贲门失弛缓症伴食管下段广泛炎症的内镜治疗体会

经口内镜下肌切开术（peroral endoscopic myotomy,POEM）治疗贲门失弛缓症（achalasia,AC）,具有创伤小、疗效高的优点,正在临床上推广。我们在对食管下段存在广泛炎症的5例AC患者行POEM治疗时,却有着不同的体会,报道如下。 一、资料与方法     

新型经口内镜下肌切开术治疗消化道疾病的临床应用与研究进展

自2009年经口内镜下肌切开术（peroral endoscopic myotomy, POEM）首次应用于治疗贲门失弛缓症,其疗效与安全性已逐步得到广泛认可。近年来,为更安全有效地实施手术,内镜医生不断进行探索,将传统POEM技术从三个方面更迭出新,即术式改良、设备更新和适应证拓展。本文即介绍新型POEM技术的临床应用和疗效评价。     

从传统到新经自然腔道内镜手术：内镜治疗的创新发展

自2007年世界首例经自然腔道内镜手术（natural orifice transluminal endoscopic surgery,NOTES）报道以来,该技术的临床应用已有近10年历史,期间经历了热潮与平静。而近年来,治疗性内镜技术又有了飞速发展和不断创新,使得更多疾病成为内镜治疗的适应证,经口内镜下肌切开术（peroral endoscopic myotomy,POEM）、经口内镜下幽门肌切开术（peroral endoscopic pyloromyotomy,POP）、内镜经黏膜下隧道肿瘤切除术（submucosal tunneling endoscopic resection,STER）、内镜下全层切除术（endoscopic full-thickness resection,EFTR）、超声内镜引导下胰腺假性囊肿引流术、超声内镜引导下胆管引流术（endoscopic ultrasonography-guided biliary drainage,EUS-BD）等就是近几年来兴起并快速发展的内镜治疗技术的代表。这些技术既继承了传统NOTES“使用内镜作为诊疗工具”、“建立手术通路短”的核心本质,又开拓出NOTES新的技术范畴,可将其统称为新NOTES。     

经口内镜下肌切开术治疗贲门失弛缓症的护理配合

贲门失弛缓症（esophageal achalasia,AC）是由于食管胃交界部（esophagogastric junction,EGJ）神经肌肉功能障碍所致的功能性疾病,患者临床表现为吞咽困难、胸骨后疼痛、食管反流以及因食管反流误吸入气管所致的咳嗽、肺部感染等症状。经口内镜下肌切开术（peroral endoscopic myotomy,POEM）是2008年首次应用于AC患者临床治疗的一种内镜微创新技术,我国起步于2010年,经过3年多的迅速发展,目前我国已成为开展POEM手术治疗最多的国家。厦门大学附属第一医院于2011年开始施行POEM手术,现将护理方法回顾性总结报道如下。     

经口内镜下肌切开术及其衍生技术应用的研究进展

经口内镜下肌切开术（peroral endoscopic myotomy，POEM）是一种通过切开食管下括约肌，改善贲门失弛缓症临床症状的微创内镜技术。作为近年来的新兴内镜技术，POEM症状缓解率高、并发症发生率低，且具有恢复快、费用低等优势。随着研究者们对POEM的关注度越来越高，有关POEM的手术方式有了新的研究进展，本文就POEM标准术式的改进、改良术式及衍生术式作一概述。     

双隧道与单隧道经口内镜下肌切开术治疗贲门失弛缓症的疗效比较

目的:评价双隧道与单隧道经口内镜下肌切开术（peroral endoscopic myotomy,POEM）治疗贲门失弛缓症的长期临床疗效。方法:设计随机对照试验,纳入2018年6月—2019年6月于南京医科大学第一附属医院消化内科行POEM治疗的30例贲门失弛缓症患者,采用计算机随机数字法将30例患者随机分为单隧道P...     

经口内镜肌切开术标准操作程序

<正>经口内镜肌切开术(peroral endoscopic myotomy,POEM)治疗贲门失弛缓症(achalasia cardiac,AC)于2010年在Endoscopy发表[1],手术近期疗效良好。POEM的手术原理是:应用内镜下黏膜剥离术(endoscopic submucosal dissection,ESD)分离食管黏膜下层,在黏膜层与固有肌层之间建立一     

高分辨率食管测压评估经口内镜下肌切开术治疗儿童贲门失弛缓症的临床研究

目的:探讨高分辨率食管测压(high resolution esophageal manometry,HREM)评估贲门失弛缓症(achalasia of cardia, AC)儿童经口内镜下肌切开术(peroral endoscopic myotomy, POEM)效果的作用。方法:收集2013年1月—2019年9月...     

经口内镜下肌切开术不同术式治疗贲门失弛缓症的比较

目的 探讨采用不同经口内镜下肌切开术（peroral endoscopic myotomy,POEM）术式治疗贲门失弛缓症的优劣。 方法 回顾性分析2015年1月至2018年9月于郑州大学第一附属医院消化内科行POEM治疗并定期随访的223例贲门失弛缓症患者的病例资料,其中采用传统POEM治疗100例,Liu-POEM治疗60例,简化POEM治疗60例,O-POEM治疗3例,对比这4种术式的手术前后症状评分（Eckardt评分）、手术时间、并发症及复发情况。 结果 这4种POEM手术成功率均为100%,且术后1个月、6个月、12个月时Eckardt评分均≤3分,均较术前显著降低,差异有统计学意义（P＜0.05）。传统POEM、Liu-POEM和简化POEM组间比较差异无统计学意义（P＞0.05）。与传统POEM相比,Liu-POEM和简化POEM手术时间和皮下气肿的发生率显著降低,差异有统计学意义（P＜0.05）。O-POEM手术时间最短,无皮下气肿。所有患者术后无复发。 结论 这4种POEM治疗贲门失弛缓症均具有较好疗效,Liu-POEM和简化POEM相比传统POEM具有操作较简单、手术时间较短、并发症发生率较低的优点。对于既往有外科手术史、反复球囊扩张、POEM术后复发等黏膜下粘连而无法建立黏膜下隧道的患者,可考虑O-POEM作为补救治疗。     

经口内镜下肌切开术治疗贲门失驰缓症疗效观察

目的观察经口内镜下肌切开术(POEM)对贲门失弛缓症(AC)的治疗效果。方法回顾性分析2013年8月至2013年11月本院诊断为AC并接受POEM治疗的3例患者的临床资料,总结术中、术后以及随访过程中并发症的发生及治疗情况。结果所有3例患者均成功接受POEM术,仅1例在术中出现皮下气肿,术后2小时后气肿消退。术后随访1~3个月,3例患者吞咽困难得到明显缓解。结论 POEM治疗AC近期疗效肯定,可以迅速缓解AC患者吞咽困难,远期疗效有待进一步随访。     

Miotomía endoscópica por vía oral de espesor total y parcial. Estudio de factibilidad en un modelo animal

BackgroundPeroral endoscopic myotomy has recently been developed and performed on patients with good results.AimsTo evaluate the technical feasibility of peroral endoscopic full-thickness and partial thickness myotomy in a porcine model.Material and methodsEighteen criollo pigs were randomly assigned to 2 groups: group A (partial-thickness myotomy) and group B (full-thickness myotomy). The mucosal defect proximal to the myotomy site was left open. On the seventh postoperative day the pig was euthanized and follow-up surgical exploration was performed. The duration of each procedure, postoperative progression of the animal, complications, and anatomopathologic findings were registered.ResultsThe procedure was viable in all the pigs. The mean surgery duration was 81 ± 35.3 min (group A 51.11 ± 11.12, group B 111 ± 22.61; P < .05). The main complication during myotomy was subcutaneous emphysema (16%). The histopathologic study of the group A surgical specimens reported complete circular myotomy in all cases, and complete circular and longitudinal myotomy was reported in 100% of the group B sample.ConclusionsThe endoscopic myotomy technique is feasible. Endoscopic partial-thickness myotomy was associated with shorter surgery duration and better results during the intraoperative period and the 7-day follow-up.     

Gastric per-oral endoscopic myotomy: Current status and future directions

Gastroparesis, or symptomatic delayed gastric emptying in the absence of mechanical obstruction, is a challenging and increasingly identified syndrome. Medical options are limited and the only medication approved by the Food and Drug Administration for treatment of gastroparesis is metoclopramide, although other agents are frequently used off label. With this caveat, first-line treatments for gastroparesis include dietary modifications, antiemetics and promotility agents, although these therapies are limited by suboptimal efficacy and significant medication side effects. Treatment of patients that fail first-line treatments represents a significant therapeutic challenge. Recent advances in endoscopic techniques have led to the development of a promising novel endoscopic therapy for gastroparesis via endoscopic pyloromyotomy, also referred to as gastric per-oral endoscopic myotomy or per-oral endoscopic pyloromyotomy. The aim of this article is to review the technical aspects of the per-oral endoscopic myotomy procedure for the treatment of gastroparesis, provide an overview of the currently published literature, and outline potential next directions for the field.     

Per-oral endoscopic myotomy for achalasia: An American perspective

Achalasia is an uncommon esophageal motility disorder characterized by the selective loss of enteric neurons leading to absence of peristalsis and impaired relaxation of the lower esophageal sphincter.Per-oral endoscopic myotomy(POEM) is a novel modality for the treatment of achalasia performed by gastroenterologists and surgeons.It represents a natural orifice transluminal endoscopic surgery(NOTES) approach to Heller myotomy.POEM has the minimal invasiveness of an endoscopic procedure that can duplicate results of the surgical Heller myotomy.POEM is conceptually similar to a surgical myotomy without the inherent external incisions and post-operative care associated with surgery.Initial high success and low complications rates promise a great future for this technique.In fact,POEM has been successfully performed on patients with end-stage achalasia as an initial treatment reserving esophagectomy for those without good response.The volume of POEMs performed worldwide has grown exponentially.In fact,surgeons who have performed Heller myotomy have embraced POEM as the preferred intervention for achalasia.However,the niche of POEM remains to be defined and long term results are awaited.We describe our experience with POEM having performed the first POEM outside of Japan in 2009,the evolution of our technique,and give our perspective on its future.     

Perspective on Peroral Endoscopic Myotomy for Achalasia: Zhongshan Experience

Worldwide, peroral endoscopic myotomy (POEM) has achieved remarkable initial outcomes in the treatment of achalasia. In China, POEM has developed very quickly since the first case was performed in our center in August 2010. With experience, we have successfully performed POEM for special cases (such as pediatric patients, patients with sigmoid-type esophagus, and patients with recurrent symptoms after previous surgery) and have altered our technique to achieve long-term symptom remission and simplify the POEM procedure. These changes include posterior wall incision, full-thickness myotomy, a “push-and-pull” technique for myotomy, and water-jet assisted POEM. In this article, our experiences in POEM are summarized, including changes in technique, applications of the procedure, and the management of possible complications.     

经口内镜下肌切除术治疗贲门失弛缓症的临床疗效观察

目的 观察经口内镜下肌切除术(POEM)治疗贲门失弛缓症的临床疗效和安全性.方法 对2010年11月至2011年11月7例确诊为贲门失弛缓症的患者行POEM手术.记录术前吞咽困难评分、术后并发症及近期远期疗效.结果 7例患者POEM手术均成功.手术时间46～113 min,平均(73±20) min.术后除2例出现皮下气肿、纵隔气肿,经内科治疗后痊愈,余均未出现相关并发症.术后随访1～12个月,7例患者吞咽困难均得到明显改善.结论 POEM手术可以迅速解除贲门失弛缓症患者吞咽困难,且具有一定的安全性.     

经口内镜下括约肌切开术对贲门失驰缓症疗效分析

[目的]分析经口内镜下括约肌切开术(POEM术)对贲门失驰缓症患者的治疗效果。[方法]以42例贲门失驰缓症患者为研究对象,随机分为试验组与对照组,每组21例。试验组患者使用POEM术治疗,对照组患者使用传统开胸Heller手术,观察比较2组患者的治疗效果、手术时间等相关指标。[结果]与对照组比较,试验组患者手术时间短、手术中出血量少、患者住院时间短,2组比较差异有统计学意义(P0.05)。[结论]POEM术治疗贲门失驰缓症的效果较好。     

Full-thickness myotomy is associated with higher rate of postoperative gastroesophageal reflux disease

AIM To compare long-term occurrence of gastroesophageal reflux disease(GERD) between two different types of peroral endoscopic myotomy(POEM) for achalasia.METHODS We included all patients with achalasia who underwent POEM at our hospital from August 2011 to October 2012 and had complete GERD evaluation with ≥ 3 years of follow-up. They were divided into circular or full-thickness myotomy groups according to the depth of myotomy. Demographics, Eckardt score, manometry results, 24-h pH monitoring, and GERD symptoms were recorded and compared between the two groups.RESULTS We studied 56 patients(32 circular myotomy and 24 fullthickness myotomy) with complete GERD evaluation. There was no significant difference between the two groups in terms of treatment success(defined as Eckardt score ≤ 3), postoperative Eckardt score, mean basal lower esophageal sphincter pressure, and 4-s integrated relaxation pressure(4s IRP). Postoperative abnormal esophageal acid exposure was found in 25 patients(44.6%). A total of 13 patients(23.2%) had GERD symptoms and 12 had esophagitis(21.4%). Clinically relevant GERD(abnormal esophageal acid exposure associated with GERD symptoms and/or esophagitis) was diagnosed in 13 patients(23.2%).Multivariate analysis revealed that full-thickness myotomy and low level of postoperative 4s IRP were predictive factors for clinically relevant GERD.CONCLUSION Efficacy and manometry are comparable between achalasia patients treated with circular or full-thickness myotomy. But patients with full-thickness myotomy and low postoperative 4sI RP have more GERD.     

Update on therapeutic interventions for the management of achalasia

Achalasia is a primary esophageal motility disorder. It is the absence of peristalsis in the esophageal body and inability of the lower esophageal sphincter to relax, which characterizes this rare condition. Its features typically include dysphagia, regurgitation, chest pain, and weight loss. The ultimate goal in treating achalasia is to relieve the patient's symptoms, improve esophageal emptying, and prevent further dilatation of the esophagus. Current treatment modalities targeted at achalasia include pharmacological therapy, endoscopic therapy, and surgery. This review focuses on the current therapeutic options and explores the role of peroral endoscopic myotomy in the management armamentarium.