Vela Marcelo F, Richter Joel E, Khandwala Farah, Blackstone Eugene H, Wachsberger Don, Baker Mark E, Rice Thomas W
Department of Gastroenterology, Center for Swallowing and Esophageal Disorders, The Cleveland Clinic Foundation, Cleaveland, Ohio, USA.
Clin Gastroenterol Hepatol. 2006 May;4(5):580-7. doi: 10.1016/s1542-3565(05)00986-9.
BACKGROUND & AIMS: Studies comparing long-term success after pneumatic dilatation (PD) and laparoscopic Heller myotomy (HM) are lacking. This study compares long-term outcome of PD (single dilatation and graded approach) and laparoscopic HM and identifies risk factors for treatment failure.
A cross-sectional follow-up evaluation of an achalasia cohort treated between 1994 and 2002 was followed-up for a mean of 3.1 years. There was a total of 106 patients treated by graded PD (1-3 dilatations with progressively larger balloons) and 73 patients treated by HM (20 had failed graded PD and crossed over to HM). A symptom assessment (structured telephone interview or clinic visit) was performed and patients were given freedom from alternative therapies to determine treatment outcome. Endoscopy, manometry, and timed barium esophagram were performed to determine the cause of treatment failure.
The success of single PD was defined as freedom from additional PDs: 62% at 6 months and 28% at 6 years (risk factors for failure: younger age, male sex, wider esophagus, and poor emptying on posttreatment timed barium esophagram). Freedom from subsequent PDs increased with each dilatation (graded PD). The success of graded PD and HM, defined as dysphagia/regurgitation less than 3 times/wk or freedom from alternative treatment, was similar: 90% vs 89% at 6 months and 44% vs 57% at 6 years (no risk factors for failure were identified). Causes of symptom recurrence were incompletely treated achalasia (96% after PD vs 64% after HM) and gastroesophageal reflux disease (4% after PD vs 36% after HM).
No treatment cures achalasia. Short- and long-term success is similar for graded PD and laparoscopic HM. Therapeutic success decreases steadily over time. Achalasia patients need careful long-term follow-up evaluation.
缺乏比较气囊扩张术（PD）和腹腔镜下贲门肌切开术（HM）后长期成功率的研究。本研究比较了PD（单次扩张和分级扩张法）与腹腔镜下HM的长期疗效，并确定治疗失败的危险因素。
对1994年至2002年间治疗的一组贲门失弛缓症患者进行横断面随访评估，平均随访3.1年。共有106例患者接受分级PD治疗（1 - 3次扩张，使用逐渐增大的球囊），73例患者接受HM治疗（其中20例分级PD治疗失败后转而接受HM治疗）。进行症状评估（结构化电话访谈或门诊就诊），并记录患者无需接受其他治疗的情况以确定治疗效果。进行内镜检查、测压和定时钡餐食管造影以确定治疗失败的原因。
单次PD的成功定义为无需再次进行PD：6个月时成功率为62%，6年时为28%（失败的危险因素：年龄较小、男性、食管较宽以及治疗后定时钡餐食管造影显示排空不良）。随着每次扩张（分级PD），无需后续PD的成功率增加。分级PD和HM的成功定义为吞咽困难/反流每周少于3次或无需接受其他治疗，两者相似：6个月时分别为90%和89%，6年时分别为44%和57%（未发现失败的危险因素）。症状复发的原因是贲门失弛缓症治疗不彻底（PD后为96%，HM后为64%）和胃食管反流病（PD后为4%，HM后为36%）。
没有哪种治疗方法能治愈贲门失弛缓症。分级PD和腹腔镜下HM的短期和长期成功率相似。治疗成功率随时间稳步下降。贲门失弛缓症患者需要仔细的长期随访评估。
