经口内镜下肌切开术动物实验的可行性研究

目的通过本研究探讨经口内镜下肌切开术（POEM）在活体家猪体内完成操作的可行性。方法 4个月大健康家猪8只,麻醉后取左侧卧位,在距贲门上方8～10cm处黏膜下注射,纵行切开长约2cm黏膜,内镜沿切口进入黏膜下进行＂隧道式＂剥离直至贲门,直视下切断长度2cm贲门处环形肌,术中随时止血;金属夹自远端向近端闭合切口。术后补液,禁食水48h,之后流质饮食,应用抗生素3d;1周后复查胃镜。结果所有实验用猪均完成POEM操作,其中1例在贲门处操作时发生气胸死亡;另外1例发生颈部皮下气肿,72h后气肿消失,其余7例均存活。结论 POEM技术是一项风险较大、相对安全的技术,具有应用的特点,同时该技术的成功,也提示使用家猪可以进行该技术的临床前训练。     

经口内镜下肌切开术术后一过性菌血症发生率的临床研究

目的 通过研究经口内镜下肌切开术（ POEM ）术后一过性菌血症的发生率,为POEM的进一步发展及推广提供理论依据.方法 前瞻性地连续选择2013 年6 月5 日至2013 年9 月12 日在解放军总医院消化内镜中心行POEM 术患者36 例.术后5 min、30 min、6 h、16 h 分别抽血行血培养及血常规、C 反应蛋白检测,记录体温,密切监测患者术后感染相关并发症.结果 32 例患者成功完成手术及抽血,其中2 例患者在术后5 min、30 min 血培养中分别培养出革兰阳性杆菌及凝固酶阴性葡萄球菌,但在各自的其他三个时间点的血培养均为阴性.此外,患者术后白细胞计数、中性粒细胞比例、C 反应蛋白量及体温均有不同程度的升高,且以中性粒细胞的升高最为明显（ P ＜ 0.001 ）.结论 POEM 术后存在一过性菌血症,但其具体发生率及最终结论尚需大样本进一步研究.     

Ling分型对经口内镜下肌切开术手术并发症的影响

目的 探讨贲门失弛缓症Ling分型对经口内镜下肌切开术(POEM)手术并发症的影响。方法 分析前瞻性记录的2010年10月至2012年9月期间POEM治疗的47例贲门失弛缓症患者的资料,对比不同Ling分型的患者接受POEM治疗时手术并发症发生率。结果 47例患者接受POEM治疗,男25例,女22例,年龄16~62岁,平均39.0岁。LingⅠ型24例,LingⅡa型5例,LingⅡb型14例,LingⅡc型4例。共14例出现并发症(29.8%),黏膜穿孔5例(10.6%),气体相关并发症10例(21.3%),其中1例同时合并黏膜穿孔和气体相关并发症。气体相关并发症包括气胸、纵隔积气、腹腔积气及皮下气肿。黏膜穿孔的发生率LingⅡb型最高,为21.4%;LingⅠ型次之,为8.3%;LingⅡa型和LingⅡc型均未发生并发症。气体相关并发症的发生率LingⅡc型最高,为50%;LingⅠ型、LingⅡa和LingⅡb型分别为25%、20%和7.1%。结论 总的并发症发生率和气体相关并发症的发生率LingⅡc型最高,黏膜穿孔发生率LingⅡb型最高。     

术前应用抗生素预防经口内镜下肌切开术感染的临床效果

目的 探讨术前应用抗生素预防经口内镜下肌切开术(POEM)术后感染的临床效果。方法 前瞻性地连续选择2012年6月至2012年9月在我院消化内镜中心行POEM术患者20例,并随机分为抗生素组和对照组。20例患者均成功完成POEM术,且满足纳入和排除标准。抗生素组术9例术前0.5～1h给予静脉滴注头孢曲松钠2.0g,对照组11例则给予等量的0.9%氯化钠溶液静脉滴注。密切监测患者术后感染相关并发症发生及实验室指标变化情况。结果 20例患者于术后第1天白细胞计数、中性粒细胞比例、C反应蛋白量及体温,较术前均明显升高(P<0.01),术后第3天时基本恢复正常。两组术后均无出现感染及体温明显升高现象。相比之下,两组白细胞计数及中性粒细胞在术前1天,术后1、3、7天的变化趋势不同(P<0.05),且对照组在白细胞计数,中性粒细胞方面升高较抗生素组更明显(P<0.05)。而两组在体温及C反应蛋白变化趋势及升高情况方面差异并不显著(P>0.05)。结论 良好的术前准备和仔细的手术操作对预防POEM术后感染是十分重要的。在此基础上,术前应用抗生素对其并无明显的临床意义。但其最终结论尚需大样本进一步研究。     

经口内镜下肌切开术环形肌断端距离与贲门失弛缓症状缓解程度的关系

目的 探讨经口内镜下肌切开术(POEM)食管下括约肌离断后断端距离对贲门失弛缓症症状缓解程度的影响。方法 2010年12月至2012年6月33例贲门失弛缓患者按切开后断端距离大小分为两组,断端距离>0.6cm为A组,≤0.6cm为B组,比较两组间症状的Eckardt分值。结果 33例贲门失弛缓症患者行POEM术前症状Eckardt分值为6~9分,平均7.9分;术后分值为0~6分,平均2.2分。A组的Eckardt分值下降明显大于B组。结论 POEM缓解贲门失弛缓症状疗效确定。环形肌离断后断端距离大小对贲门失弛缓症状的缓解有一定的影响。     

海博刀在经口内镜下肌切开术治疗贲门失弛缓症中的临床应用

目的 探讨海博刀(O型)行经口内镜下肌切开术(POEM)治疗贲门失弛缓症(AC)的安全性和可行性。方法 2012年1~9月确诊为AC,并用海博刀行横开口法POEM的患者6例(海博刀组),男1例,女5例。选取同期用常规方法行POEM的患者29例(常规组)作为对照组。比较两组在手术相关时间及并发症等方面的差异。结果 海博刀组6例AC患者均顺利应用海博刀行POEM,中位年龄36.5岁(21~59岁),病程41.5个月(6~100个月)。术前Eckardt评分(8.2±1.8)分,术后评分(1.0±0.9)分,示症状明显缓解(P=0.0002)。海博刀组手术用时42~62min,平均(52.3±8.0)min,隧道建立时间25~35min,平均(28.8±3.9)min,纵行肌切开时间6~9min,平均(7.5±1.2)min。常规组手术时间46~97min,平均(63.0±12.9)min,隧道建立时间24~60min,平均(35.4±7.5)min,纵行肌切开时间4~18min,平均(10.0±3.0)min。海博刀组在整体手术、隧道建立和肌肉切开过程中明显快于常规组(P=0.020,P=0.001,P=0.005)。海博刀组术后无并发症发生,而常规组中,5例术后出现并发症(5/29,17.2%),其中2例黏膜穿孔(2/29,6.9%),1例颈部皮下气肿,1例颈部皮下气肿并纵隔及膈下少量游离气体,1例左侧气胸合并颈部皮下气肿。结论 初步表明用海博刀(O型)不仅能有效地行POEM,而且安全性更高,速度更快。但其最终结论仍需大样本研究进一步证明。     

经口内镜全层肌切开术与环形肌切开术治疗重症贲门失弛缓症的临床疗效

目的 比较经口内镜全层肌切开术与环形肌切开术治疗重症贲门失弛缓症(AC)的临床疗效.方法 回顾性分析2011年8月至2013年5月中南大学湘雅二医院收治的123例行经口内镜肌切开术(POEM)重症AC患者的临床资料.其中70例患者行全层肌切开设为全层肌切开组,53例患者行环形肌切开设为环形肌切开组.比较两种治疗方式的临床疗效及并发症发生情况.患者术后定期门诊随访,随访时间截至2014年5月.连续计量资料以i±s表示,采用t检验;非连续资料以M(范围)表示,采用Wilcoxon秩和检验;手术前后比较采用重复测量方差分析;定性资料比较采用x2检验.结果 所有重症AC患者成功行POEM,全层肌切开组手术时间为(57±8)min,短于环形肌切开组的(63±12) min,两组比较,差异有统计学意义(=3.421,P＜0.05).全层肌切开组与环形肌切开组患者并发症发生率分别为14.3％(10/70)、11.3％ (6/53),两组比较,差异无统计学意义(x2=0.234,P＞0.05).119例患者获得随访,中位随访时间为18个月(12 ～24个月).全层肌切开组患者术后6个月和12个月的中位Eckardt评分均为0分(0～3分),环形肌切开组分别为0分(0～2分)及0分(0～3分),两组患者治疗有效率分别为98.6％(69/70)和98.1％ (52/53),两组比较,差异无统计学意义(Z=0.525,1.476,x2=0.040,P＞0.05).全层肌切开组和环形肌切开组患者术后6个月的食管直径分别为(3.2±0.3)cm、(3.4±0.4)cm,两组比较,差异无统计学意义(江1.927,P＞0.05);均小于术前的(5.9±1.0)cm和(5.9±1.0)cm,手术前后比较,差异有统计学意义(F=780.923,493.018,P＜0.05).两组患者随访期间内无一例复发.结论 经口内镜全层肌切开术与环形肌切开术治疗重症AC患者的短期疗效相当,并发症发生率相似,但全层肌切开术可缩短手术时间.     

经口内镜肌切开术治疗贲门失弛缓症并发症的护理

对203例贲门失弛缓症患者行经口内镜肌切开术,术后出现纵隔及皮下气肿86例,气胸28例,膈下气体47例,迟发性出血1例,感染2例,均保守治疗痊愈;术后3～7 d出院,术后随访1～6个月,所有患者治疗效果满意,吞咽困难得到解除.提出术后密切观察,及时发现并处理纵隔及皮下气肿、气胸、膈下气体、出血、感染等并发症,可提高治疗效果,促使患者早日康复.     

经口内镜下肌切开术对贲门失弛缓症患者的食管动力学影响

目的评价经口内镜下肌切开术（POEM）对贲门失弛缓症患者的食管动力学影响。方法2011年9．11月间复旦大学附属中山医院内镜中心对20例贲门失弛缓症患者行POEM手术．所有患者于术前和术后第3天利用固态高分辨率胃肠动力学检查系统行食管动力学检查．分析手术前后食管下括约肌静息压（LESP）、食管下括约肌4s完全松弛压（4sIRP）、食管下括约肌松弛率（LESRR）、食管下括约肌长度（LESL）和食管体部收缩性和传导性的变化。结果POEM术后,LESP由术前的（29．1±17．0）mmHg下降为（14．6±4．9）mmHg,下降幅度为49．8％（P〈0．01）;4slRP由术前的（24．2±15．1）mmHg下降为（10．4±3．4）mmHg（P〈0．01）;但手术前后LESRR和LESL的差异无统计学意义（P〉0．05）。20例患者术前食管运动均缺少蠕动性收缩,术后有7例患者食管收缩运动发生了变化,甚至出现了蠕动,但仍达不到正常水平;其余13例患者的蠕动情况无明显变化。结论POEM术可显著降低贲门失弛缓症患者食管下括约肌压力和松弛压．但对食管的收缩运动却无明显影响。     

经口内镜下肌切开术、肉毒素注射和球囊扩张治疗贲门失弛缓症的随机对照研究

目的 通过随机对照的临床研究来对比经口内镜下肌切开术(POEM)、肉毒素注射(BTI)和球囊扩张(BD)治疗贲门失弛缓症的安全性和有效性。方法 2011年11月至2012年5月45例贲门失弛缓症患者被随机平均分配到POEM组、BTI组和BD组。对治疗后3个月的疗效和安全性进行对比分析。主要结果是症状缓解率,次要结果是并发症发生率、下食管括约肌压力(LESP)和食管最大宽度。结果 所有45例患者均成功进行了内镜下的治疗,并且治疗后3个月随访成功率为100%。症状缓解率POEM组为100%,BTI组为66.7%,BD组为93.3%,其中POEM组和BTI组两组间的差异有统计学意义(P<0.05),而POEM组与BD组、BD组与BTI组之间差异无统计学意义。并发症发生率POEM组为13.3%,BTI组为0,BD组为6.7%,但3组间的差异无统计学意义。LESP、食管最大宽度在3组之间比较,术前和术后的差异均无统计学意义。结论 治疗后3个月,POEM的症状缓解率高于BTI和BD,而并发症发生率3种方法相似。     

短隧道 POEM 术在治疗 Ling IIc 型贲门失弛缓症中的作用

目的：通过研究短隧道经口内镜下肌切开术（POEM）在治疗 Ling IIc 型贲门失弛缓症（AC）中的作用,为 POEM 术的术式探索及发展提供进一步的理论依据。方法回顾性的研究自2010年11月1日至2014年4月4日在解放军总医院消化内镜中心成功实施 POEM 的25例 Ling IIc型 AC 患者,将其根据隧道开口位置分为短隧道组（A 组）和标准隧道组（B 组）,并对比两组短期临床疗效、手术时间、隧道长度、肌切开长度及并发症情况。结果 A、B 两组（A 组14例,B 组11例）在术前 Eckardt 评分、术后体重增加值、隧道长度、肌切开长度方面均有统计学差异,术后 Eckardt 评分差异则不显著。术后共有5例患者发生气体相关并发症,其中 A 组1例（气腹＋皮下积气）,B 组4例（纵膈积气＋皮下积气1例、气胸＋皮下积气1例、单纯皮下积气2例）。结论针对 Ling IIc 型 AC 患者实施短隧道 POEM 术初步证实是安全有效的,但其最终结论尚需大样本研究予以证实。     

Anesthetic management of peroral endoscopic myotomy for esophageal achalasia: a retrospective case series

Peroral endoscopic myotomy (POEM) is a newly developed, less invasive treatment for esophageal achalasia that requires general anesthesia under positive pressure ventilation. In this retrospective case series, we describe the anesthetic management of 28 consecutive patients who underwent POEM for esophageal achalasia. Anesthesia was maintained with sevoflurane and remifentanil under positive pressure ventilation through a tracheal tube. Retained contents in the esophagus were evacuated just before anesthesia induction to prevent regurgitation into the trachea. The POEM procedure was performed using an orally inserted flexible fiberscope. Elevation of end-tidal carbon dioxide after initiating esophageal carbon dioxide insufflation was observed in all patients and was treated by minute adjustments to the ventilation volume. Scopolamine butylbromide-induced tachycardia in one patient was treated with landiolol hydrochloride, which is a short-acting beta 1-selective blocker. Minor subcutaneous emphysema around the neck was observed in one patient. POEM was successfully completed, and tracheas were extubated immediately after the procedure in all patients. Our findings suggest that prevention of aspiration pneumonia during anesthesia induction, preparation for carbon dioxide insufflation-related complications, and treatment of scopolamine butylbromide-induced tachycardia play important roles in safe anesthesia management of POEM for esophageal achalasia.     

Gastroesophageal reflux symptoms do not correlate with objective pH testing after peroral endoscopic myotomy

Introduction

Peroral endoscopic myotomy (POEM) is an emerging treatment for esophageal achalasia. Postoperative reflux has been found in a significant number of patients, but it is unknown whether subjective reports of reflux correlate with objective pH testing. The purpose of this study was to compare the objective rate of reflux with standardized reflux symptom scales after POEM. Our hypothesis was that subjective symptoms would not correlate with objective measurement of reflux.

Methods and procedures

Data on all patients undergoing POEM were collected prospectively between August 2012 and June 2014 and included demographics, objective testing (48-h pH probe, manometry, endoscopy), as well as gastroesophageal reflux disease health-related quality of life (GERD-HRQL), GERD symptom scale (GERSS), and antacid use.

Results

Forty-three patients underwent POEM during the study period. The mean age was 53.5 ± 17.4 years with a BMI of 29.6 ± 8.4 kg/m², and 27 (63%) were male. Forty-two patients (98%) completed at least 6 months of follow-up, and 26 (60%) underwent repeat pH measurement. Dysphagia scores improved from 4 (0–5) at baseline to 0 (0–3) (p < 0.001). On follow-up pH testing, 11 (42%) were normal and 15 (58%) had elevated DeMeester scores. Postoperative GERSS or GERD-HRQL scores did not correlate with DeMeester scores on Spearman’s rank-order tests (r = 0.02, p = 0.93 and r = 0.04, p = 0.50, respectively). Postoperative PPI use was not significantly associated with normal or abnormal pH testing: 5 of 7 (71%) patients who were taking PPIs postoperatively had abnormal DeMeester scores compared to 9 of 18 (50%) of patients who were not taking PPIs (p = 0.332).

Conclusions

Peroral endoscopic myotomy provides excellent dysphagia relief for patients with achalasia, but is associated with a high rate of reflux on pH testing postoperatively. Subjective symptoms are not a reliable indicator of postoperative reflux. Routine pH testing should be considered in all patients following POEM.

     

Anesthetic considerations for patients with esophageal achalasia undergoing peroral endoscopic myotomy: a retrospective case series review

Purpose

Peroral endoscopic myotomy (POEM) is a novel technique for treating esophageal achalasia. During POEM, carbon dioxide (CO₂) is insufflated to aid surgical dissection, but it may inadvertently track into surrounding tissues, causing systemic CO₂ uptake and tension capnoperitoneum. This in turn may affect cardiorespiratory function. This study quantified these cardiorespiratory effects and treatment by hyperventilation and percutaneous abdominal needle decompression (PND).

Methods

One hundred and seventy-three consecutive patients who underwent POEM were included in this four-year retrospective study. Procedure-related changes in peak inspiratory pressure (p_max), end-tidal CO₂ levels (etCO₂), minute ventilation (MV), mean arterial pressure (MAP), and heart rate (HR) were analyzed. We also quantified the impact of PND on these cardiorespiratory parameters.

Results

During the endoscopic procedure, cardiorespiratory parameters increased from baseline: p_max 15.1 (4.5) vs 19.8 (4.7) cm H₂O; etCO₂ 4.5 (0.4) vs 5.5 (0.9) kPa [34.0 (2.9) vs 41.6 (6.9) mmHg]; MAP 73.9 (9.7) vs 99.3 (15.2) mmHg; HR 67.6 (12.4) vs 85.3 (16.4) min^?1 (P < 0.001 for each). Hyperventilation [MV 5.9 (1.2) vs 9.0 (1.8) L·min^?1, P < 0.001] was applied to counteract iatrogenic hypercapnia. Individuals with tension capnoperitoneum treated with PND (n = 55) had higher peak p_max values [22.8 (5.7) vs 18.4 (3.3) cm H₂O, P < 0.001] than patients who did not require PND. After PND, p_max [22.8 (5.7) vs 19.9 (4.3) cm H₂O, P = 0.045] and MAP [98.2 (16.3) vs 88.6 (11.8) mmHg, P = 0.013] decreased. Adverse events included pneumothorax (n = 1), transient myocardial ischemia (n = 1), and subcutaneous emphysema (n = 49). The latter precluded immediate extubation in eight cases. Postanesthesia care unit (PACU) stay was longer in individuals with subcutaneous emphysema than in those without [74.9 min (34.5) vs 61.5 (26.8 min), P = 0.007].

Conclusion

Carbon dioxide insufflation during POEM produces systemic CO₂ uptake and increased intra-abdominal pressure. Changes in cardiorespiratory parameters include increased p_max, etCO₂, MAP, and HR. Hyperventilation and PND help mitigate some of these changes. Subcutaneous emphysema is common and may delay extubation and prolong PACU stay.

     

内镜下食管环形肌切开术治疗贲门失弛缓症的护理

对12例贯门失弛缓症患者行内镜下食管环行肌切开术,全部顺利完成治疗,治疗后3d进流质饮食无吞咽梗阻,有效率100％,无严重并发症发生.随访6～9个月,仅1例患者2个月后出现轻度吞咽困难.提出内镜下食管环形肌切开术是治疗贲门失弛缓症的一种安全、有效、恢复快、并发症少的新型治疗方法;内镜治疗前做好评估、食管准备,治疗中密切观察病情、准确传递器械,治疗后加强生命体征监测、做好饮食护理及预防并发症护理,是取得满意疗效的重要保证.