腹腔镜联合胃镜微创治疗贲门失弛缓症的临床研究
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摘要
目的：国际上,腹腔镜贲门括约肌切开术是目前外科治疗贲门失弛缓症的首选方案。但在我国,多数较重病人仍选择内科治疗,此种手术只在极少数医院开展。本文研究腹腔镜联合胃镜行Heller肌切开术附加胃底折叠术微创治疗贲门失弛缓症的临床效果及其优势。
方法：选取天津市微创外科中心从2005年2月至2011年1月应用腹腔镜联合胃镜行Heller括约肌切开术附加Dor胃底折叠术治疗贲门失弛缓症33例患者为研究对象。其中男18例,女15例,年龄24-70岁,平均43岁。病程18-105个月,平均42个月。体重下降5-25 kg,平均10 kg。其中2例曾做球囊扩张治疗,2例曾注射肉毒碱治疗。所有纳入病例均通过上消化道造影、食管测压、胃镜检查,用以明确诊断和排除食管占位性病变。33例均经24小时pH值监测除外术前食管反流。所选病例均在全麻下行腹腔镜Heller肌切开术附加Dor胃底180度前折叠术,术中联合胃镜操作,监视肌切开范围,深度,并确认食管粘膜完全外露。同时,术中胃镜及时发现粘膜穿孔,并在直视下行粘膜修补。随访通过病例查阅获得病人基本信息,并通过电话或随访信与病人联系回访,以对其术后生活质量进行客观评价。通过对手术前后主客观指标和随访观察情况进行对比分析,客观评价腹腔镜术中联合胃镜操作的微创治疗优势和手术效果,确立腹腔镜联合胃镜治疗该病的指征,形成规范的操作规程,指导临床工作。
结果：33例均顺利完成腹腔镜手术,未有中转开腹病例,无死亡病例。手术的平均时间为90.26min(60-145min),出血量平均45ml(50-150m1)。术中1例(曾接受肉毒杆菌毒素注射治疗)由于粘连严重,食管环形肌、纵行肌融合,层次不清,术中造成贲门上方约1cm处食管粘膜破裂,经术中胃镜证实后及时行腹腔镜下穿孔修补术。术后胃镜再次检查,确认修补牢靠。术后无严重并发症,无食管瘘发生。患者术后平均住院时间5.2天(4-9天)。术后进行随访,33例病人均表示吞咽困难较术前明显改善,复查胃镜显示33例患者贲门部镜身通过无阻力,食管粘膜炎症改变明显好转；上消化道造影和术前相比显示食道下段扩张明显减轻,下端造影剂排空良好。食道测压显示33例LES静息压、残留压明显下降,松弛率升高,与手术前相比均有统计学差异(P<0.05),和正常参考值比较无统计学差异(P>0.05),表明各项指标已经恢复到正常水平。术后24小时PH检测显示未有胃食管反流。
结论：(1)腹腔镜Heller肌切开术附加Dor胃底折叠术是目前外科治疗该病的首选方案。腹腔镜治疗贲门失弛缓症具有手术创伤小、恢复快、疗效可靠的特点,术中联合胃镜操作不仅能够确认肌切开是否完全,掌握肌切开的部位、深度和长度,而且可提高手术安全性,减少并发症的发生。(2)食管下段括约肌的切开应该完全打开食管肌层,直至食管粘膜显露为标准,长度控制在4-6cm,否则会影响食管的正常蠕动功能,贲门下方胃底的切开应该在1.5cm左右,不宜超过2cm,以保存天然的抗返流屏障。(3)病程长,食管扩张严重S的形病人术后症状改善较慢,部分不理想。(4)内镜扩张或注射治疗会使食管肌层、粘膜融合,解剖层次不清。因此,既往接受过内镜治疗的患者给日后手术操作带来困难。
Objective:
Internationally, the laparoscopic gastric cardia sphincterotomy is the preferred surgical treatment of achalasia. In China, the most severe patients still choose to medical treatment. This operation can only be carried out in a very small number of hospitals.The aim of this study was to investigate the clinical outcome and advantage of laparoscopy combined with esophagogastroscopy in the treatment of achalasia.
Methods:
Between February 2005 and January 2011, a total of 33 patients with achalasia underwent a combined laparoscopic and esophagogastroscopic surgery which comprised of laparoscopic Heller myotomy and Dor fundoplication at the center of Tianjin minimally invasive surgery. Among them,18 were male and 15 were female with an average age of 43 years (24-70). Patients were symptomatic for a mean of 42 months (range,18 to 105 months) before operation. The average preoperative weight loss was 5-25kg (mean 10kg). Preoperatively,2 patients accepted endoscopic injection of botulinum toxin and 2 underwent endoscopic dilation. All patients had dysphagia and received upper gastrointestinal series (barium swallow), esophagogastroscopy, esophageal manometry to confirm the diagnosis and to exclude esophageal carcinoma, and 33 patients also had 24-hour ambulatory pH studies. All patients were operated by laparoscopic modified Heller myotomy with Dor 180°fundoplication. In addition, intraoperative esophagogastroscopy was applied to guide the scope and depth of myotomy and to confirm the esophageal mucosa exposed completely. At the same time, intraoperative endoscopy was used to detect mucosal perforation, and could help repair the mucosa directly. Follow-up was carried out by telephone or correspondence.The patients were asked about postoperative dysphagia, heartburn, chest pain. We assess the clinical value and advantage of laparoscopy combined with esophagogastroscopy in the treatment of achalasia through analyzing the preoperative data and the postoperative data.
Results:
All laparoscopic surgeries were accomplished successfully. There were no patients required conversion from laparoscopic to open operation and no operative deaths. The average operating time was 90.26 minutes (range,60-145), operative blood loss averaged 45 ml (50-150), and the median hospital stay was 5.2 day (4-9). Intraoperative mucosal perforation was encountered in one patients who undergone endoscopic injection of botulinum toxin and lead to fibrosis of the mucosa and muscular layers of the esophagus. This was noted intraoperatively by esophagogastroscopy and repaired by laparoscopic suture. After suture, esophagogastroscopy was used again to confirm. No significant morbidities and no esophageal leaks were noted in this study. With postoperative follow-up of months, all patients had dysphagia relieved. As a result, postoperative assessment consisted of endoscopic, radiologic, manometric and pH metric studies showed a satisfactory result.
Conclusions
1.The laparoscopic Heller-Dor operation is the preferred surgical treatment of achalasia.Laparoscopic cardiomyotomy is a safe, highly effective and minimally invasive treatment for achalasia. Combined with intraoperative gastroscopic guidance and examination, we can improve the security and decrease the complication during laparoscopy operation.
2. The myotomy should be carried cephalad for at about 4-6cm and through the longitudinal and circular muscle fibers down to the esophageal submucosa and extended about 1.5 cm in the caudal direction from the GEJ on the anterior stomach to ensure complete division of the sling fibers.
3. Longer duration of symptoms, sigmoidal esophageal changes impact adversely on the success of myotomy.
4. Endoscopic dilation or endoscopic injection leads to fibrosis of the mucosa and muscular layers of the esophagus. Laparoscopic myotomy is great difficult in these patients who have been previously treated with endoscopic.
方法：选取天津市微创外科中心从2005年2月至2011年1月应用腹腔镜联合胃镜行Heller括约肌切开术附加Dor胃底折叠术治疗贲门失弛缓症33例患者为研究对象。其中男18例,女15例,年龄24-70岁,平均43岁。病程18-105个月,平均42个月。体重下降5-25 kg,平均10 kg。其中2例曾做球囊扩张治疗,2例曾注射肉毒碱治疗。所有纳入病例均通过上消化道造影、食管测压、胃镜检查,用以明确诊断和排除食管占位性病变。33例均经24小时pH值监测除外术前食管反流。所选病例均在全麻下行腹腔镜Heller肌切开术附加Dor胃底180度前折叠术,术中联合胃镜操作,监视肌切开范围,深度,并确认食管粘膜完全外露。同时,术中胃镜及时发现粘膜穿孔,并在直视下行粘膜修补。随访通过病例查阅获得病人基本信息,并通过电话或随访信与病人联系回访,以对其术后生活质量进行客观评价。通过对手术前后主客观指标和随访观察情况进行对比分析,客观评价腹腔镜术中联合胃镜操作的微创治疗优势和手术效果,确立腹腔镜联合胃镜治疗该病的指征,形成规范的操作规程,指导临床工作。
结果：33例均顺利完成腹腔镜手术,未有中转开腹病例,无死亡病例。手术的平均时间为90.26min(60-145min),出血量平均45ml(50-150m1)。术中1例(曾接受肉毒杆菌毒素注射治疗)由于粘连严重,食管环形肌、纵行肌融合,层次不清,术中造成贲门上方约1cm处食管粘膜破裂,经术中胃镜证实后及时行腹腔镜下穿孔修补术。术后胃镜再次检查,确认修补牢靠。术后无严重并发症,无食管瘘发生。患者术后平均住院时间5.2天(4-9天)。术后进行随访,33例病人均表示吞咽困难较术前明显改善,复查胃镜显示33例患者贲门部镜身通过无阻力,食管粘膜炎症改变明显好转；上消化道造影和术前相比显示食道下段扩张明显减轻,下端造影剂排空良好。食道测压显示33例LES静息压、残留压明显下降,松弛率升高,与手术前相比均有统计学差异(P<0.05),和正常参考值比较无统计学差异(P>0.05),表明各项指标已经恢复到正常水平。术后24小时PH检测显示未有胃食管反流。
结论：(1)腹腔镜Heller肌切开术附加Dor胃底折叠术是目前外科治疗该病的首选方案。腹腔镜治疗贲门失弛缓症具有手术创伤小、恢复快、疗效可靠的特点,术中联合胃镜操作不仅能够确认肌切开是否完全,掌握肌切开的部位、深度和长度,而且可提高手术安全性,减少并发症的发生。(2)食管下段括约肌的切开应该完全打开食管肌层,直至食管粘膜显露为标准,长度控制在4-6cm,否则会影响食管的正常蠕动功能,贲门下方胃底的切开应该在1.5cm左右,不宜超过2cm,以保存天然的抗返流屏障。(3)病程长,食管扩张严重S的形病人术后症状改善较慢,部分不理想。(4)内镜扩张或注射治疗会使食管肌层、粘膜融合,解剖层次不清。因此,既往接受过内镜治疗的患者给日后手术操作带来困难。
Objective:
Internationally, the laparoscopic gastric cardia sphincterotomy is the preferred surgical treatment of achalasia. In China, the most severe patients still choose to medical treatment. This operation can only be carried out in a very small number of hospitals.The aim of this study was to investigate the clinical outcome and advantage of laparoscopy combined with esophagogastroscopy in the treatment of achalasia.
Methods:
Between February 2005 and January 2011, a total of 33 patients with achalasia underwent a combined laparoscopic and esophagogastroscopic surgery which comprised of laparoscopic Heller myotomy and Dor fundoplication at the center of Tianjin minimally invasive surgery. Among them,18 were male and 15 were female with an average age of 43 years (24-70). Patients were symptomatic for a mean of 42 months (range,18 to 105 months) before operation. The average preoperative weight loss was 5-25kg (mean 10kg). Preoperatively,2 patients accepted endoscopic injection of botulinum toxin and 2 underwent endoscopic dilation. All patients had dysphagia and received upper gastrointestinal series (barium swallow), esophagogastroscopy, esophageal manometry to confirm the diagnosis and to exclude esophageal carcinoma, and 33 patients also had 24-hour ambulatory pH studies. All patients were operated by laparoscopic modified Heller myotomy with Dor 180°fundoplication. In addition, intraoperative esophagogastroscopy was applied to guide the scope and depth of myotomy and to confirm the esophageal mucosa exposed completely. At the same time, intraoperative endoscopy was used to detect mucosal perforation, and could help repair the mucosa directly. Follow-up was carried out by telephone or correspondence.The patients were asked about postoperative dysphagia, heartburn, chest pain. We assess the clinical value and advantage of laparoscopy combined with esophagogastroscopy in the treatment of achalasia through analyzing the preoperative data and the postoperative data.
Results:
All laparoscopic surgeries were accomplished successfully. There were no patients required conversion from laparoscopic to open operation and no operative deaths. The average operating time was 90.26 minutes (range,60-145), operative blood loss averaged 45 ml (50-150), and the median hospital stay was 5.2 day (4-9). Intraoperative mucosal perforation was encountered in one patients who undergone endoscopic injection of botulinum toxin and lead to fibrosis of the mucosa and muscular layers of the esophagus. This was noted intraoperatively by esophagogastroscopy and repaired by laparoscopic suture. After suture, esophagogastroscopy was used again to confirm. No significant morbidities and no esophageal leaks were noted in this study. With postoperative follow-up of months, all patients had dysphagia relieved. As a result, postoperative assessment consisted of endoscopic, radiologic, manometric and pH metric studies showed a satisfactory result.
Conclusions
1.The laparoscopic Heller-Dor operation is the preferred surgical treatment of achalasia.Laparoscopic cardiomyotomy is a safe, highly effective and minimally invasive treatment for achalasia. Combined with intraoperative gastroscopic guidance and examination, we can improve the security and decrease the complication during laparoscopy operation.
2. The myotomy should be carried cephalad for at about 4-6cm and through the longitudinal and circular muscle fibers down to the esophageal submucosa and extended about 1.5 cm in the caudal direction from the GEJ on the anterior stomach to ensure complete division of the sling fibers.
3. Longer duration of symptoms, sigmoidal esophageal changes impact adversely on the success of myotomy.
4. Endoscopic dilation or endoscopic injection leads to fibrosis of the mucosa and muscular layers of the esophagus. Laparoscopic myotomy is great difficult in these patients who have been previously treated with endoscopic.
引文
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[16]. Wong RKH, Maydonovitch CL. Achalasia. In:Castell DO, Richter J, editors. [J]The esophagus.3. Philadelphia:Lippincott, WIlliams and Wilkins; 1999. pp. 185-213.
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[20]. Pandolfino JE, Kwiatek MA, Nealis T, et al. Achalasia:a new clinically relevant classification by high-resolution manometry. [J] Gastroenterology. 2008,135:1526-1533.
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[31]. Portale G, Costantini M, Rizzetto C, et al. Long-term outcome of laparoscopic Heller-Dor surgery for esophageal achalasia:possible detrimental role of previous endoscopic treatment. [J] J Gastrointest Surg.2005,9:1332-1339.
[32]. Eckardt VF, Aignherr C, Bernhard G. Predictors of outcome in patients with achalasia treated by pneumatic dilation. [J] Gastroenterology.1992,103:1732-1738.
[33]. Leyden JE, Moss AC, MacMathuna P. Endoscopic pneumatic dilation versus botulinum toxin injection in the management of primary achalasia. [J] Cochrane Database Syst Rev 2006:CD005046.
[34]. Wehrmann T, Jacobi V, Jung M, et al. Pneumatic dilation in achalasia with a low-compliance balloon:results of a 5-year prospective evaluation. [J] Gastrointest Endosc.1995,42:31-36.
[35]. Aguilar-Paiz LA, Valdovinos-Diaz MA, Flores-Soto C, et al. Prospective evaluation of gastroesophageal reflux in patients with achalasia treated with pneumatic dilatation, thoracic or abdominal myotomy. [J] Rev Invest Clin. 1999,51:345-350.
[36]. Karamanolis G, Sgouros S, Karatzias G, et al A. Long-term outcome of pneumatic dilation in the treatment of achalasia. [J] Am J Gastroenterol. 2005,100:270-274.
[37]. Mainie I, Tutuian R, Castell DO. The limitations of pH monitoring for detecting gastroesophageal reflux. [J] Clin Gastroenterol Hepatol.2006,4:1184.
[38]. Smith CD, Stival A, Howell DL, et al. Endoscopic therapy for achalasia before Heller myotomy results in worse outcomes than heller myotomy alone. [J] Ann Surg. 2006,243:579-584.
[39]. Cheng YS, Li MH, Chen WX, et al. Comp lications of stentp lacement for benign stricture of gastrointestinal tract. [J] World JGastroenterol,2004,10 (2):284-286.
[40]. Torquati A, Richards WO, Holzman MD, et al. Laparoscopic myotomy for achalasia. Predictors of successful outcome after 200 cases. [J] Ann Surg. 2006,243:587-593.
[41]. Arain MA, Peters JH, Tmhankar AP, et al. Preoperative lower esophageal sphincter pressure affects outcome of laparoscopic esophageal myotomy for achalasia. [J] J Gastrointest Surg.2004,8:328-334.
[42]. Zaninotto G, Costantini M, Rizzett C, et al. Four hundred laparoscopic myotomies for esophageal achalasia, a single center experience. [J]Ann Surg. 2008,248:986-993.
[43]. Urbach DR, Hansen PD, Khajanchee YS,et al. A decision analysis of the optimal initial approach to achalasia:laparoscopic Heller myotomy with partial fundoplication, thoracoscopic Heller myotomy, pneumatic dilatation, or botulinum toxin injection. [J] J Gastrointest Surg.2001,5:192-205.
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[45].Horgan S, Galvani C, GorodnerMV, et al. Robotic2assisted Heller myotomy versus laparoscop ic Heller myotomy for the treatment of esophageal achalasia: Multicenter study. [J] J Gastrointest Surg,2005,9:1020-1030.
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