经口内镜下肌切开术不同方式治疗贲门失弛缓症对比研究

Different surgical procedures of peroral endoscopic myotomy for achalasia: a comparative study of 56 cases

目的比较经口内镜下环形肌切开术与全层肌切开术及切开长度≤5 cm与切开长度>5 cm治疗贲门失弛缓症的临床疗效。方法回顾性分析本院2013年2月至2014年8月诊断贲门失弛缓症并行经口内镜下肌切开术(peroral endoscopic myotomy,POEM)56例患者的临床资料。其中24例患者行环形肌切开为环形肌切开组,32例患者行全层切开为全层切开组;28例患者切开长度≤5 cm为短切组,28例患者切开长度>5 cm为长切组。分别比较4组治疗贲门失弛缓症临床症状缓解情况,术前、术后食管最大直径变化情况,术中、术后并发症发生情况。结果 4组术前一般资料,包括性别、年龄、体质量指数(BMI)、术前食管最大直径、术前Eckardt评分、病程等比较差异无统计学意义(P>0.05)。环形肌切开、全层切开、长切、短切4组术前Eckardt评分分别与术后1、6、12个月比较,差异均有统计学意义(P<0.01)。全层切开组与环形肌切开组相比,术后Eckardt评分1个月[(0.50±1.07)vs(0.71±1.04)]、6个月[(0.53±1.10)vs(0.50±0.78)]、12个月[(0.37±0.75)vs(0.42±0.82)],术后6个月食管最大直径[(26.44±7.88)vs(24.00±5.82)mm]以及气体并发症[(5/24)vs(13/32)]差异均无统计学意义(P>0.05);短切组与长切组相比,术后Eckardt评分1个月[(0.46±0.83)vs(0.71±1.42)]、6个月[(0.39±0.68)vs(0.64±1.19)]、12个月[(0.32±0.72)vs(0.46±0.84)],术后6个月食管最大直径[(24.81±7.87)vs(25.98±6.37)mm]以及气体并发症[(9/28)vs(9/28)]差异均无统计学意义(P>0.05)。结论治疗贲门失弛缓症建议采用经口内镜下食管环行肌切开术,且以切开长度≤5 cm为宜。

Objective To compare the clinical efficacy of circular myotomy and full-thickness myotomy guided by peroral endoscopy in treatment of incision length of ≤5 cm and of 〉5 cm in achalasia patients. Methods Clinical data of 56 achalasia patients who were treated with peroral endoscopic myotomy（ POEM） in our hospital from February 2013 to August 2014 were collected and then retrospectively analyzed in this study. Twenty-four of them received circular myotomy and were assigned in the circular myotomy group,and other 32 patients undergoing full-thickness myotomy in the full-thickness myotomy group. Twentyeight patients who received incision length of ≤5 cm were in the short-myotomy group,and the other 28 patients with myotomy incision length 〉5 cm were in the long-myotomy group. Esophageal diameters before and after operation,and intra- and post-operative incidences of complications were compared among the above4 groups. Results Before the treatment,there were no significant differences in sex,age,body mass index,Eckardt score,esophageal diameter and illness course among the patients from 4 groups（ P〉0. 05）.Significant differences were seen in the changes of preoperative Eckardt scores in 1,6 and 12 months postoperatively in the 4 groups（ P〉0. 05）. When the full-thickness myotomy group was compared with circular myotomy group,there was no significant differences in Eckardt scores in postoperative 1（ 0. 50 ± 1. 07 vs 0. 71 ± 1. 04）,6（ 0. 53 ± 1. 10 vs 0. 50 ± 0. 78）,and 12 months（ 0. 37 ± 0. 75 vs 0. 42 ± 0. 82）,esophageal diameter in 6 months postoperatively（ 26. 44 ± 7. 88 vs 24. 00 ± 5. 82 mm）,gas complications（ 5 /24 vs 13 /32,all P〉0. 05）. When the short-myotomy group was compared with long-myotomy group,no significant differences were found in Eckardt scores in 1（ 0. 46 ± 0. 83 vs 0. 71 ± 1. 42）,6（ 0. 39 ± 0. 68 vs0. 64 ± 1. 19）,and 12 months postoperatively（ 0. 32 ± 0. 72 vs 0. 46 ± 0. 84）,esophageal diameter in 6months（ 24. 81 ± 7. 87 vs 25. 98 ± 6. 37 mm）,and gas complications（ 9 /28 vs 9 /28,all P〉0. 05）.Conclusion POEM is recommended for the treatment of achalasia,and circular myotomy and incision length of ≤5 cm are better.