腹腔镜联合胃镜微创治疗贲门失弛缓症26例分析

目的 探讨采用腹腔镜联合胃镜微创手术治疗贲门失弛缓症的可行性及临床价值。方法 2005年12月至2009年3月,天津市南开医院对26例贲门失弛缓症病人实施腹腔镜Heller括约肌切开加Dor胃底折叠术,术中联合胃镜进行定位、检查,对围手术期相关指标进行分析,并随访观察治疗效果。结果 26例均完成腹腔镜手术,无中转开腹病例,术后无严重并发症。1例术中食管黏膜破损,经胃镜证实后行腹腔镜下修补术,随访观察4～42个月无吞咽困难,1例术后1年内出现轻度胃食管反流及胸骨后疼痛症状,术后3个月复查食管测压、胃镜、上消化道造影提示均基本恢复正常。结论 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,术中联合胃镜操作可提高手术安全性,减少并发症的发生。     

Intraoperative distensibility measurement during laparoscopic Heller's myotomy for achalasia may reduce the myotomy length without compromising patient outcome

Our study aimed to assess whether intraoperative esophagogastric junction (EGJ) distensibility measurement using the EndoFLIP EF325 catheter (Crospon Ltd., Galway, Ireland) could potentially be used to guide laparoscopic Heller's myotomy (LHM), potentially modifying the operation outcome and comparing this clinically to our previous technique of gastroscopic assessment. Following a full diagnostic assessment with manometry and endoscopy patients with achalasia were divided into two groups. A retrospective cohort of patients operated on between 2007 and 2010 had a gastroscopy‐guided LHM (G‐LHM) with a standardized myotomy of 8 cm on the esophagus and 3 cm on the stomach. From 2010, patients were prospectively studied with an EndoFLIP‐guided LHM (E‐LHM). The length of the myotomy was dictated by intraoperative distensibility monitoring of the EGJ. All patients with achalasia recorded Urbach quality of life scoring preoperatively and 6 months postoperatively. A further group of normal laparoscopic control patients (E‐LC) without any esophageal pathology also underwent intraoperative EGJ distensibility monitoring. Thirty‐eight patients took part, 15 in the E‐LC group, 8 in G‐LHM group and 15 in the E‐LHM group. We revealed that patients with achalasia in the E‐LHM group had a significantly smaller EGJ cross‐sectional area and distensibility than the E‐LC group. Myotomy and fundoplication increased the distensibility of the EGJ to a value greater than normal control patients. Patients in the G‐LHM group had a standard myotomy of 11 cm; patients in the E‐LHM group had a variable length myotomy of 6 cm (IQR 5.0–6.0). In both G‐LHM and E‐LHM groups, there was a significant improvement in patient's quality of life with no significant difference between the groups. Our study has shown that the EndoFLIP system was effective at measuring distensibility changes during LHM. LHM significantly increases the distensibility of the EGJ and also significantly improves patient symptoms. E‐LHM may reduce the overall myotomy length, and this does not appear to compromise the clinical outcome.     

Peroral endoscopic myotomy for the treatment of esophageal achalasia: systematic review and pooled analysis

Peroral endoscopic myotomy (POEM) is a novel approach to performing esophageal myotomy for the treatment of achalasia. This review aims to assess subjective and objective metrics of achalasia treatment efficacy, perioperative adverse events and the incidence of postoperative gastroesophageal reflux disease in patients treated with POEM. Secondary aims include a pooled analysis comparison of the clinical outcomes and procedural safety of POEM versus laparoscopic Heller's myotomy (LHM). A systematic review of the literature, up to and including January 15, 2015, was conducted for studies reporting POEM outcomes. Studies comparing POEM to LHM were also included for the purpose of pooled analysis. Outcomes from 1122 POEM patients, from 22 studies, are reported in this systematic review. Minor operative adverse events included capno/pneumo‐peritoneum (30.6%), capno/pneumo‐thorax (11.0%) and subcutaneous emphysema (31.6%). Major operative adverse events included mediastinal leak (0.3%), postoperative bleeding (1.1%) and a single mortality (0.09%). There was an improvement in lower esophageal sphincter pressure and timed barium esophagram column height of 66% and 80% post‐POEM, respectively. Symptom improvement was demonstrated with a pre‐ and post‐POEM Eckardt score ± standard deviation of 6.8 ± 1.0 and 1.2 ± 0.6, respectively. Pre‐ and post‐POEM endoscopy showed esophagitis in 0% and 19% of patients, respectively. The median (interquartile range) points scored for study quality was 15 (14–16) out of total of 32. Pooled analysis of three comparative studies between LHM and POEM showed similar results for adverse events, perforation rate, operative time and a nonsignificant trend toward a reduced length of hospital stay in the POEM group. In conclusion, POEM is a safe and effective treatment for achalasia, showing significant improvements in objective metrics and achalasia‐related symptoms. Randomized comparative studies of LHM and POEM are required to determine the most effective treatment modality for achalasia.     

腹腔镜Heller's术治疗儿童贲门失弛缓症

目的 总结介绍腹腔镜下Heller's术治疗儿童贲门失弛缓症,分析经腹腔镜途径的优点.方法 总结作者团队11年间收治并经腹腔镜下Heller's术治疗的儿童贲门失弛缓症病例,结合文献及作者体会分析胸、腹腔镜Heller's术的利弊.结果 2003年8月至2014年5月,上海交通大学医学院附属新华医院小儿外科诊断收治并经腹腔镜手术的儿童贲门失弛缓症15例,其中男9例,女6例,年龄10个月至13岁.主要症状为:进食哽噎、吞咽困难,进食后呕吐,部分患儿曾有食管扩张史.所有患儿完善术前检查后行手术治疗,其中13例顺利在腹腔镜下完成Heller's术+Thal's术,1例术中食管黏膜损伤穿孔,随后完成镜下修补和胃底折叠术,1例因合并有巨十二指肠症中转开放手术.所有病例术后3～4d进食,7～10d出院.术后随访2～6年,所有患儿术后体重增加、生长发育好.结论 腹腔镜下Heller's术对于儿童贲门失弛缓症效果确切,术后恢复时间短,并发症少,是值得推荐的首选手术途径.     

Cricopharyngeal achalasia treated with myectomy and post-operative high-resolution manometry

Cricopharyngeal achalasia is an uncommon cause of dysphagia in neonates or children. A nine-year-old female patient was referred to us with a long history of dysphagia, recurrent pulmonary infection and growth stunting. A gastrostomy was introduced to improve her nutritional condition and to minimize potential inflammation in the pharynx. Subsequently, cervical cricopharyngeal myectomy was conducted. The surgical intervention allowed prompt resolution of symptoms without complications. High-resolution manometry post myectomy demonstrated a significant reduction in upper esophageal pressure together with proper relaxation at deglutition. The patient was able to consume solid food and liquid normally, and remained asymptomatic without medications six months after the surgery.     

How to effectively use and interpret the barium swallow: Current role in esophageal dysphagia

Background

The barium swallow is a commonly performed investigation, though recent decades have seen major advances in other esophageal diagnostic modalities.

Purpose

The purpose of this review is to clarify the rationale for components of the barium swallow protocol, provide guidance on interpretation of findings, and describe the current role of the barium swallow in the diagnostic paradigm for esophageal dysphagia in relation to other esophageal investigations. The barium swallow protocol, interpretation, and reporting terminology are subjective and non-standardized. Common reporting terminology and an approach to their interpretation are provided. A timed barium swallow (TBS) protocol provides more standardized assessment of esophageal emptying but does not evaluate peristalsis. Barium swallow may have higher sensitivity than endoscopy for detecting subtle strictures. Barium swallow has lower overall accuracy than high-resolution manometry for diagnosing achalasia but can help secure the diagnosis in cases of equivocal manometry. TBS has an established role in objective assessment of therapeutic response in achalasia and helps identify the cause of symptom relapse. Barium swallow has a role in the evaluating manometric esophagogastric junction outflow obstruction, in some cases helping to identify where it represents an achalasia-like syndrome. Barium swallow should be performed in dysphagia following bariatric or anti-reflux surgery, to assess for both structural and functional postsurgical abnormality. Barium swallow remains a useful investigation in esophageal dysphagia, though its role has evolved due to advancements in other diagnostics. Current evidence-based guidance regarding its strengths, weaknesses, and current role are described in this review.     

经口内镜下环形肌切开术治疗21例贲门失弛缓症的护理

目的总结21例内镜下环形肌切开术（POEM）的护理体会。方法对2011年6月-2012年6月21例确诊为贲门失弛缓症（AC）并接受POEM治疗护理进行回顾性分析。结果21例患者均成功行POEM治疗。其中3例术中少许渗血,经内镜下电凝止血,出血停止;2例出现纵隔和皮下气肿,2～3d后气肿消退。结论术前术中术后精心的护理,可减少并发症,提高手术成功率。     

Swallowing function following extensive resection of oral or oropharyngeal cancer with laryngeal suspension and cricopharyngeal myotomy

OBJECTIVE: To investigate factors that influence postoperative swallowing function in patients who underwent tongue and oropharynx resection. METHODS: Sixty-two subjects who had undergone extensive resection of oral or oropharyngeal cancer between 1993 and 2005 participated in this study. All surgical procedures involved excision of the bilateral suprahyoid muscles or of >or=50% of the tongue base. Laryngeal suspension and cricopharyngeal myotomy were performed on all subjects. A multivariate analysis of the effects of extensive tongue and oropharynx resection on swallowing function was performed. RESULTS: A total of 53 (85.5%) of the 62 subjects achieved independent oral intake and no longer required tube feeding. Six months after surgery, better eating capabilities had been attained by younger patients as compared with older patients; patients with less extensive tongue base resections; patients who had not undergone radiotherapy; and patients reconstructed with free flaps rather than pedicled flaps. CONCLUSIONS: Age was found to be the most important factor in determining whether a patient could achieve independent oral intake after extensive oral or oropharyngeal resection. The main factors in determining the quality of diet attained by the patient were found to be age, the percentage of tongue base resection, and the method of postoperative reconstruction.     

Flexible endoscopic clip-assisted Zenker's diverticulotomy: the first case series (with videos)

Background: In treating Zenker's diverticulum (ZD), there are potential risks associated with performing flexible endoscopic diverticulotomy without suturing or stapling. We recently introduced flexible endoscopic clip‐assisted diverticulotomy (ECD) in treating ZD by securing the septum prior to dissection. Objective: To evaluate the feasibility and safety of ECD for complete septum dissection. Study Design: Case series at an academic center. Seven consecutive patients (mean age 71 y; range 48–91 y) with symptomatic ZD of various craniocaudal sizes based on radiographic measurements (mean 2.6 cm; range 0.8 cm–4.5 cm) were included. The mean depth of the septum was 1.73 cm (range 0.3 cm–3.1 cm). The mean duration of symptoms was 4.8 years (range 0.5–10 y). Methods: After endoclips were placed on either side of the cricopharyngeal bar, the septum was dissected between these two clips down to the inferior end of the diverticulum with a needle‐knife. Procedures including “one‐step ECD” (n = 1), “stepwise ECD” (n = 3), and “bottom ECD” (n = 2) were performed based on the septum depth of the ZD during endoscopy. ECD was not performed on one patient due to severe mucosal fragility of the esophageal inlet. Iatrogenic blunt dissection of the septum by the endoscopic hood occurred secondary to patient retching during the procedure. Main outcome measurements were symptom resolution and complications. Results: All patients (n = 6) who underwent ECD had complete resolution of esophageal symptoms at a minimum 6‐month follow‐up. There were no procedural complications. The patient who did not undergo ECD developed an esophageal perforation. She was managed conservatively without surgical intervention. On follow‐up, her dysphagia was completely resolved. Conclusions: ECD is feasible, safe, and effective for complete septum dissection. ECD and endoscopic stapler‐assisted diverticulotomy are complimentary rather than competing strategies in approaching ZD. Study limitations include the case series design and limited follow‐up period.