功能性胃食管连接部流出道梗阻的临床特征与食管动力关系的单中心研究

Single-center study on the relationship between the clinical features of functional esophagogastric junction outflow obstruction and esophageal motility

目的:分析功能性胃食管连接部流出道梗阻(EGJOO)患者的临床特征,提高对功能性EGJOO的认知。方法:收集2015年1月至2019年12月在南京医科大学第一附属医院胃肠动力中心接受高分辨率食管测压(HREM)检查,符合食管动力障碍芝加哥分类标准(第3版)中EGJOO的诊断标准,同时通过胃镜、上消化道造影等检查排除器质性疾病的91例功能性EGJOO患者资料。分析功能性EGJOO患者的临床表现、治疗方法、疗效和临床转归,不同临床表现患者的HREM参数,以及不同治疗方法患者的症状和HREM参数。采用最小显著差异法或Tamhanes T2检验、Mann-Whitney U或Wilcoxon检验、卡方检验或Fisher确切概率法进行统计学分析。 结果:91例功能性EGJOO患者最常见的临床表现为吞咽困难(34/91,37.4%);有吞咽困难患者的食管下括约肌压力(LESP)和食管下括约肌松弛期间的食团内部压力(IBP LESR)值均高于无吞咽困难者[30.95 mmHg (26.27 mmHg, 39.37 mmHg)(1 mmHg=0.133 kPa)比27.35 mmHg (24.60 mmHg, 34.87 mmHg)、(8.25±4.64) mmHg比(5.69±4.65) mmHg],差异均有统计学意义( Z=2.076, t=2.539;P=0.038、0.013)。30例(33.0%)患者无特殊治疗,52例(57.1%)患者采用药物治疗,9例(10.0%)患者行经口内镜下肌切开术(POEM)。行POEM患者治疗前的吞咽困难发生率、最大食团内部压力值均高于无特殊治疗和采用药物治疗者[8/9比43.3%(13/30)和25.0%(13/52)、21.80 mmHg (15.45 mmHg, 28.95 mmHg)比12.20 mmHg (10.00 mmHg, 18.10 mmHg)和13.70 mmHg (11.07 mmHg, 17.82 mmHg)],差异均有统计学意义(Fisher确切概率法、Fisher确切概率法, Z=2.814、2.390;P=0.023、 P<0.01, P=0.005、0.017);行POEM、无特殊治疗和采用药物治疗的患者治疗前食管排空延迟或扩张的发生率分别为6/9、5/14和3/18,3组间差异有统计学意义(Fisher确切概率法, P=0.039),其中行POEM的患者治疗前食管排空延迟或扩张的发生率高于采用药物治疗的患者,差异有统计学意义(Fisher确切概率法, P=0.026)。24.2%(22/91)的患者症状可自行缓解,随访过程中2例(2.2%)患者演变为Ⅱ型贲门失弛缓症。 结论:功能性EGJOO患者的主要表现为吞咽困难,LESP、IBP LESR明显升高者更易发生吞咽困难。对于存在明显胃食管连接部梗阻征象者更倾向选择POEM治疗,部分功能性EGJOO患者可自行缓解,少部分患者可发展为贲门失弛缓症。

Objective To analyze the clinical characteristics of functional esophagogastric junction outflow obstruction(EGJOO)and to improve the knowledge of functional EGJOO.Methods From January 2015 to December 2019,at the Gastrointestinal Motility Center of The First Affiliated Hospital with Nanjing Medical University,91 patients who underwent high resolution esophageal manometry(HREM)and met the EGJOO criteria of Chicago Classification for esophageal motility disorders,3rd edition and excluded organic diseases by examination such as gastroscopy or upper gastrointestinal radiography were collected.The clinical manifestations,treatment methods,effect and clinical outcome of patients with functional EGJOO,the HREM parameters of patients with different clinical manifestations as well as symptoms and HREM parameters of patients with different treatments were analyzed.Least significant difference test or Tamhanes T2 test,Mann-Whitney U or Wilcoxon test,chi-square test or Fisher exact test were used for statistical analysis.Results The most common symptom of 91 functional EGJOO patients was dysphagia(34/91,37.4%).The lower esophageal sphincter pressure(LESP)and the intrabolus pressure during relaxation of the lower esophageal sphincter(IBPLESR)of patients with dysphagia were both higher than those of patients without dysphagia(30.95 mmHg(26.27 mmHg,39.37 mmHg)(1 mmHg=0.133 kPa)vs.27.35 mmHg(24.60 mmHg,34.87 mmHg);(8.25±4.64)mmHg vs.(5.69±4.65)mmHg),and the differences were statistically significant(Z=2.076,t=2.539;P=0.038,0.013).Thirty patients(33.0%)had no special treatment,52 patients(57.1%)were treated with medication,and nine patients(10.0%)underwent peroral endoscopic myotomy(POEM).The incidence of dysphagia before treatment and maximum intrabolus pressure of patients who underwent POEM were both higher than those of patients without special treatment and medication treatment(8/9 vs 43.3%,13/30 and 25.0%,13/52;21.80 mmHg(15.45 mmHg,28.95 mmHg)vs.12.20 mmHg(10.00 mmHg,18.10 mmHg)and 13.70 mmHg(11.07 mmHg,17.82 mmHg)),and the differences were statistically significant(Fisher exact test,Fisher exact test;Z=2.814,2.390;P=0.023,P<0.01,P=0.005,0.017).The incidences of delayed esophageal emptying or esophageal dilation of patients who underwent POEM,without special treatment and with medication treatment was 6/9,5/14 and 3/18,respectively,and the differences were statistically significant among three groups(Fisher exact test,P=0.039).Among them,the incidence of delayed esophageal emptying or esophageal dilation of patients received POEM before treatment was higher than that of patients with medication treatment(Fisher exact test,P=0.026).The symptoms of 24.2%(22/91)was spontaneously relieved,and two patients(2.2%)developed typeⅡachalasia during follow-up.Conclusions The main manifestation of patients with functional EGJOO is dysphagia.Patients with significantly increased LESP and IBPLESP are more likely to have dysphagia.Patients with obvious signs of esophageal gastric junction obstruction are more inclined to choose POEM treatment.Some patients with functional EGJOO can relieve themselves,and a few patients can develop achalasia.