改良经口内镜下肌切开术治疗51例贲门失弛缓症的临床疗效

Clinical efficacy of modified peroral endoscopic myotomy in the treatment of 51 cases of achalasia

目的评估改良经口内镜下肌切开术(POEM)对贲门失弛缓症(AC)患者的食管动力学影响和临床疗效。方法回顾性纳入2013年1月至2014年12月中山大学附属第一医院确诊为AC并行改良POEM的51例患者,根据芝加哥分类标准分为Ⅰ、Ⅱ、Ⅲ型。应用食管高分辨率测压(HRM)比较改良POEM前后食管动力学变化,24 h食管阻抗-pH监测观察术后反流情况,采用吞咽困难障碍问卷(IDQ)、Eckardt评分和简明健康状况调查表(SF-36)评估AC患者的临床症状和生命质量。统计学方法采用配对t检验、独立样本t检验、Wilcoxon秩和检验和Pearson积矩相关分析。结果AC患者术后3个月、1年的下食管括约肌静息压(LESP)和整合松弛压(IRP)均低于术前[分别为(23.89±12.68)、(23.44±12.56)mmHg(1 mmHg=0.133 kPa)比(39.29±16.14)mmHg和(16.13±9.43)、(15.37±8.36)mmHg比(30.57±11.31)mmHg],差异均有统计学意义(t=7.520、7.866和7.641、8.909,P均<0.05)。Ⅰ型与Ⅱ型AC患者的LESP和IRP同期比较差异均无统计学意义(P均>0.05)。改良POEM后食管体部恢复部分收缩功能者术后1年的LESP低于同期食管体部未恢复收缩功能者[(15.38±4.54)mmHg比(25.65±13.19)mmHg],差异有统计学意义(t=0.039,P<0.05)。AC患者术后3个月、1年病理性酸反流发生率分别为7.8%(4/51)、2.0%(1/51)。AC患者术后3个月、1年的IDQ和Eckardt评分均低于术前[分别为4分(0分,10分)、4分(0分,11分)比23分(18分,30分)和2分(1分,3分)、1分(0分,1分)比5分(4分,5分)],差异均有统计学意义(Z=-6.036、-6.104和-5.971、-6.209,P均<0.01)。根据Eckardt评分,术后3个月、1年的临床缓解期比例高于术前[98.0%(50/51)、100.0%(51/51)比19.6%(10/51)],差异均有统计学意义(χ^2=64.76、68.56,P均<0.05)。AC患者术后3个月、1年SF-36问卷一般健康和社会功能评分均高于术前[0.55分(0.45分,0.70分)、0.55分(0.45分,0.70分)比0.45分(0.30分,0.55分)和0.88分(0.75分,1.00分)、0.88分(0.75分,1.12分)比0.75分(0.75分,1.00分)],差异均有统计学意义(Z=-4.439、-4.225和-2.123、-2.320,P均<0.05),健康变化评分均低于术前[3.00分(2.00分,3.00分)、2.00分(1.00分,3.00分)比4.00分(3.00分,4.00分)],差异均有统计学意义(Z=-4.827、-4.841,P均<0.05)。改良POEM前后LESP变化值与IRP变化值均呈正相关(r=0.624、0.592,P均<0.01)。结论改良POEM可显著改善AC患者的临床症状和LES松弛功能,术后反流发生率较低。

Objective To evaluate the effects of modified peroral endoscopic myotomy(POEM)on esophageal dynamics and clinical efficacy in achalasia(AC)patients.Methods From January 2013 to December 2014,51 patients diagnosed with AC and received modified POEM at The First Affiliated Hospital of Sun Yat-sen University were retrospectively enrolled.AC patients were classified as typeⅠ,typeⅡand typeⅢaccording to Chicago classification.The changes of esophageal dynamics before and after the modified POEM were compared by high resolution manometry(HRM).The reflux after the operation was evaluated by 24-hour esophageal impedance-pH monitoring.The clinical symptoms and the quality of life of AC patients were assessed by impaction dysphagia questionnaire(IDQ),Eckardt scale and short-form 36 item health survey(SF-36).Paired t test,independent sample t test,Wilcoxon rank sum test and Pearson correlation analysis were used for statistical analysis.Results At three months and one year after operation,lower esophageal sphincter pressure(LESP)and integrated relaxation pressure(IRP)were all lower than those before operation((23.89±12.68)and(23.44±12.56)mmHg(1 mmHg=0.133 kPa)vs.(39.29±16.14)mmHg;(16.13±9.43)and(15.37±8.36)mmHg vs.(30.57±11.31)mmHg),and the differences were statistically significant(t=7.520,7.866,7.641 and 8.909,all P<0.05).There were no statistically significant differences in LESP and IRP during the same period between patients with typeⅠAC and typeⅡAC(all P>0.05).The LESP of patients with partial esophageal peristalsis function recovered one year after operation was lower than that of patients with unrecovered esophageal peristalsis function((15.38±4.54)mmHg vs.(25.65±13.19)mmHg),and the difference was statistically significant(t=0.039,P<0.05).The proportions of pathologic acid reflux of AC patients at three months and one year after operation were 7.8%(4/51)and 2.0%(1/51),respectively.The IDQ and Eckardt scores of patients with AC at three months and one year after operation were both lower than those before operation(4 points,0 points to 10 points and 4 points,0 points to 11 points vs.23 points,18 points to 30 points;2 points,1 points to 3 points and 1 points,0 points to 1 points vs.5 points,4 points to 5 points),and the differences were statistically significant(Z=-6.036,-6.104,-5.971 and-6.209,all P<0.01).According to Eckardt score,the proportions of clinical remission at three months and one year after operation were higher than that before operation(98.0%,50/51 and 100.0%,51/51 vs.19.6%,10/51),and the differences were statistically significant(χ^2=64.76 and 68.56,both P<0.05).The SF-36 general health and social function scores at three months and one year after operation were both higher than those before operation(0.55 points,0.45 points to 0.70 points and 0.55 points,0.45 points to 0.70 points vs.0.45 points,0.30 points to 0.55 points;0.88 points,0.75 points to 1.00 points and 0.88 points,0.75 points to 1.12 points vs.0.75 points,0.75 points to 1.00 points);and the differences were statistically significant(Z=-4.439,-4.225,-2.123 and-2.320,all P<0.05);and the health change scores were lower than those before operation(3.00 points,2.00 points to 3.00 points and 2.00 points,1.00 points to 3.00 points vs.4.00 points,3.00 points to 4.00 points),and the differences were statistically significant(Z=-4.827 and-4.841,both P<0.05).Before and after modified POEM,the changes of LESP were positively correlated with the changes of IRP(r=0.624 and 0.592,both P<0.01).Conclusion Modified POEM can significantly improve the symptoms and LES relaxation function of AC patients,with a low incidence of post-operative reflux.