophagus and esophagogastric junction group （3.3%, 1/30, both P〈0. 05）. The operation score of the gastric antrum and angle group was also significantly higher than that of the other two groups （both P〈0. 01）. Vigorous peristalsis was significantly inhibited after immediate intravenous injection of anisodamine, and ESD procedure were successfully completed. There were no significant differences in the incidences of blurred vision or bellyache in PACU, or the incidences of pharyngalgia, bellyache, fever, dysuresia, nausea or vomiting in 24 h after operation between groups （all P〉0. 05）. Conclusion In the process of ESD under general anesthesia, the incidence of vigorous peristalsis is high in patients with foci located on gastric antrum and angle. Intravenous injection of racanisodamine 10 mg can inhibit significantly the peristalsis and facilitate ESD.