Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.
Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
Surg Endosc. 2024 Feb;38(2):659-670. doi: 10.1007/s00464-023-10571-3. Epub 2023 Nov 27.
Laparoscopic Heller's myotomy (LHM) is an established treatment for achalasia cardia. Anti-reflux procedures (ARP) are recommended with LHM to reduce the post-operative reflux though the optimal anti-reflux procedure is still debatable. This study reports on the long-term outcomes of LHM with Angle-of-His accentuation (AOH) in patients of achalasia cardia.
One hundred thirty-six patients of achalasia cardia undergoing LHM with AOH between January 2010 to October 2021 with a minimum follow-up of one year were evaluated for symptomatic outcomes using Eckardt score (ES), DeMeester heartburn (DMH) score and achalasia disease specific quality of life (A-DsQoL) questionnaire. Upper gastrointestinal endoscopy, high resolution manometry (HRM) and timed barium esophagogram (TBE) were performed when feasible and rates of esophagitis and improvement in HRM and TBE parameters evaluated. Time dependent rates of success were calculated with respect to improvement in ES and dysphagia-, regurgitation- and heartburn-free survival using Kaplan-Meier analysis.
At a median follow-up of 65.5 months, the overall success (ES ≤ 3) was 94.1%. There was statistically significant improvement in ES, heartburn score and A-DsQoL score (p < 0.00001, p = 0.002 and p < 0.00001). Significant heartburn (score ≥ 2) was seen in 12.5% subjects with 9.5% patients reporting frequent PPI use (> 3 days per week). LA-B and above esophagitis was seen in 12.7%. HRM and TBE parameters also showed a significant improvement as compared to pre-operative values (IRP: p < 0.0001, column height: p < 0.0001, column width: p = 0.0002). Kaplan-Meier analysis showed dysphagia, regurgitation, and heartburn free survival of 75%, 96.2% and 72.3% respectively at 10 years.
LHM with AOH gives a lasting relief of symptoms in patients of achalasia cardia with heartburn rates similar to that reported in studies using Dor's or Toupet's fundoplication with LHM. Hence, LHM with AOH may be a preferred choice in patients of achalasia cardia given the simplicity of the procedure.
腹腔镜 Heller 肌切开术（LHM）是治疗贲门失弛缓症的一种既定方法。尽管抗反流手术（ARP）被推荐与 LHM 联合使用以降低术后反流，但最佳的抗反流手术仍存在争议。本研究报告了 LHM 联合食管胃角（Angle-of-His，AOH）在贲门失弛缓症患者中的长期疗效。
2010 年 1 月至 2021 年 10 月期间，我们对 136 例接受 LHM 联合 AOH 治疗的贲门失弛缓症患者进行了评估，这些患者的随访时间至少为 1 年，采用 Eckardt 评分（ES）、DeMeester 烧心评分（DMH）和贲门失弛缓症特异性生活质量问卷（A-DsQoL）评估症状改善情况。当可行时进行上消化道内镜、高分辨率测压（HRM）和时间分辨钡食管造影（TBE）检查，并评估食管炎的发生率以及 HRM 和 TBE 参数的改善情况。通过 Kaplan-Meier 分析计算 ES 改善和吞咽困难、反流和烧心无症状生存的时间依赖性成功率。
中位随访 65.5 个月时，整体成功率（ES≤3）为 94.1%。ES、烧心评分和 A-DsQoL 评分均有统计学显著改善（p<0.00001、p=0.002 和 p<0.00001）。12.5%的患者存在明显烧心（评分≥2），9.5%的患者报告经常使用质子泵抑制剂（每周>3 天）。LA-B 及以上食管炎发生率为 12.7%。与术前相比，HRM 和 TBE 参数也有显著改善（IRP：p<0.0001、柱高：p<0.0001、柱宽：p=0.0002）。Kaplan-Meier 分析显示，10 年后患者的吞咽困难、反流和烧心无症状生存分别为 75%、96.2%和 72.3%。
LHM 联合 AOH 可持久缓解贲门失弛缓症患者的症状，烧心发生率与 LHM 联合 Dor 或 Toupet 胃底折叠术报道的相似。因此，鉴于该手术的简单性，LHM 联合 AOH 可能是贲门失弛缓症患者的首选治疗方法。
