内镜经黏膜下隧道憩室间脊切开术治疗食管憩室初探

Preliminary results of submucosal tunneling endoscopic septum division in the treatment ofesophageal diverticulum

目的探讨内镜经黏膜下隧道憩室间脊切开术（STESD）治疗食管憩室的初步疗效及安全性。方法2016年4—11月复旦大学附属中山医院内镜中心对6例食管憩室患者进行了STESD，回顾分析这组患者的临床资料。STESD手术简要操作为：距食管憩室间脊3 cm处，行黏膜下注射并切开黏膜；朝向间脊建立黏膜下隧道；在间脊暴露满意后，内镜分离至憩室底部；夹闭隧道入口黏膜。记录并总结患者的术中、术后情况以及手术前后患者的症状评分变化（使用改良Eckardt评分系统,包括吞咽困难、烧心、反流、体质量减轻和胸骨后疼痛5项症状，每项评分0- 3分，最高15分，最低0分，评分越高，症状越严重）。结果全组男4例、女2例，年龄50- 67（中位数56.5）岁；2例Zenker憩室，4例膈上憩室；患病时间为5月至29年（中位数2.5年）；既往均未接受过任何治疗。全组6例患者均顺利完成STESD术。间脊切开长度1- 4 （中位数2.5） cm，关闭黏膜入口使用金属夹2-6（中位数5）枚。手术时间为33- 135（中位数51.5）min，无术中及术后穿孔、出血等严重并发症的发生。术后住院时间为3- 9（中位数5）d。出院时，所有患者均表示症状有所缓解，其中1例Zenker憩室患者主诉手术后异物感，2周后主诉缓解。全组患者随访4- 10（中位数5）月，均无严重不良事件的发生，未见复发，内镜随访见间脊明显消失。6例患者术前症状评分为1- 13（中位数4.5）分；术后评分为0- 4（中位数0.5）分，其中术前评分分别为13分、1分和1分的3例患者术后评分均下降到0分；术前评分分别为5分和4分，2例患者术后评分下降到1分，且主要以反流为主诉；患病达29年的1例患者术前症状评分为5分，术后降为4分，但自觉症状改善不明显。结论内镜经黏膜下隧道憩室间脊切开术（STESD）治疗食管憩室短期疗效好，安全性高。

ObjectiveTo evaluate the safety and efficacy of submucosal tunneling endoscopic septum division （STESD） for escophageal diverticulum.MethodsClinical data of six consecutive patients with symptomatic esophageal diverticula who received STESD in Endoscopy Center of Zhongshan Hospital, Fudan University from April 2016 to November 2016 were analyzed retrospectively. STESD was performed as following： mucosal entry was made 3 cm from the septum of esophageal diverticulum; submucosal tunnel was created towards the septum; after the satisfactory exposure of the septum, endoscopic division was made down to the bottom of the diverticulum; mucosal closure of the tunnel entry was made. The symptoms were scored using a system modified according to Eckardt score, namely dysphagia, heartburn, regurgitation, weight loss and retrosternal pain with each ranging from 0 to 3 （maximum score 15, minimum score 0, the higher the score, the more severe the symptoms） .ResultsThere were four males and two females with median age of 56.5 （range 50-67） years. Four patients were epiphrenic diverticula, and the other two were Zenker′s diverticula. Median duration of disease was 2.5 years （range 5 months-29 years） . No previous treatment was attempted. All the patients completed STESD successfully. The median septum division length was 2.5 （1-4） cm. The median number of metallic clips for mucosal closure was 5 （2-6） . The median operation time was 51.5 （33-135） min. No major adverse events, such as perforation or bleeding were found in perioperative period. The median time of hospital stay was 5 （3-9） days. All the patients had symptom relief after operation. One patient with Zenker′s diverticulum reported foreign body sensation after operation and experienced relief two weeks afterwards. During a median follow-up time of 5 （4-10） months, the median symptom score of 6 cases was 4.5 （1-13） before and 0.5 （0-4） after operation. The symptom scores went down to zero in 3 patients （preoperative scores 13, 1, 1, respectively） , and down to 1 in 2 patients with main symptom of backflow （preoperative scores 5, 4, respectively） . One patient with 29 years history of disease did not report obvious improvement in symptoms （preoperative and postoperative scores 5, 4, respectively） .ConclusionSubmucosal tunneling endoscopic septum division is efficient and safe to relieve symptomatic esophageal diverticulum in short term.