经口内镜下肌切开术后贲门失弛缓症患者食管下括约肌及食管体部动力变化的初步研究

Indications of esophageal body motility improvement after POEM in patients with achalasia

目的 探讨经口内镜下肌切开术（POEM）术后贲门失弛缓症症（AC）患者食管下括约肌（LES）和食管体部动力变化,并进行Ling分型亚组分析。方法 选取2009年3月至2014年7月经解放军总医院消化科确诊的66例AC患者行POEM术治疗,所有患者于术前及术后1-6月之内行高分辨率食管测压检查,分析其中治疗前、后食管体部动力数据有改变的16例患者的食管下括约肌（LES）残余压、食管体部远端收缩积分（DCI）、收缩前沿速度（CFV）及同步收缩百分比的变化,分析该变化的影响因素,并比较术后不同Ling分型患者食管压力及体部动力的变化。结果 （1）16例患者POEM术后LES残余压[（30.12±8.56）vs（17.13±7.60）,P〈0.05]、DCI[（3533.95±3704.15）vs（1034.06±892.89）,P〈0.05]及同步收缩百分比[（69.09±27.12）vs（42.73±31.36）,P〈0.05]明显降低,且差异均有统计学意义;术后CFV平均值虽降低,但差异无统计学意义[（25.8±77.89）vs（4.02±25.04）,P〉0.05],且其中4例蠕动收缩有一定程度的恢复;（2）只有病程为POEM术后食管体部动力变化的影响因素（P〈0.05）,其余指标均无显著性差异（P〉0.05）;（3）Ling I型LES残余压经PEOM后术降低显著（30.55 vs 19.85,P〈0.05）,其余分型变化不明显,亚组间比较亦无显著差异。结论 （1）POEM术后部分患者短期内（1-6月）LES及食管体部动力有所改善;（2）AC患者的病程是POEM术后食管体部动力恢复的一个影响因素,病程越短、食管体部动力越容易恢复,即AC患者越早行POEM术越有利于食管体部动力的恢复;（3）POEM术后,不同Ling分型患者LES及食管体部动力变化的差异尚无明确定论,需要大样本随机对照资料进一步验证。

Objective This study aimed to assess the esophageal body motility in patients with achalasia nndergoing peroral endoscopic myotomy （POEM） and to analyze the factors involved in this phenomenon. Methods The study group comprised 66 patients with achalasia who underwnt POEM at our Digestive Endoscopic Center and received pre-and postoperative high-resolution manometry （HRM） within 1-6 month after POEM. Of these patients,55 （83.3%） had no changes between the pre-and postoperative esophageal body motility ,while in the remaining 11 （16.7%） patients, lower esophageal sphincter （LES）, residual pressure, distal contraction integral （DCI）, contraction of front velocity （CFV） and synchronous contraction percentage were analyzed and esophageal body motility data were changed. In addition, statistical comparison of demographic characteristics were made between the 11 and 55 patients. Results In 18.4% of the patients after POEM LES residual pressure [ （30.12 ±8.56） vs （ 17.13 ±7.60） ,P 〈 0.05 ], DCI （3533.95 ± 3704. 15 ） vs （ 1034. 06 ± 892. 89） , P 〈 0. 05 ] and synchronous contraction percentage [ （ 69. 09 ± 27. 12） vs （42. 73 ＋ 31. 36）, P 〈 0. 05 ] decreased and the difference was statistically significant, （ CFV mean value reduced but the difference was not statistically significant [ （25.8 ±77.89 ） vs （4. 02 ± 25.04 ） , P 〉 0.05 ] and 4 cases presented areturn of peristalsis. The duration of patients with esophageal body motility improvement was significantly shorter than the patients without esophageal body motility improvement and the difference was statistically significant [ （1.53 ±0.96） vs （6. 37 ±7.05 ）,P 〈 0. 05]. The other characteristics showed no significant difference between group A and group B. The tpyeLing I LES residual pressure decreased significantly after POEM [ （ 30.55 ± 7.36 ） vs （ 19. 85 ± 6. 70） , P 〈 0. 05 ] ,the other types of Ling classification didn＇t change significantly. Comparisons between the subgroups had no significant differences as well. Conclusions POEM can improve esophageal bodymotility in a certain group of patients with achalasia in the short term （ 1-6 month ） ; Peroral endoscopic myotomy improves esophageal body motility in patients with short achalasia duration;Esophageal body motility had no significant difference in different types of Ling classifications of patients after POEM which still remains to be further studied.