内镜黏膜下剥离术治疗难治性胃食管反流病临床分析

Endoscopic submucosal dissection in the treatment of refractory gastroesophageal reflux disease

目的探讨内镜黏膜下剥离术(endoscopic submucosal dissection, ESD)治疗难治性胃食管反流病(refractory gastroesophageal reflux disease, RGERD)的临床效果及安全性。方法 38例RGERD患者均行ESD,术前和术后6个月均行24 h食管pH值监测,观察pH值<4的反流次数、pH值<4的时间百分比、pH值<4长于5 min的反流次数、DeMeester评分,并进行比较;比较术前和术后6个月患者GerdQ量表评分、食管外症状量表评分、汉密尔顿焦虑量表评分、抑郁量表评分。随访6~31个月,观察治疗效果、不良反应发生情况及质子泵抑制剂停用情况。结果 38例患者均成功行ESD,术后6个月患者GerdQ量表评分[(6.60±2.48)分]、食管外症状量表评分[(2.26±0.79)分]、汉密尔顿焦虑量表评分[(5.97±3.44)分]、汉密尔顿抑郁量表评分[(7.60±3.87)分]均低于术前[(13.37±2.78)、(6.95±1.16)、(13.61±5.26)、(14.10±6.47)分](P<0.05)。术后6个月患者pH值<4的反流次数[(46.59±14.44)次]、pH值<4的时间百分比[(2.74±0.74)%]、pH值<4长于5 min的反流次数[(3.68±0.92)次]、DeMeester评分[(28.78±8.70)分]均低于术前[(149.50±20.21)次、(7.12±1.05)%、(9.12±1.80)次、(71.08±12.43)分](P<0.05)。术中发生黏膜下小动脉出血1例,后止血成功;术中、术后无穿孔发生;术后发热1例,出现上腹部不适2例,对症处理后症状缓解,随访6~31个月,患者食管、食管外症状及患者焦虑、抑郁情况较术前改善;内镜下复查可见食管黏膜糜烂较术前改善,贲门口无明显松弛;质子泵抑制剂停用35例。结论 ESD可改善RGERD患者食管、食管外症状及食管黏膜糜烂情况,缓解患者焦虑、抑郁情绪,治疗RGERD安全、有效。

Objective To investigate the clinical efficacy and safety of endoscopic submucosal dissection(ESD) in the treatment of refractory gastroesophageal reflux disease(RGERD). Methods Thirty-eight patients with RGERD were treated with ESD, and received 24-h monitoring of pH value in the oesophagus to detect and compare the frequency of reflux, time percentage of reflux, frequency of reflux >5 min, and DeMeester score in patients with pH<4 before and 6 months after operation.GerdQ scale, extraesophageal symptoms, Hamilton anxiety scale and Hamilton depression scale were compared before and 6 months after operation.All patients were followed up for 6 to 31 months to observe the therapeutic effect, adverse reactions and withdrawal of proton pump inhibitor. Results ESD was successfully performed in all 38 patients.The score of RgerQ scale, extraesophageal symptom, Hamilton anxiety scale and Hamilton depression scale were lower 6 months after operation(6.6±2.48, 2.26±0.79, 5.97±3.44, 7.60±3.87) than those before operation(13.37±2.78, 6.95±1.16, 13.61±5.26, 14.10±6.47)(P<0.05).The frequency of reflux, percentage of reflux, frequency of reflux >5 min and DeMeester score in patients with pH<4 were higher 6 months after operation [46.59±14.44,(2.74±0.74)%, 3.68±0.92, 28.78±8.70] than those before operation [149.50±20.21,(7.12±1.05)%, 9.12±1.80, 71.08±12.43](P<0.05). Hemorrhage in submucosal arterides occurred in one patient during operation, which was stopped successfully. No perforation occurred during and after operation.Fever occurred in 1 patient and epigastric discomfort occurred in two patients, which were relieved after symptomatic treatment.After the follow-up survey for 6 to 31 months, esophageal and extraesophageal symptoms, anxiety and depression were relieved,the esophageal mucosal erosion was corrected,and no chalasia of cardia was found.The proton pump inhibitor was withdrawn in 35 patients.Conclusion ESD is effective and safe to alleviate the esophageal and extraesophageal symptoms,correct the mucosal erosion,and relieve depression and anxiety in patients with RGERD.