内镜直视下机械扩张治疗贲门失弛缓症62例

目的评价内镜直视下机械扩张治疗贲门失弛缓症的疗效。方法利用自行设计并改良的机械扩张器械在上消化道内镜直视下对62例贲门失弛缓症进行机械扩张。其中1例为Heller手术失败，4例为气囊扩张失败。结果2例食管破裂中转开胸手术治愈；1例不能耐受手术而放弃；1例一次扩张效果不好，二次扩张后痊愈；其余58例一次成功。扩张时间2—5min，平均3．5min。术中均见黏膜少量出血，无活动性出血。术后2小时进冷流质饮食，6小时后软成形饮食，之后过渡为普通饮食。58例随访2—11年，平均7．5年，均获治愈。结论内镜直视下机械扩张贲门失弛缓症创伤小，费用低，无反流，长期随访效果可靠，有推广价值。     

Robotic-assisted heller myotomy versus laparoscopic heller myotomy for the treatment of esophageal achalasia: multicenter study

Laparoscopic Heller myotomy (LHM) has become the standard treatment option for achalasia. The incidence of esophageal perforation reported is about 5%–10%. Robotically assisted Heller myotomy (RAHM) is emerging as a safe alternative to LHM. Data comparing the two approaches are scant. The aim of this study was to compare RAHM with LHM in terms of efficacy and safety for treatment of achalasia. A total of 121 patients underwent surgical treatment of achalasia at three institutions. A retrospective review of prospectively collected perioperative data was performed. Patients were divided into two groups: group A (RAHM), 59 patients, and group B (LHM), 62 patients. All the operations were completed using minimally invasive techniques. There were 63 women and 58 men, with a mean age of 45 ±19 years (14–82 years). Fifty-one percent of patients in group A and 95% of patients in group B reported weight loss. Duration of symptoms was equal for both groups. Dysphagia was the main complaint in both groups (P = NS). There was no difference in preoperative endoscopic treatment in both groups (44% versus 27%, P = NS). Operative time was significantly shorter for LHM in the first half of the experience (141 ± 49 versus 122 ± 44 minutes, P < .05). However, in the last 30 cases there was no difference in operative time between the groups (P = NS). Intraoperative complications (esophageal perforation) were more frequent in group B (16% versus 0%). The incidence of postoperative heartburn did not differ by group. There were no deaths. At 18 and 22 months, 92% and 90% of patients had relief of their dysphagia. This study suggests that RAHM is safer than LHM, because it decreases the incidence of esophageal perforation to 0%, even in patients who had previous treatment. At short-term follow-up, relief of dysphagia was equally achieved in both groups. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (oral presentation). This study was supported in part by a grant provided by Intuitive Surgical, Inc. and Ethicon Endo-Surgery, Inc.     

Efficacy of botulinum toxin injection before pneumatic dilatation in patients with idiopathic achalasia

Graded pneumatic dilatation (PD) is an appropriate long-term therapy and botulinum toxin injection (BT) is a relatively short-term therapy in idiopathic achalasia. Their combination has not been previously scrutinized. This study aimed to evaluate the role of BT in enhancing the efficacy of PD with 30 mm balloons. Patients who underwent PD with 30 mm balloons after botulinum toxin injections and a group of age- and sex-matched controls who were treated only with PD were enrolled in the study. Symptom scores were taken before, 1 month after and then every 3 months after PD. There were no significant differences between the two groups in gender, duration or severity of symptoms. One of the 12 patients in the case group relapsed 30 months after PD but the others were in remission for an average of 25.6 months. In the control group, all the patients relapsed after a mean of 12.6 months and needed a 35-mm PD. The cumulative remission rate was significantly higher in the case group compared with the control group (P < 0.01). The mean symptom score decreased by 76% in the case group (P < 0.001) and 53% in the controls (P < 0.01) at the end of the first month. Neither age, sex, nor duration or severity of symptoms were predictive of patients' responses to treatment. It seems that BT may be a meaningful enhancing factor in long-term efficacy of PD. PD with a 30 mm balloon after a BT session may resolve the need for the future higher grade PD.     

贲门失驰缓症介入治疗的疗效评价

目的：评价贲门失弛缓症球囊扩张介入治疗的疗效。方法：对20例贲门失驰缓症患者行球囊扩张术。结果：20例患者共进行了31次球囊扩张，人均1．5次（其中12例扩张1次，5例扩张2次，3例扩张3次）。术后患者吞咽困难明显缓解，主要并发症为疼痛和返流。术后随访无症状期为3－13个月。结论：球囊扩张术是治疗门失弛缓症的有效方法。     

Anal Tonometry in the Neonatal Period for the Diagnosis of Hirschsprung's Disease

ABSTRACT. A double balloon technique was used for anal tonometry in 22 infants. The weight was less than 2500 g in 10 of the infants. Ileus or delayed passage of meconium was seen in 9 infants. Thirteen infants had not revealed any symptoms of intestinal obstruction during the first week of life. In all cases, except one, it was possible to demonstrate reflexes from the internal anal sphincter. In 18 infants normal curves were registered from the internal anal sphincter. None of these developed Hirschsprung's disease. In 3 infants a pathological pattern of contractions of the internal anal sphincter was demonstrated. Two of them proved to have Hirschsprung's disease. In the third case normal reflexes were registered after one year. Possibly the innervation of rectum and the internal anal sphincter was disrupted during the neonatal period in connection with enterocolitis and ileus, thus representing a reversible case of achalasia.     

贲门失弛缓症术式探讨

目的 探讨治疗贲门失弛缓症的理想术式。方法 回顾分析66例贲门失弛缓症患者的治疗效果，评估手术方式与其疗效的关系。结果 单纯Heller肌层切开术15例，Heller手术附加Belsey MarkⅣ底折叠术17例，自行设计的改良Heller手术附加胃底折叠术34例。全组随访3年以上，失访3例按无效计算，疗效优，良者占91．2％（60／66）／单纯Heller手术病例术后复发3例（3／15，20．0％），发生反流性食管炎4例（4／15，26．7％）;Heller手术附加Belsey MarkⅣ底折叠发生反流性食管炎2例（2／17，11．8％），膈裂孔疝1例（1／17，5．9％），而改良Heller手术附加胃底折叠术无复发及反流。全组无手术死亡及其他并发症。结论 改良式Heller手术加胃底折叠术式治疗贲门失弛缓症疗效较好。     

胃镜下探条或自制气囊扩张治疗贲门失弛缓症疗效的对比研究

目的对比分析胃镜下应用探条或自制气囊扩张治疗贲门失弛缓症的疗效。方法1998年1月～2007年12月，胃镜下治疗贲门失弛缓症45例，其中应用自制气囊扩张22例（自制气囊组），应用探条扩张23例（探条组），比较2组疗效。结果探条组23例扩张1～9次，平均3．6次；自制气囊组22例扩张1～6次，平均2．3次。2组术中及术后均无并发症发生。首次治疗费用探条组（1542．57±281．30）元，自制气囊组（861．91±176．48）元（t=9．671，P=0．000）。扩张后3个月的疗效2组差异无显著性[探条组显效14例（61％）、有效8例（35％）、无效1例（4％），自制气囊组显效15例（68％）、有效5例（23％）、无效2例（9％），Z=-0．351，P=0．726]。扩张后6个月的疗效2组差异有显著性[探条组显效5例（22％）、有效3例（13％）、无效15例（65％），自制气囊组显效10例（45％）、有效7例（32％）、无效5例（23％），Z=2．564，P=0．010]。结论胃镜下应用探条和自制气囊扩张治疗贲门失弛缓症安全、简便，患者恢复快，尤其自制气囊扩张器设备简单，就地取材，疗效肯定，在基层医院具有良好的推广价值。     

Pseudoachalasia: not only esophago-gastric cancer

Pseudoachalasia is a rare clinical entity which has clinical, radiographic and manometric features often indistinguishable from achalasia. A small primary adenocarcinoma arising at the gastroesophageal junction or a tumor of the distal esophagus are the most frequent causes. Rarely, processes other than esophagogastric cancers may lead to the development of pseudoachalasia. We present three cases of pseudoachalasia in which the primary cause of the disease was not an esophagogastric cancer. The causes were a pancreatic carcinoma, a breast cancer and an histiocytosis X. Aspects of these three patients' diagnostic and therapeutic course are discussed in detail.     

原发性贲门失弛缓症的外科治疗(附10例报告)

作者对10例原发性贲门失弛级症进行手术治疗．采用Heller术8例，食管下段贲门切除术3例，其中再手术3例，附加幽门成形术4例。本组资料表明，Olsen分期Ⅰ～Ⅲ期行Heller术效果满意，不需附加手术，Ⅲ期需行食管下段贲门切除术。作者对手术方法、手术径路、附加手术与手术效果的关系等进行探讨。     

One-year follow-up after laparoscopic Heller-Dor operation for esophageal achalasia

Background: The Heller-Dor operation has recently been proposed for the treatment of esophageal achalasia even via a laparoscopic approach. Methods: To measure the medium-term effectiveness of this new minimally invasive technique, an evaluation of pre- and postoperative symptoms, esophagogram, endoscopic findings, esophageal manometry, and pH monitoring was prospectively designed in 43 patients with primary esophageal achalasia. The mean clinical follow-up for all the patients is 12 months (range 3–43), while the mean radiological follow-up is 11 months (range 1–23). Endoscopic data 1 year after surgery are currently available for 27 patients (63%), whereas a 12-month (range 1–26) functional follow-up (including manometric and pH-monitoring studies of the esophagus) is currently available for 35 patients (81.4%). Results: No dysphagia was reported in 38 cases (88.4%); two (4.6%) complained of occasional swallowing discomfort which regressed spontaneously; two (4.6%) had persistent dysphagia which regressed with pneumatic dilatation. One patient (2.8%) reported mild occasional dysphagia after a 1-year asymptomatic period. Preoperatively, esophagograms showed an average maximum diameter of 40.6 ± 9.1 mm which decreased to 24.1 ± 6.0 mm after operation. Mean lower esophageal sphincter (LES) resting and residual pressures decreased significantly from 28.6 ± 10.7 mmHg to 8.8 ± 4.1 mmHg and from 17.0 ± 9.7 mmHg to 4.7 ± 4.0 mmHg, respectively (p < 0.0001). These effects on esophageal diameter and LES function seem to persist over time. The complete absence of any peristaltic contractions recorded preoperatively in all cases remained unchanged after surgery in all but four patients. However, this rare recovery of peristalsis proved to be transient, and patients revealed a manometric impairment of their esophageal body function, but without complaining of dysphagia. Twenty-four-hour pH monitoring showed abnormal gastroesophageal reflux episodes in two (5.7%) of the 35 patients who were monitored: one was asymptomatic; the other had heartburn and endoscopically demonstrated grade II esophagitis. Conclusions: Laparoscopic Heller-Dor operation achieves excellent medium-term results which, together with the already-demonstrated advantages of a minimal surgical trauma and rapid convalescence, validate the use of such a minimally invasive approach to treat patients with primary achalasia of the esophagus. Received: 19 March 1996/Accepted: 15 May 1996