双隧道与单隧道经口内镜下肌切开术治疗贲门失弛缓症的疗效比较

Comparison between double-tunnel and traditional peroral endoscopic myotomy for achalasia cardia

目的评价双隧道与单隧道经口内镜下肌切开术(peroral endoscopic myotomy,POEM)治疗贲门失弛缓症的长期临床疗效。方法设计随机对照试验,纳入2018年6月-2019年6月于南京医科大学第一附属医院消化内科行POEM治疗的30例贲门失弛缓症患者,采用计算机随机数字法将30例患者随机分为单隧道POEM组(行传统POEM治疗)和双隧道POEM组(在传统POEM基础上,在第一隧道对侧建立第二隧道并对食管前壁行肌切开术),每组各15例。记录术中手术情况并对患者定期随访,比较2种术式的临床疗效及并发症。结果单隧道和双隧道POEM组的手术均成功,2组术中并发症发生率差异无统计学意义(5/15比4/15,P=1.000),住院时间及费用差异均无统计学意义(P>0.05)。单隧道组随访时间为(17.20±4.83)个月,双隧道组为(15.33±4.67)个月,2组患者术后Eckardt评分差异无统计学意义[1.53(2.00)分比1.60(3.00)分,Z=-0.363,P=0.744]。2组治疗有效患者均为14例。术后高分辨率食管测压结果显示,双隧道组的4s综合松弛压为(11.27±3.14)mmHg(1 mmHg=0.133 kPa),低于单隧道组的(15.05±4.21)mmHg(t=2.794,P=0.009)。2组患者术后胃食管反流病问卷评分差异无统计学意义[(4.40±1.64)分比(4.20±1.42)分,t=0.357,P=0.724]。结论单隧道和双隧道POEM治疗贲门失弛缓症疗效相当,但双隧道POEM可更有效地降低术后4s综合松弛压。

Objective To evaluate the long-term efficacy of double-tunnel peroral endoscopic myotomy(POEM)and traditional POEM in the treatment of achalasia cardia.Methods A randomized controlled trial was performed on the data of 30 patients with achalasia cardia,who underwent POEM in the First Affiliated Hospital of Nanjing Medical University from June 2018 to June 2019.The 30 consecutive patients were randomly assigned to double-tunnel POEM group(15 cases,a second tunnel was established opposite to the traditional one)and traditional POEM group(15 cases).Intraoperative information was recorded,and patients were followed up regularly to compare the efficacy and complications between the two groups.Results Double-tunnel POEM and traditional POEM were all completed with technical success.There were no significant differences in the intraoperative complications(5/15 VS 4/15,P=1.000),hospitalization time or cost between the two groups.The follow-up time was 17.20±4.83 months and 15.33±4.67 months in the traditional POEM group and the double-tunnel POEM group,respectively.The Eckardt scores after surgery between the two groups had no significant difference[1.53(2.00)VS 1.60(3.00),Z=-0.363,P=0.744].The symptom relief cases were both 14 in the two groups.The postoperative 4-second integrated relaxation pressure(4 s IRP)of the double-tunnel group(11.27±3.14 mmHg)was significantly lower than that of the traditional group(15.05±4.21 mmHg,Z=2.794,P=0.009).There was no significant difference in postoperative gastroesophageal reflux disease questionnaire scores between the two groups(4.40±1.64 VS 4.20±1.42,t=0.357,P=0.724).Conclusion Double-tunnel POEM has almost the same efficacy as the traditional POEM except for a lower post-POEM 4 sIRP.