南方医科大学学报

南方医科大学学报 ›› 2016, Vol. 36 ›› Issue (07): 892-.

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经口内镜下肌切开术治疗贲门失弛缓症安全性和有效性的影响因素

马晓冰，令狐恩强，李惠凯，翟亚奇，柴宁莉，彭丽华，王向东，杜红，孟江云，王红斌，朱静，郭明洲， 王潇潇，卢忠生   

  • 出版日期:2016-07-20 发布日期:2016-07-20

Factors affecting the safety and efficacy of peroral endoscopic myotomy for achalasia

  • Online:2016-07-20 Published:2016-07-20

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摘要： 目的通过大样本临床资料，筛选出的经口内镜下肌切开术（POEM）治疗贲门失弛缓症的术安全性和有效性的影响因 素。方法分析2010年12月~2015年12月在我院成功接受POEM治疗的439例贲门失弛缓症患者的临床资料，包括患者一般 情况、手术时长、隧道开口方式、肌切开方式、并发症发生、术后随访等资料。结果439例患者总体并发症发生率28.7%（126/ 439）。中位随访时间6个月（1月~48月），症状缓解率94.5%（344/364），术前Eckardt评分vs术后Eckardt评分6.7±1.5（2~10）vs 1.2±1.1（0~5）（P<0.05）。通过Logistic回归分析，手术年度（以2015年为参照，2011年之前OR=9.454，95% CI 为2.499~35.76； 2012 年OR=2.177，95% CI 为0.794~5.974；2013 年OR=3.975，95% CI 为1.904~8.298；2014 年OR=1.079，95% CI 为0.601~ 1.940）、隧道开口方式（以纵行开口为参照，倒T 型开口OR=0.369，95% CI 为0.165~0.824；横行开口OR=0.456，95% CI 为 0.242~0.859）是并发症发生的影响因素，肌切开方式（以眼镜式为参照，渐进全层肌切开OR=0.363，95% CI为0.059~2.250；内环 肌切开OR=2.137，95% CI为0.440~10.378；内环肌切开+球囊塑形OR=4.385，95% CI为0.820~23.438；全层肌切开复发率为0） 是复发的影响因素。结论随年度推移并发症发生风险逐渐减小，在3种隧道开口方式中倒T型开口对并发症的控制作用最 优。综合复发、手术时长等因素，渐进全层肌切开较其他肌切开方式表现更为突出。

Abstract: Objective To identify the factors that affect the safety and efficacy of peroral endoscopic myotomy (POEM) for treatment of achalasia. Methods Data of consecutive patients undergoing POEM for confirmed achalasia between December, 2010 and December, 2015 were collected, including the procedure time, approach of tunnel entry incision, approach of myotomy, complications and follow-up data. Results Among the total of 439 patients enrolled, the overall complication rate was 28.7% (126/439). Treatment success (Eckardt score≤3) was achieved in 94.5% of 364 patients followed up for a median of 6 months (1-48 months), and the mean score was reduced significantly from 6.7 ± 1.5 before treatment to 1.2 ± 1.1 after the treatment (P<0.05). Logistic regression revealed that the year when POEM was performed and the approach of entry incision were two significant factors contributing to complications: with the year 2015 as the reference, the odds ratio (OR) was 9.454 (95% CI: 2.499-35.76) for the years before 2011, 2.177 (95% CI: 0.794-5.974) for 2012, 3.975 (95% CI: 1.904-8.298) for 2013, and 1.079 (95% CI: 0.601-1.940) for 2014; with the longitudinal entry incision as the reference, the OR was 0.369 (95% CI: 0.165-0.824) for inverted T entry incision and 0.456 (95%CI: 0.242-0.859) for transverse entry incision. The approach of myotomy was the significantly associated with symptomatic relapse: with full-thickness myotomy combined with indwelling an anti-reflux belt as the reference, the OR was 0.363 (95% CI: 0.059-2.250) for gradual full-thickness myotomy, 2.137 (95% CI: 0.440-10.378) for circular muscle myotomy, and 4.385 (95% CI: 0.820-23.438) for circular muscle myotomy in combination with balloon shaping; the recurrence rate was 0 with a full-thickness myotomy. Conclusion The complication rates of POEM appears to decrease over time, and an inverted T entry incision is the best choice for controlling the complications. Gradual full-thickness myotomy is an excellent approach for treatment of achalasia in terms of the relapse rate, procedure time and the incidence of reflux esophagitis.