经腹腔镜Heller肌切开治疗贲门失弛缓症的远期结果及影响因素  

Long-term results and influencing factors of laparoscopic Heller myotomy for achalasia

作　　者：刘俊峰[1] 刘新波[1] 王岩[1] 孙旭晟 王继华 王继云 李海洋 王国臣 Liu Junfeng;Liu Xinbo;Wang Yan;Sun Xusheng;Wang Jihua;Wang Jiyun;Li Haiyang;Wang Guochen(Department of Thoracic Surgery,Fourth Hospital,Hebei Medical University,Shijiazhuang 050011,China;Department of Thoracic Surgery,the Fourth People's Hospital of Langfang,Langfang 065799,China;Department of Thoracic Surgery,Hebei Petrochina Central Hospital,Shijiazhuang 050011,China;Department of Thoracic Surgery,Affiliated Hospital of North China University of Science and Technology,Tangshan 063210,China)

机构地区：[1]河北医科大学第四医院胸外科,石家庄050011 [2]河北省廊坊市第四人民医院胸外科,065799 [3]河北中石油中心医院胸外科,石家庄050011 [4]华北理工大学附属医院胸外科,唐山063210

出　　处：《中华胸心血管外科杂志》2021年第11期654-659,共6页Chinese Journal of Thoracic and Cardiovascular Surgery

基　　金：国家自然科学基金(30471713)。

摘　　要：目的评价经腹腔镜食管下段与贲门肌层切开术(LHM)附加胃前壁180°包绕抗反流手术(Dor手术)治疗贲门失弛缓症的远期结果及影响因素。方法回顾性分析2011年1月至2019年12月单一术者应用LHM+Dor手术治疗贲门失弛缓症的连续病例共54例,已除外术后复发再手术和合并癌变者。术前、术后应用症状问询、食管造影检查评价手术疗效;术前应用胃镜检查除外食管黏膜癌变,食管测压检查进行分型,24 h食管pH监测观察食管酸暴露。分析上述术前因素对手术疗效的影响。结果所有患者均有不同程度的吞咽困难,症状持续6.5年(0.5~30.0年)。术中4例(7.4%)黏膜穿孔,无术后并发症和手术死亡。随访中位值5.2年(0.5~9.0年),吞咽困难症状由术前100%降至5.6%(P<0.001),术后烧心症状发生率3.7%,Eckardt临床症状评分由术前4.85±1.64降至0.71±1.08(P=0.000),手术疗效优良率94.4%。术后5年无症状(Eckardt评分≤1)率88.8%。术前有、无夜间呛咳症状患者相比,术后5年无症状率分别为54.6%和91.7%(P=0.047)。术前Ⅰ、Ⅱ度食管扩张与Ⅲ、Ⅳ度食管扩张患者相比,术后5年无症状率分别为92.3%和79.0%(P=0.027)。多因素分析结果显示:术前食管扩张程度较重是术后症状控制较差的独立预测因素(P=0.026)。结论LHM+Dor手术治疗贲门失弛症安全可靠、症状缓解率高且疗效持久,术前食管扩张程度是手术疗效的独立预测因素。Objective To assess the long-term outcome and influencing factors of laparoscopic Heller myotomy plus Dor fundoplication(LHM+Dor)for achalasia by a single operator.Methods Fifty-four patients who underwent LHM+Dor consecutively from January 2011 to December 2019 were retrospectively reviewed.Those who had already undergone surgical or endoscopic myotomy and who were complicated with cancer were ruled out.Symptom inquiry and esophagogram were conducted both before and after surgery for assessing surgical results.Esophagoscopy,esophageal manometry and 24 h pH monitoring were performed before surgery,and the effects of these preoperative factors on the long-term outcome were analyzed.Results All patients had dysphagia for average 6.5 years,ranging from 0.5-30.0 years.Intra-operative mucosal perforation occurred in 4(7.4%)patients,and there were no postoperative morbidity and mortality.At a median follow-up of 5.2 years,the morbidity of dysphagia decreased from 100%before surgery to 5.5%after surgery(P<0.001),Eckardt scores from 4.85±1.64 to 0.71±1.08(P=0.000).After surgery,94.4%of patients had excellent and good relief of symptoms and good control of gastroesophageal reflux,the morbidity of heartburn being 3.7%.At 5 years after surgery,the probability of being symptoms free(Eckardt score≤1)was 91.7%in patients without preoperative night cough,compared to 54.6%in those with preoperative night cough(P=0.047).The probability was 92.3%in patients with gradeⅠandⅡdilation of the esophagus and 79.0%in patients with gradeⅢandⅣdilation(P=0.027).At multivariate analysis,heavier esophageal dilation was the independent predicator for poor symptom control after surgery.Conclusion LHM+Dor can be safely performed and durably relieve achalasia symptoms.Severe esophageal dilation before surgery is an independent predictor of a poor response to surgery.

关 键 词：贲门失弛缓症 腹腔镜 Heller肌切开术 远期疗效 

分 类 号：R655.4[医药卫生—外科学]