腹腔镜食管肌切开术治疗 60 岁以上贲门失弛缓症的疗效分析。
Excellent outcomes of laparoscopic esophagomyotomy for achalasia in patients older than 60 years of age.
机构信息
Department of Surgery, University of California San Francisco, 521 Parnassus Avenue, Room C-347, San Francisco, CA 94143, USA.
出版信息
Surg Endosc. 2010 Oct;24(10):2562-6. doi: 10.1007/s00464-010-1003-4. Epub 2010 Apr 2.
BACKGROUND
The effectiveness of an esophagomyotomy for dysphagia in elderly patients with achalasia has been questioned. This study was designed to provide an answer.
METHODS
A total of 162 consecutive patients with achalasia who had a laparoscopic myotomy and Dor fundoplication and who were available for follow-up interview were divided by age: < 60 years (range, 14-59; 118 patients), and ≥ 60 years (range, 60-93; 44 patients). Primary outcome measures were severity of dysphagia, regurgitation, heartburn, and chest pain before and after the operation as assessed on a four-point Likert scale, and the need for postoperative dilatation or revisional surgery.
RESULTS
Follow-up averaged 64 months. Older patients had less dysphagia (mean score 3.6 vs. 3.9; P < 0.01) and less chest pain (1.0 vs. 1.8; P < 0.01). Regurgitation (3.0 vs. 3.2; P = not significant (NS)) and heartburn (1.6 vs. 2.0, P = NS) were similar. Older patients were no different in degree of esophageal dilation, manometric findings, number of previous pneumatic dilatations, or previous botulinum toxin therapy. None of the older patients had previously had an esophagomyotomy, whereas 14% of younger patients had (P < 0.01). After laparoscopic myotomy, older patients had better relief of dysphagia (mean score 1.0 vs 1.6; P < 0.01), less heartburn (0.8 vs. 1.1; P = 0.03), and less chest pain (0.2 vs. 0.8, P < 0.01). Complication rates were similar. Older patients did not require more postoperative dilatations (22 patients vs. 10 patients; P = 0.7) or revisional surgery for recurrent or persistent symptoms (3 vs. 1 patients; P = 0.6). Satisfaction scores did not differ, and more than 90% of patients in both groups said in retrospect they would have undergone the procedure if they had known beforehand how it would turn out.
CONCLUSIONS
This retrospective review with long follow-up supports laparoscopic esophagomyotomy as first-line therapy in older patients with achalasia. They appeared to benefit even more than younger patients.
背景
食管肌切开术治疗老年贲门失弛缓症患者的吞咽困难的效果受到质疑。本研究旨在提供一个答案。
方法
总共 162 例连续接受腹腔镜肌切开术和 Dor 胃底折叠术的贲门失弛缓症患者，可进行随访访谈，按年龄分为<60 岁（范围 14-59；118 例）和≥60 岁（范围 60-93；44 例）。主要观察指标为术前和术后 4 分制 Likert 量表评估的吞咽困难、反流、烧心和胸痛的严重程度，以及术后扩张或再次手术的需要。
结果
平均随访 64 个月。老年患者的吞咽困难程度较轻（平均评分 3.6 对 3.9；P<0.01），胸痛程度较轻（1.0 对 1.8；P<0.01）。反流（3.0 对 3.2；P=无显著性差异（NS））和烧心（1.6 对 2.0，P=NS）相似。老年患者食管扩张程度、测压结果、既往气囊扩张次数或既往肉毒毒素治疗无差异。没有老年患者以前接受过食管肌切开术，而年轻患者中有 14%（P<0.01）。腹腔镜肌切开术后，老年患者吞咽困难缓解更好（平均评分 1.0 对 1.6；P<0.01），烧心减少（0.8 对 1.1；P=0.03），胸痛减少（0.2 对 0.8，P<0.01）。并发症发生率相似。老年患者不需要更多的术后扩张（22 例对 10 例；P=0.7）或因复发或持续症状而进行再次手术（3 例对 1 例；P=0.6）。满意度评分无差异，两组患者中超过 90%的患者表示，回想起来，如果他们事先知道手术结果，他们会选择接受手术。
结论
本研究为回顾性研究，随访时间较长，支持腹腔镜食管肌切开术作为老年贲门失弛缓症患者的一线治疗方法。他们似乎比年轻患者获益更多。
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