Salvador Renato, Provenzano Luca, Capovilla Giovanni, Briscolini Dario, Nicoletti Loredana, Valmasoni Michele, Moletta Lucia, Merigliano Stefano, Costantini Mario
Department of Surgical, Oncological and Gastroenterological Sciences, School of Medicine, University of Padova, Padova, Italy.
J Laparoendosc Adv Surg Tech A. 2020 Feb;30(2):97-102. doi: 10.1089/lap.2019.0035. Epub 2019 Mar 20.
Achalasia is currently classified in three manometric patterns. Pattern III is the least common pattern, and reportedly correlated with the worst outcome after all available treatments. We aimed to investigate the final outcome in pattern III achalasia patients after classic laparoscopic myotomy (CLM) as compared with a myotomy lengthened both downward and upward (long laparoscopic myotomy [LLM]). The study population consisted of 61 consecutive patients with a diagnosis of pattern III achalasia who underwent laparoscopic myotomy between 1997 and 2017. In CLM the total length of the myotomy was ≤9 cm, whereas myotomies extending both downward and upward to a length >9 cm were defined as LLM. Of the 61 patients considered, 24 had CLM and 37 had LLM. The postoperative improvement in symptom score differed between the two groups: it dropped from 22 (17-26) to 4 (0-8) in the CLM group and from 20 (17-24) to 3 (0-6) in the LLM group ( < .001). There were 8 of 24 failures (33.3%) in the former group and 4 of 37 (10.8%) in the latter group ( < .05). An abnormal acid exposure was detected after the treatment of CLM in 4 patients and after the treatment of LLM in 3 patients ( = n.s.). Although with the intrinsic limitations of this study (retrospective, different time windows of the two procedures, and different lengths of follow-up), the results indicate that extending the myotomy both downward and upward improves the final outcome of laparoscopic Heller-Dor surgery in pattern III achalasia patients. A longer myotomy does not affect any onset of postoperative gastroesophageal reflux.
贲门失弛缓症目前分为三种测压模式。模式III是最不常见的模式，据报道在所有可用治疗后其预后最差。我们旨在研究经典腹腔镜肌切开术（CLM）与向下和向上延长的肌切开术（长腹腔镜肌切开术[LLM]）相比，模式III贲门失弛缓症患者的最终结局。研究人群包括1997年至2017年间连续61例诊断为模式III贲门失弛缓症并接受腹腔镜肌切开术的患者。在CLM中，肌切开术的总长度≤9厘米，而向下和向上延伸至长度>9厘米的肌切开术被定义为LLM。在纳入研究的61例患者中，24例行CLM，37例行LLM。两组术后症状评分改善情况不同：CLM组从22（17-26）降至4（0-8），LLM组从20（17-24）降至3（0-6）（<0.001）。前一组24例中有8例失败（33.3%），后一组37例中有4例失败（10.8%）（<0.05）。CLM治疗后检测到4例患者有异常酸暴露，LLM治疗后检测到3例患者有异常酸暴露（P=无显著差异）。尽管本研究存在固有局限性（回顾性研究、两种手术的时间窗口不同以及随访时间不同），但结果表明，向下和向上延长肌切开术可改善模式III贲门失弛缓症患者腹腔镜Heller-Dor手术的最终结局。更长的肌切开术不会影响术后胃食管反流的发生。
