海博刀在经口内镜下肌切开术治疗贲门失弛缓症中的临床应用

目的 探讨海博刀(O型)行经口内镜下肌切开术(POEM)治疗贲门失弛缓症(AC)的安全性和可行性。方法 2012年1~9月确诊为AC,并用海博刀行横开口法POEM的患者6例(海博刀组),男1例,女5例。选取同期用常规方法行POEM的患者29例(常规组)作为对照组。比较两组在手术相关时间及并发症等方面的差异。结果 海博刀组6例AC患者均顺利应用海博刀行POEM,中位年龄36.5岁(21~59岁),病程41.5个月(6~100个月)。术前Eckardt评分(8.2±1.8)分,术后评分(1.0±0.9)分,示症状明显缓解(P=0.0002)。海博刀组手术用时42~62min,平均(52.3±8.0)min,隧道建立时间25~35min,平均(28.8±3.9)min,纵行肌切开时间6~9min,平均(7.5±1.2)min。常规组手术时间46~97min,平均(63.0±12.9)min,隧道建立时间24~60min,平均(35.4±7.5)min,纵行肌切开时间4~18min,平均(10.0±3.0)min。海博刀组在整体手术、隧道建立和肌肉切开过程中明显快于常规组(P=0.020,P=0.001,P=0.005)。海博刀组术后无并发症发生,而常规组中,5例术后出现并发症(5/29,17.2%),其中2例黏膜穿孔(2/29,6.9%),1例颈部皮下气肿,1例颈部皮下气肿并纵隔及膈下少量游离气体,1例左侧气胸合并颈部皮下气肿。结论 初步表明用海博刀(O型)不仅能有效地行POEM,而且安全性更高,速度更快。但其最终结论仍需大样本研究进一步证明。     

经口内镜下环形肌切开术治疗42例贲门失弛症

目的 探讨经口内镜下环形肌切开术（POEM）治疗贲门失弛症（AC）的疗效和可行性。方法回顾性分析2010年8月至2011年3月42例确诊为Ac并接受POEM治疗患者的临床资料。POEM的主要步骤包括：食管黏膜层切开;分离黏膜下层,建立黏膜下“隧道”;胃镜直视下切开环形肌：金属夹关闭黏膜层切口。结果42例患者平均年龄43．9（10～70）岁,病程3个月至50年。全组患者均顺利完成POEM术,手术时间（68．5±25．5）min,黏膜下隧道长度（10．5±1．5）cm,环形肌切开长度（9．5±2．5）cm,无一例出现与POEM相关的严重并发症。术后中位随访时间2．5（1-6）个月．41例吞咽困难明显得到解除：1例术后15d出现进食困难及呕吐,胃镜检查发现黏膜下窦道形成．行内镜下窦道切开。结论作为一种新的微创治疗方法,POEM治疗Ac短期疗效肯定,可以迅速解除AC患者吞咽困难．但其长期疗效及远期并发症仍有待随访和观察。     

经口内镜下肌切开术环形肌断端距离与贲门失弛缓症状缓解程度的关系

目的 探讨经口内镜下肌切开术(POEM)食管下括约肌离断后断端距离对贲门失弛缓症症状缓解程度的影响。方法 2010年12月至2012年6月33例贲门失弛缓患者按切开后断端距离大小分为两组,断端距离>0.6cm为A组,≤0.6cm为B组,比较两组间症状的Eckardt分值。结果 33例贲门失弛缓症患者行POEM术前症状Eckardt分值为6~9分,平均7.9分;术后分值为0~6分,平均2.2分。A组的Eckardt分值下降明显大于B组。结论 POEM缓解贲门失弛缓症状疗效确定。环形肌离断后断端距离大小对贲门失弛缓症状的缓解有一定的影响。     

Ling分型对经口内镜下肌切开术手术并发症的影响

目的 探讨贲门失弛缓症Ling分型对经口内镜下肌切开术(POEM)手术并发症的影响。方法 分析前瞻性记录的2010年10月至2012年9月期间POEM治疗的47例贲门失弛缓症患者的资料,对比不同Ling分型的患者接受POEM治疗时手术并发症发生率。结果 47例患者接受POEM治疗,男25例,女22例,年龄16~62岁,平均39.0岁。LingⅠ型24例,LingⅡa型5例,LingⅡb型14例,LingⅡc型4例。共14例出现并发症(29.8%),黏膜穿孔5例(10.6%),气体相关并发症10例(21.3%),其中1例同时合并黏膜穿孔和气体相关并发症。气体相关并发症包括气胸、纵隔积气、腹腔积气及皮下气肿。黏膜穿孔的发生率LingⅡb型最高,为21.4%;LingⅠ型次之,为8.3%;LingⅡa型和LingⅡc型均未发生并发症。气体相关并发症的发生率LingⅡc型最高,为50%;LingⅠ型、LingⅡa和LingⅡb型分别为25%、20%和7.1%。结论 总的并发症发生率和气体相关并发症的发生率LingⅡc型最高,黏膜穿孔发生率LingⅡb型最高。     

经口内镜全层肌切开术与环形肌切开术治疗重症贲门失弛缓症的临床疗效

目的 比较经口内镜全层肌切开术与环形肌切开术治疗重症贲门失弛缓症(AC)的临床疗效.方法 回顾性分析2011年8月至2013年5月中南大学湘雅二医院收治的123例行经口内镜肌切开术(POEM)重症AC患者的临床资料.其中70例患者行全层肌切开设为全层肌切开组,53例患者行环形肌切开设为环形肌切开组.比较两种治疗方式的临床疗效及并发症发生情况.患者术后定期门诊随访,随访时间截至2014年5月.连续计量资料以i±s表示,采用t检验;非连续资料以M(范围)表示,采用Wilcoxon秩和检验;手术前后比较采用重复测量方差分析;定性资料比较采用x2检验.结果 所有重症AC患者成功行POEM,全层肌切开组手术时间为(57±8)min,短于环形肌切开组的(63±12) min,两组比较,差异有统计学意义(=3.421,P＜0.05).全层肌切开组与环形肌切开组患者并发症发生率分别为14.3％(10/70)、11.3％ (6/53),两组比较,差异无统计学意义(x2=0.234,P＞0.05).119例患者获得随访,中位随访时间为18个月(12 ～24个月).全层肌切开组患者术后6个月和12个月的中位Eckardt评分均为0分(0～3分),环形肌切开组分别为0分(0～2分)及0分(0～3分),两组患者治疗有效率分别为98.6％(69/70)和98.1％ (52/53),两组比较,差异无统计学意义(Z=0.525,1.476,x2=0.040,P＞0.05).全层肌切开组和环形肌切开组患者术后6个月的食管直径分别为(3.2±0.3)cm、(3.4±0.4)cm,两组比较,差异无统计学意义(江1.927,P＞0.05);均小于术前的(5.9±1.0)cm和(5.9±1.0)cm,手术前后比较,差异有统计学意义(F=780.923,493.018,P＜0.05).两组患者随访期间内无一例复发.结论 经口内镜全层肌切开术与环形肌切开术治疗重症AC患者的短期疗效相当,并发症发生率相似,但全层肌切开术可缩短手术时间.     

腹腔镜时代胆总管结石的治疗选择

目的 比较腹腔镜胆囊切除＋胆总管切开探查取石术（LC＋LCBDE）和腹腔镜胆囊切除＋术中内镜下括约肌切开取石术（LC＋EST）的临床效果和住院费用。方法 对48例胆总管结石患者全部行LC，其中A组26例行LCBDE，B组22例行EST。统计手术时间、术中出血量、术后住院时间、术后并发症和总住院费用。结果 48例患者均未中转开腹，1例接受LCBDE的患者术后胆道残留结石，2例接受EST的患者术后出现一过性高淀粉酶血症，1例术后出现一过性黄疸加重，无其他并发症。两组的手术时间、术中出血量和术后住院时间等无显著性差异；A组住院费用平均为（11640±1171）元，B组患者住院费用平均（16455±2015）元，A组显著低于B组。结论 同EST（B组）相比，LCBDE（A组）是处理胆总管结石更为理想的手术方式。     

经口内镜下肌切开术动物实验的可行性研究

目的通过本研究探讨经口内镜下肌切开术（POEM）在活体家猪体内完成操作的可行性。方法 4个月大健康家猪8只,麻醉后取左侧卧位,在距贲门上方8～10cm处黏膜下注射,纵行切开长约2cm黏膜,内镜沿切口进入黏膜下进行＂隧道式＂剥离直至贲门,直视下切断长度2cm贲门处环形肌,术中随时止血;金属夹自远端向近端闭合切口。术后补液,禁食水48h,之后流质饮食,应用抗生素3d;1周后复查胃镜。结果所有实验用猪均完成POEM操作,其中1例在贲门处操作时发生气胸死亡;另外1例发生颈部皮下气肿,72h后气肿消失,其余7例均存活。结论 POEM技术是一项风险较大、相对安全的技术,具有应用的特点,同时该技术的成功,也提示使用家猪可以进行该技术的临床前训练。     

多切口隧道浮线术治疗低位蹄铁型肛周脓肿的疗效观察

目的观察多切口隧道浮线术治疗低位蹄铁型肛周脓肿的疗效。方法将63例低位蹄铁型肛周脓肿患者随机分为治疗组A、治疗组B和对照组各21例,治疗组均采用多切口隧道浮线术（A组采用橡皮浮线、B组采用多股丝线浮线）,对照组采用多切口隧道引流术。结果治疗组术后疼痛持续时间以及创面愈合时间均比对照组短（P〈0.05）;但治愈率、平均创面瘢痕面积、肛门功能状况以及术后复发率比较,差异无统计学意义（P〉0.05）。结论多切口隧道浮线术治疗低位蹄铁型肛周脓肿疗效显著。     

腹腔镜下腹会阴切除术两种结肠造口方式的比较

目的探讨腹腔镜下腹会阴切除术（LAPR）乙状结肠单腔造口的手术方式，以减少造口并发症的发生。方法63例患者中，低位直肠癌53例，直肠肛管癌10例。有61例用圆形吻合器行乙状结肠与腹壁皮肤吻合造口，2例手工缝合乙状结肠造口。腹腔内腹直肌型结肠造口37例（A组）；腹膜外隧道腹直肌型结肠造口26例（B组）。结果全组在腹腔镜下完成降结肠、乙状结肠和直肠的分离以及会阴部的直肠肛门开放性切除。无中转开腹，无手术死亡。两组的平均手术时间差异无统计学意义（P〉0．05）；而术后人工肛门排气时间[A组（2．4±1．1）d与B组（1．9±0．8）d比较，P〈0．05]、术后平均住院日[A组（19．9±7．8）d与B组（14．5±3．9）d比较，P〈0．01]及造口相关并发症的发生率（A组29．4％，B组4．0％；两组比较P〈0．05）差异均有统计学意义；B组患者术后平均住院日较A组短，造口相关并发症低于A组。结论LAPR手术中。采用圆形吻合器经腹膜外隧道和腹直肌行乙状结肠单腔造口，可有效地减少造口并发症的发生和缩短手术后的住院时间。     

眼镜式经口内镜下肌切开术的可行性报道两例

病例1:患者男,68岁,胃镜检查见食管管壁半月形结构形成(LingⅡb型)[1]。经口内镜下肌切开术(peroral endoscopic myotomy,POEM)手术操作步骤:齿状线距门齿约48cm,于距门齿38cm处黏膜下注射美兰、0.9%氯化钠溶液注射液后,于食管右侧壁切开约1.5cm的横行切口,于黏膜下层与肌层之间建立一纵行隧道,隧道向下延伸至贲门下4cm。用三角刀离断7cm的内环肌后,继续离断相应的纵行肌,但于齿状线相对位置保留     

Per Oral Endoscopic Myotomy (POEM) for pediatric achalasia: Institutional experience and outcomes

BackgroundThe surgical treatment of achalasia by both laparoscopic and endoscopic approaches has been recognized as the definitive management in children. Despite reported low volumes in many centers, there has been an increasing worldwide experience with endoscopic approaches to pediatric achalasia. The aim of this study is to report our institutional experience with per oral endoscopic myotomy (POEM) as first-line or revisional therapy for achalasia.MethodsAn IRB approved retrospective review of all patients who underwent operative procedures for achalasia, specifically with the POEM technique, from July 2015 to September 2021. Data including demographics, intra-operative details, pre and post operative Eckardt scores, complications, outcomes, and follow-up were obtained.ResultsDuring the study period, a total of 43 children underwent 46 operations for achalasia including POEM and laparoscopic Heller myotomy (LHM). Operations included 37 POEMS (33 primary POEMS; 3 POEMS after failed LHM; and 1 POEM after failed POEM). Additionally, 9 LHM operations including, 4 primary LHM; 3 attempted POEMS converted to LHM; 1 attempted POEM after failed LHM converted to redo LHM; and 1 LHM after failed POEM. In the POEM group (n = 37), based on the high resolution esophageal manometry findings Chicago Classification types at diagnosis were as follows: 9 patients were type I (24.3%); 25 patients were type II (67.6%); 2 patients were type III (5.9%) and 1 patient was unknown type (2.7%). Sixteen children (43.2%) had prior endoscopic treatment of achalasia prior to POEM [Pneumatic Balloon Dilatation (PBD), and/or Botox injection (BTI)],), while prior operative intervention occurred in 4 patients (10.8%), 3 LHM and 1 POEM. Age at operation was 2–18 years (mean ± SD age: 11.6 ± 4.5 years). Weight at operation 11.8–100.7 kg (mean ± SD kg; 39 ± 19.9 kg). Range of baseline Eckardt score was 4–10 (mean ± SD: 6.73 ± 1.5). Operative time was 64–359 min (mean ± SD minutes: 138.1 ± 62.2 min). Intraoperative complications occurred in 16 patients (43.2%) but did not require reoperation during index admission including: 4 mucosotomy (11.8%); 9 pneumothoraces (24.3%); 2 pneumomediastinum (5.4%); 10 pneumoperitoneum (27%); 0 sub-mucosal tunnel bleeding (0%); 0 open conversion/death (0%). Post operative complications included: 5 recurrent dysphagia (13.5%); 0 esophageal leak (0%); 3 GERD (8.1%); 1 failed POEM (2.7%). Median length of stay was 2 days (mean ± SD days: 2.4 ± 0.9 day). Follow-up ranged from 1 to 74 months (median 15 months), mean follow-up 22.6 months ± 20 months. Post POEM Eckardt score was 0.6 ± 0.9. Five patients required a single PBD post POEM (13.5%) and 1 patient required a repeat myotomy (LHM) after POEM (2.7%) for a 16.2% reintervention rate. Subsequent normalization of Eckardt scores (≤ 3) and symptomatic relief was achieved in all patients (100%).ConclusionsPOEM as first-line therapy for pediatric achalasia, or as a secondary procedure after failed prior myotomy or POEM, in our experience is safe and effective. We have shown equivalent results to our own prior experience with LHM. Long-term follow-up will be performed to monitor for recurrent symptoms, adequate physical growth, and general development.Level of evidenceII.     

Lessons learned from early experience of per oral endoscopic myotomy in children

Background/AimsAchalasia cardia (AC) is rare in children, and the standard treatment is open or Laparoscopic Heller's myotomy with or without fundoplication if pneumatic dilatation has failed. Per oral endoscopic myotomy (POEM) is a novel technique for management of achalasia with good results in adults. We report POEM in four children and the outcome with special emphasis on the technique and management of intra-operative complications.MethodFour children aged 7–15 years presenting with progressive dysphagia, cough, night-time aspirations, and weight loss of six months to one year were investigated with upper GI contrast study, flexible endoscopy and biopsy, oesophageal manometry, and a diagnosis of Type 1 & 2 AC was made. An experienced adult endoscopist in collaboration with the paediatric surgical team performed POEM.ResultsPOEM was performed successfully using ERBE HYBRID knife setup and waterjet injection for the submucosal tunnelling. Operative time was 25–40 min (mean 31 min). The hospital stay was 3–8 days with last 3 patients discharged on day three. No major intraoperative or post-operative complications were seen. The Eckardt score changed from above 4 to 0 at one-month follow-up. All four are well at one year post-operatively and beyond. Two patients had subcutaneous emphysema post-operatively. One developed pneumoperitoneum intra-operatively.ConclusionPOEM was successfully performed with only minor adverse events in experienced hands. Anticipation and preparation for potential intraoperative complications and assigned responsibilities to each team helped the safe completion in the shortest time. Rectifying pneumoperitoneum concurrently without interruption of the operation exemplified teamwork.Level of EvidenceIII     

经口内镜下肌切开术对贲门失弛缓症患者的食管动力学影响

目的评价经口内镜下肌切开术（POEM）对贲门失弛缓症患者的食管动力学影响。方法2011年9．11月间复旦大学附属中山医院内镜中心对20例贲门失弛缓症患者行POEM手术．所有患者于术前和术后第3天利用固态高分辨率胃肠动力学检查系统行食管动力学检查．分析手术前后食管下括约肌静息压（LESP）、食管下括约肌4s完全松弛压（4sIRP）、食管下括约肌松弛率（LESRR）、食管下括约肌长度（LESL）和食管体部收缩性和传导性的变化。结果POEM术后,LESP由术前的（29．1±17．0）mmHg下降为（14．6±4．9）mmHg,下降幅度为49．8％（P〈0．01）;4slRP由术前的（24．2±15．1）mmHg下降为（10．4±3．4）mmHg（P〈0．01）;但手术前后LESRR和LESL的差异无统计学意义（P〉0．05）。20例患者术前食管运动均缺少蠕动性收缩,术后有7例患者食管收缩运动发生了变化,甚至出现了蠕动,但仍达不到正常水平;其余13例患者的蠕动情况无明显变化。结论POEM术可显著降低贲门失弛缓症患者食管下括约肌压力和松弛压．但对食管的收缩运动却无明显影响。     

Pre-treatment Eckardt score is a simple factor for predicting one-year peroral endoscopic myotomy failure in patients with achalasia

Background

Peroral endoscopic myotomy (POEM) is a novel treatment for achalasia with excellent outcomes. But the predictor for treatment failure is not well defined. This study was aimed to prospectively investigate the factors for predicting failed POEM.

Methods

From June 2011 to May 2015, a total of 115 achalasia patients treated by POEM were included for the retrospective cohort study from Nanfang Hospital and the First People’s Hospital of Yunnan Province. Patients were followed up with Eckardt score, high-resolution manometry and endoscope. POEM failure was defined as primary failure (Eckardt score failed to decrease to 3 or below) and recurrences (decrease of Eckardt score to 3 or below, then rise to more than 3) during one-year follow-up. Univariate and multivariate Cox regression analyses were performed to assess the predictive factor. For the associated factor, receiver operating characteristic curve (ROC) was utilized to determine the cutoff value of the predicting factor.

Results

The failure rate of POEM after 1 year was 7.0% (8/115), including 5 primary failure cases and 3 recurrences. Multivariate analysis showed higher pre-treatment Eckardt score was the single independent factor associated with POEM failure [9.5 (6–12) vs. 7 (2–12), odds ratio (OR) 2.24, 95 confidence interval (95% CI) 1.39–3.93, p = 0.001]. The cutoff value (Eckardt score ≥9) had 87.5 sensitivity (95% CI 47.3–99.7%) and 73.8% specificity (95% CI 64.4–81.9%) for predicting failed POEM.

Conclusions

Pre-treatment Eckardt score could be a predictive factor for failed POEM. Eckardt score ≥9 was associated with high sensitivity and specificity for predicting POEM failure.

     

Per oral endoscopic myotomy (POEM) in pediatric patients with esophageal achalasia: First Latin-American experience

BackgroundAchalasia is the most common primary motor disorder of the esophagus, but its incidence in pediatric patients is low. Laparoscopic Heller myotomy (LHM) is the current surgical standard of care treatment. Per-oral endoscopic myotomy (POEM) has emerged as a safe and effective therapeutic alternative in adult patients. We herein report the outcomes of a cohort of pediatric patients with achalasia treated by POEM at a Chilean medical center.MethodsThis is a retrospective analysis of prospectively collected data on children who underwent POEM for esophageal achalasia. Clinical follow-up was evaluated by recording the Eckardt score, a high-resolution esophageal manometry (HREM) three months after the procedure, and an annual upper gastrointestinal endoscopy.ResultsFive patients with esophageal achalasia confirmed by HREM and with a mean age of 11 (5 to 15) years underwent POEM between 2017 and 2019. One patient had a previous LHM. No morbidity or mortality was observed. All patients resolved their dysphagia and no patient required further interventions. Mean Eckardt score reduced from 10 points preoperatively to 1 point postoperatively.Two patients currently have mild esophagitis (confirmed by endoscopy).ConclusionOur results support the previously reported safety and effectiveness of POEM. Longer follow-up and larger cohorts will be important to confirm its role in the treatment of children with esophageal achalasia.Type of studyTreatment study.Level of evidenceLevel IV.     

Peroral Endoscopic Myotomy (POEM): Feasible as Reoperation Following Heller Myotomy

Purpose

The purpose of this study was to demonstrate the feasibility of performing peroral endoscopic myotomy (POEM) in the management of recurrent achalasia after failed myotomy.

Methods

Eight patients presented to our institution between October 2010 and June 2013 with recurrent/persistent symptoms after prior laparoscopic Heller myotomy. Three patients underwent redo laparoscopic Heller myotomy, and five patients consented to redo myotomy with POEM.

Results

Demographics were similar between the groups with exception of age (POEM 69.5 vs. laparoscopic Heller myotomy (LHM) 34.5, p?=?0.003). Preoperative Eckardt scores, motility, and prior interventions were not significantly different. Three patients who underwent POEM and two who underwent laparoscopic Heller myotomy had prior fundoplication. There was one perforation identified after laparoscopic Heller myotomy and one patient with persistent subcutaneous emphysema after POEM. Both POEM and laparoscopic Heller myotomy demonstrated significant improvement in symptoms and Eckardt scores at average follow-up of approximately 5 months (p?<?0.05).

Conclusion

POEM is a feasible option for patients after failed myotomy even in the presence of prior fundoplication. The procedure can be performed safely using a similar technique as for primary myotomy with the exception of creating the myotomy laterally along the right side of the esophagus and lesser curvature avoiding the previous anterior myotomy.     

腹腔镜直肠癌根治术气腹及腹壁切口长度对血浆血管内皮生长因子水平的影响及其临床意义

目的:探讨腹腔镜直肠癌根治术(laparoscopic radical resection,LR)CO2气腹压力、腹壁辅助切口长度对血浆血管内皮生长因子(vascular endothelial growth factor,VEGF)水平的影响及其临床意义。方法:入选患者88例,其中51例行腹腔镜手术(LR组),腹腔镜组内根据腹壁切口长度、气腹压力又分为腹壁长切口、高压力组(LR-Ⅰ组,n=21)与短切口、低压力组(LR-Ⅱ组,n=30);37例行开腹结肠癌根治术(open radical resection,OR,OR组)。采用酶联免疫组化法检测3组患者手术前后不同时段血浆VEGF水平,并进行组间同一时段、组内不同时段的对比。结果:术后腹壁切口平均长度方面,OR与LR组相比、LR-Ⅰ组与LR-Ⅱ组相比差异均有统计学意义(P<0.05)。术前3组患者VEGF水平差异无统计学意义(P>0.05)。术后VEGF水平3组患者均有所升高;自术后第3天,OR组与LR组患者同一时段相比差异有统计学意义(P<0.05);LR-Ⅰ组与LR-Ⅱ组相比差异无统计学意义(P>0.05)。与术前相比,LR组仅术后第7天差异有统计学意义(P<0.05),余差异均无统计学意义(P>0.05);而OR组术后第1天至第7天差异均有统计学意义(P<0.05)。结论:腹腔镜及开腹结直肠癌根治术后VEGF水平均有所升高,但腹腔镜组升幅低于开腹组;LR-Ⅰ组与LR-Ⅱ组的手术切口、气腹压力对VEGF水平的影响差异无统计学意义(P>0.05)。腹腔镜直肠癌根治术是安全、可行的。     

Comparison of Perioperative Outcomes Between Peroral Esophageal Myotomy (POEM) and Laparoscopic Heller Myotomy

Background

Peroral esophageal myotomy (POEM) is a novel endoscopic operation for the treatment of achalasia. Few POEM outcome data exist, and no study has compared POEM with the surgical standard, laparoscopic Heller myotomy (LHM).

Methods

Perioperative outcomes were compared between POEM and LHM performed in a nonrandomized fashion. Patients in both groups met the following eligibility criteria: diagnosis of achalasia, age 18–85, and absence of prior achalasia treatment.

Results

Eighteen patients underwent POEM, and 55 patients underwent LHM. Operative times were shorter for POEM (113 vs. 125 min, p?<?.05), and estimated blood loss was less (≤10 ml in all cases vs. 50 ml, p?<?.001). Myotomy lengths, complication rates, and length of stay were similar. Pain scores were similar upon post-anesthesia care unit arrival and on postoperative day 1 but were higher at 2 h for POEM patients (3.5 vs. 2, p?=?.03). Narcotic requirements were similar, although fewer POEM patients received ketorolac. POEM patients’ Eckardt scores decreased (median 1 postop vs. 7 preop, p?<?.001), and 16 (89 %) patients had a treatment success (score ≤3) at median 6-month follow-up. Six weeks after POEM, routine follow-up manometry and esophagram showed normalization of esophagogastric junction pressures and contrast column heights.

Conclusions

POEM and LHM appear to have similar perioperative outcomes. Further investigation is needed regarding long-term results after POEM.     

目标性后腹腔镜下肾上腺病损切除术的学习曲线

目的 以手术时间、术中出血量为观察指标分析目标性后腹腔镜下肾上腺病损切除术的学习曲线。方法 回顾性分析连云港市第一人民医院泌尿科2019年1月至2022年1月由同一团队完成的60例目标性后腹腔镜下肾上腺病损切除术患者的临床资料,按时间顺序平均分为四组：A组（病例1~15）、B组（病例16~30）、C组（病例31~45）、D组（病例46~60）。统计每组手术的手术时间、术中出血量、切口长度及术后住院时间,比较组间差异。结果 通过统计分析可见,随着手术例数增加,手术时间、术中出血量呈下降趋势,进行两两比较,A组的手术时间和术中出血量与B、C、D三组有明显差异（P<0.05）,B组的手术时间和术中出血量与C、D两组有明显差异（P<0.05）,C组的手术时间和术中出血量与D组比较,无显著性差异（P>0.05）。四组的切口长度和术后住院时间无显著性差异（P>0.05）。结论 对于具有丰富后腹腔镜肾上腺病损切除术经验的泌尿外科医师,30例左右是目标性后腹腔镜肾上腺病损切除术的学习曲线。     

异体胫前肌Y型双束双隧道移植重建后交叉韧带的临床研究

目的探讨异体胫前肌Y型双束双隧道重建后交叉韧带（PCL）的临床效果及手术技术改进的方法。方法自2001年3月至2008年1月，采用成人异体胫前肌编制成“Y”型双束，长度为130mm，A端为长束（A束），B端为两短束（B1、B2束）。韧带安装时两端均从膝前内侧工作通道的切口进入，即：外（膝前内侧工作通道）→内（股骨、胫骨隧道内口）→外（股骨、胫骨隧道外口）。可吸收界面钉先固定胫骨隧道侧，然后再固定股骨侧：固定前外侧束时屈膝90°，固定后内侧束时屈膝30°。术后予膝关节角度锁定助行器辅助锻炼8～10周，3个月后行走基本正常。结果本组47例患者均获得随访，平均随访49．5个月，平均手术时间（45±15）min。Lachmann后向试验术前均阳性，术后38例阴性、5例弱阳性、4例阳性。KT-1000试验术前（9．0±4．0）mm，术后（3．0±1．5）mm，差异有统计学意义（t=3．12，P〈0．01）；Lysholm评分术前（51．4±5．2）分，术后（93．3±4．1）分，差异有统计学意义（t=3．13，P〈0．01）；Tegner活动水平术后（6．9±1．3）分，术前（3．5±0．7）分，差异有统计学意义（t=3．12，P〈0．01）。结论异体胫前肌编制双束有足够的长度和直径重建PCL，其抗拉力强；改进后的韧带过隧道方法，韧带通过隧道时顺畅，简单易操作，省时；准确的隧道内口、正常的张力（角度）固定是效果的保证；动静结合的早期功能锻炼有利于早期功能恢复。