三种方法治疗贲门失弛缓症效果观察

目的观察比较内镜下球囊扩张术、胸腔镜Heller手术及开胸Heller手术治疗贲门失弛缓症的中远期效果。方法内镜/钡餐检查诊断为贲门失弛缓症的53例患者按治疗方法分为:内镜下球囊扩张术治疗组(扩张组)14例,胸腔镜Heller手术治疗组(胸腔镜组)11例,开胸Heller手术治疗组(开胸组)28例。比较各组治疗前后症状、食管中下段直径及食管pH值;以首次扩张治疗后6个月~1年为中期疗效、1年以上为远期疗效,计算该疗法的中远期有效率。结果开胸组和胸腔镜组近期疗效均优于扩张组(P均<0.05),三组中期疗效及胸腔镜组远期疗效均达100%,开胸组远期疗效为97.73%,扩张组远期疗效为86.96%。3例复发再次扩张治疗后症状缓减。无食管大出血、穿孔等严重并发症发生。结论内镜下球囊扩张术、胸腔镜Heller手术及开胸Heller手术治疗贲门失弛缓症均具有良好的中远期疗效。球囊扩张术可经门诊治疗、操作简便、疗效确切、费用低廉、创伤小,是贲门失弛缓症的首选治疗方法;外科手术治疗为最有效的方法,但不作为首选方法。     

山莨菪碱试验鉴别假性贲门失弛症和贲门失弛症

目的监测山莨菪碱肌注前后食管动力的变化,探讨其在假性贲门失弛症和贲门失弛症鉴别诊断中的价值。方法 10例贲门失弛症和3例胃底贲门癌致假性贲门失弛症的患者,通过8通道袖套式测压导管持续观察食管动力在肌注山莨菪碱前后的变化。结果 10例贲门失弛症患者在肌注山莨菪碱后下食管括约肌松弛程度达47.4%～74.0%,食管体部静息压明显降低;3例假性贲门失弛症患者食管括约肌松弛程度仅2.2%～8.8%,食管体部静息压亦无明显变化。结论山莨菪碱试验可作为贲门失弛症食管测压诊断时的重要补充,也是贲门失弛症和假性贲门失弛症鉴别诊断的手段之一。     

Esophageal motility differences among aged patients with achalasia: a Taiwan report

BACKGROUND AND AIM: There are limited reports on esophageal motility pressures in aged patients with achalasia and these are inconclusive. The aim of the present retrospective study was to understand the changes of esophageal motility in aged achalasia patients among the Taiwan population. METHODS: Manometric studies of 49 patients with achalasia had been performed through January 1998 to June 2005. The findings of lower esophageal sphincter (LES) basal and residual pressures and esophageal body contraction amplitudes were calculated and compared between the older and younger patient groups at different age cut-offs. RESULTS: Higher basal LES pressure increased significantly from the cut-off age of 65 years (i.e. patients over 65 had significantly higher basal LES pressure than younger patients: 37.0 +/- 4.19 mmHg vs 30.0 +/- 1.32 mmHg, P = 0.045). With patients > or =70 years old, it was more obvious (46.0 +/- 3.7 mmHg vs 29.6 +/- 1.2 mmHg, P = 0.001). Beginning at the cut-off age of 55, the LES residual pressure was significantly higher in older patients than those who were younger (14.0 +/- 11.06 mmHg vs 11.1 +/- 0.6 mmHg, P = 0.017). LES residual pressure is more significant in the older groups. A linear correlation between age and residual LES pressures (r = 0.383) was found. No differences were found in esophageal contraction pressure. CONCLUSIONS: Older achalasia patients in Taiwan have higher basal LES pressures, with a linear correlation between age and residual LES pressures. Age has no influence on esophageal contraction pressure.     

Patient perception of a clinical pathway for laparoscopic foregut surgery

Clinical pathways have been implemented for a number of surgical procedures, yet few data are available that explore the patients’ perception of these changes in clinical practice. A clinical pathway was developed for laparoscopic fundoplication, Heller myotomy, and paraesophageal hernia repair. Data collected from a cohort of patients undergoing surgery with the pathway over a 12-month period was compared with a group of patients operated on in the 12 months prior to pathway implementation. A questionnaire examining patient-based outcomes and perceptions was completed 6 weeks after surgery. From November 2001 through November 2003, 49 patients underwent primary laparoscopic foregut surgery, 27 before and 22 after pathway implementation. There were no differences in age, gender, procedure, or ASA Class. Parenteral opioid use diminished significantly without compromising the patients’ perceived pain control. The number of patients undergoing postoperative investigations diminished, as did length of stay. Of the 20 postpathway patients completing satisfaction questionnaires, 95% were satisfied or very satisfied with their care during admission. Pathway implementation resulted in a significant reduction in direct postoperative hospital costs. A clinical pathway for laparoscopic foregut surgery was successfully implemented in a single-payer system, resulting in decreased utilization of hospital resources while maintaining high patient satisfaction. Presented in part at Digestive Disease Week, May 17, 2004, New Orleans, Louisiana. Funded by an unrestricted educational grant from Tyco Healthcare, Canada.     

Gastroesophageal reflux disease progressing to achalasia

Two achalasia patients with former complaints of heartburn were examined. Antisecretory drugs were used by the patients when dysphagia occurred. Barium X-ray and esophageal manometry were performed and achalasia was diagnosed in both patients. Twenty-four-hour pH-metry showed significant and long-lasting acid reflux during supine position. Prolonged reflux episodes can be explained not only by the swallow-unrelated transient relaxation of lower esophageal sphincter (LES) and mechanical damage of the esophageal body, but also by its chemical insensitivity. Thus preoperative detection of reflux should determinate either the operational procedure and the postoperative follow up of the patient.     

经口与经鼻导尿管球囊扩张术治疗脑干卒中后环咽肌失弛缓症的影响

目的比较经口与经鼻导尿管球囊扩张术治疗脑卒中后环咽肌失弛缓症患者的疗效。 方法选取脑卒中后环咽肌失弛缓患者30例,按随机数字表法将其分为经口扩张组和经鼻扩张组,每组患者15例。2组均给予常规吞咽康复训练,在此基础上,经口扩张组通过口腔置管行导尿管球囊扩张术,经鼻扩张组给予经鼻腔插管行导尿管球囊扩张术。记录2组患者在行扩张治疗时监测患者心率变化,并于每次治疗结束后观察2组患者鼻黏膜出血、水肿、疼痛等并发症的发生情况。采用吞咽疗效评分和视频吞咽造影检查（VFSS）对2组患者治疗前、后的吞咽功能进行评估和比较。 结果治疗后,经口扩张组的藤岛一郎吞咽疗效评分为（7.26±2.52）分,经鼻扩张组为（7.18±2.64）分,分别与组内治疗前比较,差异均有统计学意义（P<0.05）,2组间差异无统计学意义（P>0.05）;治疗后,2组患者的VFSS评分分别为（2.26±0.46）分和（2.19±0.53）分,分别与组内治疗前比较,差异均有统计学意义（P<0.05）,2组间差异无统计学意义（P>0.05）。治疗过程中,经口扩张组心率较组内治疗前增加（9.12±1.4）次,明显低于经鼻扩张组的（18.6±2.9）次,差异有统计学意义（P<0.05）,且经口扩张组治疗接受率为98.2%,明显高于经鼻扩张组80.1%,差异有统计学意义（P<0.05）。经口扩张组患者发生黏膜出血、喉头水肿、疼痛等并发症分别为1例、1例、（1.0±0.7）分,分别与经鼻扩张组的9例、7例、（3.1±0.4）分比较,差异均有统计学意义（P<0.05）。 结论导尿管球囊扩张术是脑卒中后环咽肌失弛缓所导致吞咽障碍的有效治疗方法,经口腔置管行球囊扩张术的患者的鼻黏膜水肿、喉头水肿、疼痛等并发症均优于经鼻置管行球囊扩张术的患者,且患者接受率更高。     

经口内镜下肌切开术与经胸Heller术治疗贲门失弛缓症的临床疗效对比

目的对比分析贲门失弛缓患者经口内镜下肌切开术(POEM)与经胸食管贲门部黏膜外肌层切开手术(即Heller术)的临床疗效及安全性。方法回顾性研究2012年1月-2014年10月该院78例确诊为贲门失弛缓症患者。其中,接受POEM术患者为42例,接受Heller术患者36例,观察并对比两组患者术后症状缓解情况、食管下段括约肌(LES)静息压力、Eckardt评分、术中和术后并发症发生率、手术时长、住院时间及住院费用等。结果两组患者术后均获得明显的临床缓解,POEM组患者的并发症发生率、Eckardt评分及LES静息压力和Heller术组相比差异无统计学意义(P0.05)。而POEM组患者的手术耗时、住院时长及住院费用均明显低于Heller术组(P0.05)。结论 POEM作为一种近期疗效显著的内镜微创手术方式,与外科手术疗效相当,对患者造成的创伤小,痛苦小,使患者耐受性好,住院时间及住院费用减少,值得推广。     

Differences in response of the proximal esophagus to wet swallows in patients of Chagas'' disease and idiopathic achalasia

Chagas' disease and idiopathic achalasia have similar esophageal manifestations such as absent or incomplete lower esophageal sphincter relaxation and aperistalsis in the esophageal body (alterations seen mainly in the distal esophageal body). Our aim in this paper was to study the response of the proximal esophageal body to wet swallows in patients with Chagas' disease and patients with idiopathic achalasia. We retrospectively analyzed the time interval between the onset of the pharyngeal contractions 1 cm proximal to the upper esophageal sphincter, as well as 5 cm distal to the pharyngeal measurement. Amplitude, duration and area under the curve of contractions in the proximal esophagus were also determined in 42 patients with Chagas' disease (15 with associated esophageal dilatation), 21 patients with idiopathic achalasia (14 with concomitant esophageal dilatation) and 31 control subjects. The time between the onset of pharyngeal and proximal esophageal contractions was longer in patients with Chagas' disease and in those with esophageal dilatation (1.39 +/- 0.16 s) than in control subjects (0.86 +/- 0.04 s, P < 0.01). The amplitude of proximal esophageal contractions was lower in patients with idiopathic achalasia and esophageal dilatation (60.9 +/- 16.3 mmHg) than in control subjects (89.7 +/- 6.9 mmHg, P = 0.06). The authors conclude that in patients with advanced esophageal disease, the proximal esophageal contractions in Chagas' disease have a delayed response to wet swallows when compared with controls, and that the amplitude of proximal esophageal contractions was lower than expected in patients with idiopathic achalasia.     

Dysphagia in Crohn''s disease: a diagnostic challenge

Dysphagia is a rare manifestation in a patient with Crohn's disease. We report on the case of a patient with long-standing Crohn's disease who developed progressive dysphagia over 3 years. Endoscopy showed minimal distal oesophagitis with non-specific histological findings. Further investigation with cinematography, barium swallow and manometry established an achalasia-like motility disorder. Biopsies obtained from the oesophagus were non-specific. Balloon dilatation was performed. Initial success was followed by recurrent dysphagia. At repeat endoscopy, an oesophageal fistula was detected. An attempt at conservative medical management failed and oesophagectomy was successfully performed. Pathology results of the resected specimen confirmed the suspected diagnosis of oesophageal Crohn's disease. Even if achalasia is suspected in a Crohn's patient, it should be taken into consideration that the motility disorder could be the result of a transmural inflammation with or without fibrosis caused by Crohn's disease.