胸腔镜手术治疗贲门失弛缓症对食管功能改变及症状改善的研究

Esophageal function changes and symptom relief after video-assisted thoracoscopic surgery for achalasia of cardia

目的通过对胸腔镜手术治疗贲门失弛缓症(AC)对食管功能改变、症状改善等方面的回顾性临床研究,评价胸腔镜手术治疗在临床中的应用价值。方法回顾性分析贵州医科大学附属医院胸外科2012年3月至2014年9月行胸腔镜下改良Heller手术34例AC患者的临床资料,其中男11例、女23例,中位年龄35(11~67)岁。根据患者治疗和随访时间分为术前组、术后1个月组、术后3个月组和术后6个月组。对患者治疗前后的临床症状变化、影像学改变、食管动力学改变等进行客观数据统计,应用统计学方法分别对不同分组的情况进行分析。结果各组患者年龄、性别差异无统计学意义(P>0.05)。全组病例术中操作顺利,术中未出现相应并发症、死亡。经外科手术治疗后患者相应症状不同程度上得到改善,且术前、术后临床症状评分有明显下降趋势(P<0.05)。除食管下括约肌长度(LESL)较术前变化程度较小(P>0.05)外,食管下括约肌静息压(LESP)、食管下括约肌松弛压(LESRP)、食管体部静息压(EBP)均较术前明显降低,食管下括约肌松弛率(LESRR)较术前提高,差异均有统计学意义(P<0.05)。术前组与术后3个月组对比食管钡餐造影食管最大宽度明显缩小(P<0.05)。随访中3例患者出现胃食管反流,2例术后发生食管穿孔,1例术后因食管胸膜瘘导致脓胸。无上消化道大出血、食道裂孔疝等并发症发生。结论外科手术治疗可明显缓解患者的临床症状,改善食管动力,且具有简单易行、术后并发症少、远期疗效显著等优点。胸腔镜下改良Heller手术极大地减少了传统开胸手术的创伤,由于其微创的特点,已被广泛认可。食管测压可对该病的诊断、患病程度及疗效起到客观指导作用。

Objective Through a retrospective study on esophageal function changes and symptom relief after video-assisted thoracoscopic surgery treatment for achalasia of cardia （AC） to assess the clinical value of this operation. Methods We reviewed the data of 34 AC patients who received modified Heller operation by video-assisted thoracoscopic surgery in the Affiliated Hospital of Guizhou Medical University from March 2012 to September 2014. There were 11 males and 23 females with a median age of 35 （11-67） years. These patients were divided into four groups according to the time of treatment and follow-up： preoperative group, postoperative one-month group, postoperative three-month group and postoperative six-month group. Changes of symptoms, radiography and esophageal dynamics before and after therapy were collected. These different groups were analyzed based on statistical methods. Results There was no statistical difference in ages and genders among groups （P〉0.05）. The surgery was successful and no complication or death occurred. Symptoms of patients showed different degrees of relief and the postoperative grade of clinical symptoms decreased （P〈0.05）. After surgery, lower esophageal sphincter pressure （LESP）, lower esophageal sphincter resting pressure （LESRP） and esophageal body pressure （EBP） decreased significantly, while lower esophageal sphincter relax rate （LESRR） increased （P〈0.05）. While there was no significant difference in length of lower esophageal sphincter （LESL, P〉0.05）. Angiography of upper digestive tract revealed that compared to the preoperative group, the maximum width in postoperative three-month group decreased significantly （P〈0.05）. During the follow-up, 3 patients suffered gastroesophageal reflux, 2 patients esophageal perforation and 1 patient empyema due to esophago-pleural fistula. No massive hemorrhage of upper digestive tract and hiatal hernia occured. Conclusion Sugery can significantly ameliorate the clinical symptoms of the patients with AC, and improve esophageal dynamics. And it is simple and easy to perform with less complications and better long-term outcomes. Improved Heller operation by video- assisted thoracoscopy is a less invasive procedure when compared with the traditional thoracotomy. Moreover, esophageal manometry can objectively assist in the diagnosis and degree of the disease and effect of therapy.