Migliore M, Payne H R, Jeyasingham K
Department of Thoracic Surgery, Frenchay Hospital, Bristol, UK.
Eur J Cardiothorac Surg. 1996;10(5):365-71. doi: 10.1016/s1010-7940(96)80096-0.
High or pharyngo-oesophageal dysphagia (PD) is defined as difficulty in initiating the act of swallowing within 1s. It involves the mechanisms controlling the tongue, pharynx and upper oesophageal sphincter (UOS) and is associated with a wide variety of local, neurologic and muscular disorders, and can also occur after surgery in the area and in response to gastro-oesophageal reflux (GOR). Our study aims at defining the criteria for surgery in PD and to evaluate the clinical results of such treatment. Twenty-three patients who underwent surgery were evaluated with pharyngo-oesophageal motility and ambulatory 24-hr pH-metry. The following parameters were measured: 1) pharyngeal contraction amplitude, 2) duration, 3) repetitive pharyngeal contractions, 4) UOS tone, 5) percentage of UOS relaxation, 6) duration of relaxation, 7) UOS closing pressure, 8) UOS closing duration, 9) co-ordination of UOS closing pressure and upper oesophageal (UO) contractions. Preoperative manometry showed a variety of abnormalities in several of the parameters, such as prolonged pharyngeal contraction ("spasm"), unco-ordinated pharyngeal contractions and UOS relaxation, low amplitude pharyngeal contractions, unco-ordinated UOS closing tone and UO contractions and hypotonic UO. Surgery was directed at the specific abnormality in each patient taking into consideration the presence or absence of GOR. Seventeen patients (74%) had excellent results. Three other patients (13%), who had improved swallowing but who continued to have GOR complicated by some oesophageal dysmotility, oesophagitis and an oesophageal web, underwent subsequent anti-reflux surgery with relief of symptoms. In conclusion, pharyngo-oesophageal motility measurement is mandatory in PD, especially when a diverticulum is absent. Cricopharyngeal myotomy with or without diverticulectomy as indicated produces excellent results. Associated oesophageal problems have to be dealt with appropriately.
高位或咽食管吞咽困难（PD）被定义为在1秒内开始吞咽动作困难。它涉及控制舌头、咽部和食管上括约肌（UOS）的机制，与多种局部、神经和肌肉疾病相关，也可在该区域手术后以及对胃食管反流（GOR）的反应中出现。我们的研究旨在确定PD的手术标准并评估这种治疗的临床效果。对23例接受手术的患者进行了咽食管动力和24小时动态pH监测评估。测量了以下参数：1）咽部收缩幅度，2）持续时间，3）重复性咽部收缩，4）UOS张力，5）UOS松弛百分比，6）松弛持续时间，7）UOS关闭压力，8）UOS关闭持续时间，9）UOS关闭压力与食管上段（UO）收缩的协调性。术前测压显示几个参数存在多种异常，如咽部收缩延长（“痉挛”）、咽部收缩与UOS松弛不协调、咽部收缩幅度低、UOS关闭张力与UO收缩不协调以及UO张力减退。手术针对每位患者的特定异常情况，同时考虑是否存在GOR。17例患者（74%）效果极佳。另外3例患者（13%）吞咽功能有所改善，但仍有GOR，并伴有一些食管动力障碍、食管炎和食管蹼，随后接受了抗反流手术，症状得到缓解。总之，在PD中，尤其是不存在憩室时，咽食管动力测量是必要的。根据需要进行的环咽肌切开术加或不加憩室切除术效果极佳。相关的食管问题必须妥善处理。
