Lynch K L, Yang Y-X, Metz D C, Falk G W
Department of Internal Medicine, Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
Dis Esophagus. 2017 Jun 1;30(6):1-6. doi: 10.1093/dote/dox004.
Esophagogastric junction outflow obstruction, characterized by preserved peristalsis in conjunction with an elevated integrated relaxation pressure, can result from specific anatomic variants or may represent achalasia in evolution. There is limited information on the clinical significance of this diagnosis. The aim of this study is to describe the clinical characteristics and outcomes in our cohort of patients with esophagogastric junction outflow obstruction.Consecutive adult patients who had undergone high-resolution esophageal manometry between February 2013 and November 2015 with a diagnosis of esophagogastric junction outflow obstruction were identified. Electronic medical records were reviewed to determine: (1) secondary causes of esophagogastric junction outflow obstruction; (2) treatment; and (3) natural history. Improvement in symptoms noted during follow-up evaluation was considered to be a favorable outcome. Worsening of symptoms or no change in symptoms was considered to be an unfavorable outcome.Of 874 manometries performed during this time period, 83 met the criteria for esophagogastric junction outflow obstruction. Of these patients, 11 had secondary causes: paraesophageal hernia (4), Nissen fundoplication (2), esophageal stricture (3), prior laparoscopic band placement (1), and diverticulum (1). All of these secondary causes were identified by barium esophagram. The remaining 72 patients were categorized as idiopathic esophagogastric junction outflow obstruction. Two patients developed type II achalasia on follow-up. An additional two patients had no symptoms as testing was performed for preoperative evaluation prior to bariatric surgery, leaving 68 patients for symptom follow-up analysis. Of these, 19 had a favorable outcome, 18 had an unfavorable outcome, and 31 were lost to follow-up. Of those with a favorable outcome, 6 patients underwent treatment: medication (3), botulinum toxin injection followed by laparoscopic Heller myotomy (1), botulinum toxin injection and medication (1), and bougie dilation (1). Of the 18 patients with an unfavorable outcome, 6 patients underwent treatment: botulinum toxin injection (5) and medication (1). Computed tomography scan or endoscopic ultrasound was performed in 40% of patients with available follow-up and none of these studies revealed secondary causes. The overall median follow-up time was 5 months.Esophagogastric outflow obstruction is a manometric finding of unclear significance. Secondary causes should first be excluded with structural studies. The evolution of esophagogastric junction outflow obstruction to achalasia is rare. Symptoms in patients with esophagogastric junction outflow obstruction do not always require treatment and treatment response is variable. The challenge in managing these patients lies in distinguishing which patients will need intervention. Further studies are needed for consideration of subgrouping this disease or modifying the categorization into clinically relevant entities.
食管胃交界部流出道梗阻的特征是蠕动保留且综合松弛压升高，可由特定的解剖变异引起，也可能代表处于演变过程中的贲门失弛缓症。关于这一诊断的临床意义的信息有限。本研究的目的是描述我们队列中食管胃交界部流出道梗阻患者的临床特征和结局。
确定了2013年2月至2015年11月期间接受高分辨率食管测压且诊断为食管胃交界部流出道梗阻的连续成年患者。查阅电子病历以确定：（1）食管胃交界部流出道梗阻的继发原因；（2）治疗方法；（3）自然病程。随访评估期间症状的改善被认为是良好结局。症状恶化或症状无变化被认为是不良结局。
在此期间进行的874次测压中，83次符合食管胃交界部流出道梗阻的标准。在这些患者中，11例有继发原因：食管旁疝（4例）、nissen胃底折叠术（2例）、食管狭窄（3例）、既往腹腔镜束带置入术（1例）和憩室（1例）。所有这些继发原因均通过食管钡餐造影确定。其余72例患者被归类为特发性食管胃交界部流出道梗阻。2例患者在随访中发展为II型贲门失弛缓症。另外2例患者因在减肥手术前进行术前评估而无症状，因此有68例患者进行症状随访分析。其中，19例有良好结局，18例有不良结局，31例失访。在有良好结局的患者中，6例接受了治疗：药物治疗（3例）、肉毒杆菌毒素注射后行腹腔镜Heller肌切开术（1例）、肉毒杆菌毒素注射和药物治疗（1例）以及探条扩张术（1例）。在18例有不良结局的患者中，6例接受了治疗：肉毒杆菌毒素注射（5例）和药物治疗（1例）。40%有可用随访结果的患者进行了计算机断层扫描或内镜超声检查，这些检查均未发现继发原因。总体中位随访时间为5个月。
食管胃流出道梗阻是一种意义不明确的测压结果。应首先通过结构研究排除继发原因。食管胃交界部流出道梗阻演变为贲门失弛缓症的情况很少见。食管胃交界部流出道梗阻患者的症状并非总是需要治疗，且治疗反应因人而异。管理这些患者的挑战在于区分哪些患者需要干预。需要进一步研究以考虑对该疾病进行亚组分类或修改分类以使其成为临床相关的实体。
