Beckingham I J, Callanan M, Louw J A, Bornman P C
Surgical Gastroenterology, Gastrointestinal Clinic, E23, Groote Schuur Hospital, Observatory 7925, Cape Town, South Africa.
Surg Endosc. 1999 May;13(5):493-6. doi: 10.1007/s004649901020.
This study was designed to determine the feasibility and outcome of laparoscopic cardiomyotomy in patients with achalasia who have persistent or recurrent dysphagia following balloon dilatation.
Ten patients who had undergone a minimum of two (range, two to seven) previous balloon dilatations underwent a single anterior cardiomyotomy extending from the gastroesophageal junction onto the esophagus proximally for 6 cm. Four patients had a Toupet fundoplication. Patients were analyzed using pre- and postoperative DeMeester symptom scores for dysphagia, regurgitation, and heartburn (0 = none-3 = maximal) and esophageal manometry.
Mean operating time was 90 min. Periesophagitis was noted in some patients but was rarely troublesome. Submucosal fibrosis was present in all patients and made dissection more difficult particularly around the cardioesophageal junction. As a result, three patients had mucosal perforations that required repair by laparoscopic suturing. There were no subsequent postoperative complications. Median (IQR) postoperative stay was 3 (2-4) days. At 3-month reassessment, there was a reduction in the median dysphagia score from 3 to 0, and also in the regurgitation score from 3 to 0. At last follow-up (median, 22 months), one patient had developed recurrent dysphagia (grade 2), which improved with dilatation. Overall success of the laparoscopic procedure was therefore 90%. Only one patient developed new symptoms of reflux (mild, grade 1) after surgery.
Laparoscopic cardiomyotomy provides good control of the symptoms of dysphagia and regurgitation without the morbidity of a laparotomy or thoracotomy incision. Although technically more difficult, the technique can be extended to those who have had previous balloon dilatation with complication and success rates similar to published results in patients who have not undergone previous dilatation.
本研究旨在确定在贲门失弛缓症患者中，经球囊扩张后仍有持续性或复发性吞咽困难时，腹腔镜下贲门肌切开术的可行性及疗效。
10例患者此前至少接受过两次（范围为2至7次）球囊扩张，接受了单次前位贲门肌切开术，从胃食管交界处向食管近端延伸6厘米。4例患者进行了Toupet胃底折叠术。使用术前和术后的DeMeester症状评分来分析患者的吞咽困难、反流和烧心症状（0 = 无 - 3 = 最严重），并进行食管测压。
平均手术时间为90分钟。部分患者出现食管周围炎，但很少造成困扰。所有患者均存在黏膜下纤维化，这使得解剖更加困难，尤其是在贲门食管交界处周围。结果，3例患者出现黏膜穿孔，需要通过腹腔镜缝合进行修复。术后无其他并发症。术后中位住院时间为3（2 - 4）天。在3个月的复查中，吞咽困难评分中位数从3降至0，反流评分也从3降至0。在最后一次随访（中位时间为22个月）时，1例患者出现复发性吞咽困难（2级），经扩张后改善。因此，腹腔镜手术的总体成功率为90%。术后只有1例患者出现了新的反流症状（轻度，1级）。
腹腔镜贲门肌切开术能有效控制吞咽困难和反流症状，且无开腹或开胸手术的并发症。尽管技术上更具挑战性，但该技术可应用于既往球囊扩张出现并发症的患者，其成功率与未接受过先前扩张的患者的已发表结果相似。
