经口内镜肌切开术治疗贲门失弛缓症的实验及临床经验初探

目的利用猪食管-胃模型进行经口内镜肌切开术（POEM）实验，为临床开展POEM术积累经验并探讨POEM治疗贲门失弛缓症的安全性和有效性。方法止血钳结扎离体猪的胃幽门出口，并将离体猪的食管口侧末端固定于带孔泡沫塑料，制成简易训练模型，然后以带透明帽内镜按如下步骤进行POEM术：（1）建立黏膜下隧道；（2）切断食管环形肌层；（3）封闭隧道口。经模型练习熟练掌握POEM技巧后，对4例贲门失弛缓症患者实施手术。结果5例猪食管-胃模型，2例成功完成POEM术，1例食管纵行肌层裂开穿孔，1例切断环形肌层时切除过深导致穿孔，1例于食管一胃连接部切破黏膜层。经模型练习后在临床成功开展POEM术4例，操作时间平均110min，隧道长度8—11cm，平均10．5cm，环形切断长度5～8cm，平均7cyn，术中1例出血较多，但在内镜下成功止血。食管测压提示，术后平均LES压力从术前47．07mmHg降至17．4mmHg。术后随访1～4个月，4例患者吞咽困难症状明显缓解。结论猪食管-胃模型制作简单，可作为简易的训练模型模拟POEM术过程。POEM术治疗贲门失弛缓症近期疗效肯定，远期疗效有待进一步随访。

Animal experiment and clinical pilot study of peroral endoscopic myotomy for achalasia

Objective The procedure of peroral endoscopic myotomy (POEM) was practiced in porcine esophagus-stomach model and the efficacy and safety of POEM for patients with achalasia were evaluated.Methods The ex-vivo esophagus-stomach was obtained and the pylorus was closed by hemostatic forceps.The entrance of the esophagus was fixed to foamed plastics.To perform POEM,a submucosal tunnel was created,after which the circular muscle layer was dissected and the mucosal entry was finally closed with clips.After successful animal experiment,we performed POEM on 4 patients with achalasia.Results POEM was completed in 5 porcine training models,in which 2 procedures were successful without any complication,2 were complicated with perforation in muscularis propria layer and 1 with rupture in mucosal layer.POEM was successfully performed in 4 patients with achalasia,with a mean operation time of 110min.The mean length of the submucosal tunnel was 10.5cm ( ranging 8-11 cm) and the mean length of myotomy of circular muscle layer was 7 cm (ranging 5-8 cm).The resting pressure of lower esophageal sphincter (LES) decreased from 52.4 mm Hg before POEM to 19.9 mm Hg.Massive bleeding occurred at the gastroesophageal junction in the first case and perforation occurred in mucosal layer during endoscopic hemostasis.All patients were followed up for 1-4 months,and the symptom of dysphasia was relieved significantly.Conclusion The ex-vivo esophagus-stomach model can be used as training model for procedure of POEM,enabling endoscopists with enough experience for its use in patients.POEM is an effective therapy for achalasia,while the long-term efficacy and managements for complications are still to be elucidated.