经口内镜下肌切开术治疗婴幼儿肥厚性幽门狭窄的临床实践

Clinical practice of peroral endoscopic myotomy for infantile hypertrophic pyloric stenosis

目的:总结经口内镜下肌切开术(peroral endoscopic myotomy,POEM)治疗婴幼儿肥厚性幽门狭窄(infantile hypertrophic pyloric stenosis,IHPS)的临床实践经验。方法:出生35 d,出生体重3600 g的男性患儿,因"非胆汁样呕吐1周"于2019年2月15日收治于上海市儿童医院普外科。根据患儿术前临床表现、B型超声及上消化道造影检查确诊为IHPS。于出生后40 d在全身麻醉下实施POEM术:距幽门2 cm切开胃黏膜,在胃黏膜下层建立"隧道"直至幽门,海博刀纵行完整切开肥厚、增生的幽门环肌,电凝止血后钛夹关闭胃黏膜切口。结果:手术顺利完成,总用时38 min;术后2 d拔出胃管,术后4 d行上消化道造影检查示幽门通畅无穿孔;进食无呕吐,患儿于术后7 d出院。术后1个月余随访无呕吐等症状,体重增加2 kg。结论:POEM是治疗IHPS的一种新方法,患儿近期疗效良好;开展该手术需要有丰富的内镜手术经验,其远期疗效有待多中心大宗病例研究进一步探索。

Objective To summarize the clinical practice of peroral endoscopic myotomy(POEM)for infantile hypertrophic pyloric stenosis(IHPS).Methods A 35-day-old boy with a birth weight of 3500 gram was admitted for nonbilious vomiting over 1 week on February 15,2019.With a diagnosis of IHPS based upon clinical features and findings of ultrasound and barium upper gastrointestinal contrast,POEM was performed under general anesthesia at Day 40.Gastric mucosal entrance was located at 2 cm proximal to pylorus and a submucosal tunnel created.After with exposure of muscular layer,complete myotomy of hypertrophic circular muscle layer was performed by a hybrid knife until longitudinal muscular layer.Upon a completion of myotomy,endoscopic clips were applied for hemostasis and mucosal incision was then closed.Results The procedure was completed successfully within 38 min.Nasogastric tube was removed at Day 2 postoperatively.Neither pyloric obstruction nor perforation was observed on the following upper gastrointestinal contrast study.Discharge occurred at Day 7 postoperatively without any vomiting.During a follow-up period of 1 month,there was a gain of body weight of 2 kg without any symptomatic recurrence.Conclusions POEM may be a new treatment for IHPS.Surgeons should master a certain endoscopic proficiency.Multicenter researches and larger trials are still required for validating the long-term outcomes of POEM for IHPS.