贲门失弛缓症治疗的现状和进展

贲门失弛缓症尚无根治的方法,但90%以上的患者经积极治疗后可得到缓解。对于初发贲门失弛缓症患者,临床症状轻,可通过调整饮食习惯及药物治疗缓解症状,随着时间的延长,病情逐渐加重,药物治疗不满意时,可行内镜下治疗。内镜下球囊扩张治疗、BT注射治疗及暂时性支架置入治疗,均具有良好的短期疗效和安全性,但长期疗效暂时性支架置入治疗优于扩张治疗,扩张治疗优于BT注射治疗。对老年患者、不能行扩张或手术者,可予内镜下BT注射治疗。POEM作为一种新技术,具有较好的发展前景。手术治疗创伤大,费用高,但是对于扩张治疗失败或需多次扩张治疗的患者,手术治疗是一种有效的治疗方式。本文就贲门失弛缓症的治疗现状及进展作此综述,旨在为患者寻找一种个性化、有效、创伤小、费用低的治疗方式。     

胸腔镜联合胃镜微创治疗贲门失驰症

目的探讨胸腔镜与胃镜联合在贲门失驰症患者治疗中的应用与效果。方法抽选我院收治的65例贲门失驰症患者作为观察对象,均给予其胸腔镜与胃镜联合治疗,观察其治疗效果。结果术后吞咽困难程度评分、吞咽困难频率评分与LESP、食管最大宽度显著低于术前,比较差异显著(P0.05)。结论针对临床贲门失驰症患者,给予其胸腔镜与胃镜联合治疗,可明显改善患者情况,效果显著,值得临床推广应用。     

青少年注射性臀肌挛缩症手术治疗分析

目的：探讨臀肌挛缩松解术结合术后康复训练治疗青少年注射性臀肌挛缩症的临床疗效。方法：对97例青少年注射性臀肌挛缩症患者行臀肌挛缩松解术治疗,结合术后康复训练,术后随访10月～46月,平均33个月,临床疗效根据黄耀添评价标准评定。结果：所有患者中：优75例,良13例,可8例,差1例,优良率为90.7%。结论：对于青少年注射性臀肌挛缩患者,手术彻底松解挛缩组织,减少创伤,结合术后有效的康复训练,可获得满意疗效。     

针刺联合红外线照射治疗腰椎间盘突出症的随机对照研究

目的：评价针刺联合红外线照射治疗腰椎间盘突出症的临床疗效。方法：选择2010 年9 月～2012 年1 月我院收治的90 例 腰椎间盘突出症患者为研究对象,并将其随机分为对照组和治疗组,每组45 例。对照组患者给予药物治疗,而治疗组患者给予针 刺联合红外线照射治疗,治疗后评价和比较两组患者的临床疗效及腰腿痛的改善情况。结果：针刺联合红外线照射治疗腰椎间盘 突出症显效率为62.2%,药物组显效率为26.7%,两组有显著性差异(Ｐ<0.05)。治疗后,治疗组患者腰腿痛疼痛评分明显低于对照 组,差异有统计学意义(P<0.01)。结论：以针刺联合红外线照射治疗腰椎间盘突出症的临床疗效肯定,值得临床推广。     

腹腔镜与开腹术治疗120例门脉高压症患者的临床效果研究

目的:对比分析完全腹腔镜与开腹脾切除加贲门周围血管离断术治疗肝硬化门脉高压症的手术治疗效果。方法:120例研究对象均来自于2012年1月-2013年12月第四军医大学唐都医院普外科收治的肝硬化门静脉高压患者,将所有患者分为观察组与对照组,每组60例。两组患者均给予脾切除加贲门周围血管离断术,观察组在腹腔镜下操作完成,对照组传统开腹完成手术。比较两组患者术中出血量、手术及住院时间、胃肠道功能恢复时间及并发症发生情况。结果:120例患者均按分组要求顺利完成手术,手术时间比较无统计学差异(P0.05);观察组术中出血量、术后住院时间及胃肠道恢复排气时间均优于对照组(P0.05);术后发热、切口感染、腹腔出血积液及门静脉系统血栓等为术后常见并发症,观察组术后并发症发生率低于对照组(P0.05)。结论:腹腔镜下脾切除+贲门周期血管离断术治疗门静脉高压症临床效果显著,安全性高,患者术后恢复快。     

PCI术后是否抗凝治疗的临床疗效比较

目的：研究PCI术后是否应用依诺肝素抗凝治疗对患者临床疗效的影响。方法：于2011年5月至2012年1月间,连续入选在我院行冠状动脉造影并置入了支架的患者158例,将符合标准的患者随机分为非抗凝组或抗凝组两组各79名。非抗凝组术后常规应用阿司匹林和氯吡格雷。抗凝组术后加用依诺肝素。对入选患者进行院内随访记录其主要心脏不良事件及出血事件。结果：支架植入成功率100%。术后抗凝组113处病变共置入支架135枚;非抗凝组109处病变置入支架115枚。院内随访：主要心脏不良事件和严重出血差异无统计学意义。小出血事件抗凝组多于非抗凝组（P=0.007）。结论：冠状动脉支架置入术后非抗凝治疗组缺血不良事件发生率较抗凝组无明显增加,小出血并发症明显减少。该研究结果表明,对PCI术无特殊并发症的患者术后无需常规抗凝治疗。     

探条扩张术治疗食管贲门狭窄69例分析

食管贲门良恶性狭窄病变是临床常见疾病,我院及镇江市江滨医院自2004年3月至2009年12月,采用探条扩张术治疗食管贲门狭窄患者69例,取得了良好的疗效,现报告如下。     

外固定支架及开放手术治疗肘关节严重异位骨化疗效分析

目的:探讨外固定支架及开放手术治疗治疗肘关节严重异位骨化的方法及疗效。方法:自2007年9月至2012年9月,对18例(其中男13例女5例,平均年龄33.5岁)创伤后严重异位骨化性肘关节僵硬患者进行开放手术及外固定支架治疗。所有患者均采用相同的手术方式,即取出原有内固定,前置尺神经,松解关节囊粘连,清除异位骨化。对患者肘关节屈伸范围术前及术后均评估,采用Mayo肘关节评分肘关节功能(MEPI)评估疗效。术后予以指导康复锻炼。结果:术后患者的屈伸分别平均增加到125°和10°,MEPI评分由术前的平均50分提高到术后的90分。结论:外固定支架及开放手术治疗治疗严重异位骨化性肘关节僵硬具有确切的疗效。     

支架置入术治疗椎动脉起始段狭窄的临床疗效及术后支架内再狭窄的影响因素分析

摘要 目的：研究支架置入术（SI）治疗椎动脉起始段狭窄（VAOS）的临床疗效及术后支架内再狭窄（ISR）的影响因素。方法：选择从2018年1月到2020年2月在我院接受SI治疗的VAOS患者83例纳入本次研究。剔除1例手术失败及1例死亡患者的病例后,对剩余81例患者根据患者是否发生ISR,将其分成ISR组28例和无ISR组53例。随访分析患者的临床疗效,对患者发生ISR进行单因素及多因素Logistic回归分析,同时分析患者美国国立卫生院卒中量表（NIHSS）评分与血管狭窄情况及血流动力学指标的相关性。结果：83例VAOS患者接受SI术式治疗后,手术成功率为98.80%（82/83）。术后有3例患者发生动脉痉挛,另有1例患者在术后7 d由于继发脑出血而死亡,并发症的总发生率为4.82%（4/83）。ISR组的高脂血症、合并颈内动脉的狭窄、椎动脉的狭窄部位为双侧、支架类型为裸支架的比例分别高于无ISR组（均P＜0.05）。根据Pearson法分析相关性显示,患者NIHSS评分与血管狭窄率、狭窄血管长度、收缩期峰值流速（PSV）和舒张期末流速（EDV）均呈正相关（P＜0.05）。根据Logistic回归分析显示,患者发生ISR影响因素包含高脂血症和支架类型为裸支架,以及合并颈内动脉的狭窄和并发双侧椎动脉的狭窄（P＜0.05）。结论：SI术式治疗的VAOS患者的临床疗效较好,且术后ISR的影响因素主要包含高脂血症和支架类型为裸支架,以及合并颈内动脉的狭窄和并发双侧椎动脉的狭窄,临床上应引起相应的重视。     

经皮椎间孔镜治疗腰椎间盘突出症临床疗效观察

目的:评估经皮椎间孔镜技术(percutaneous transforaminal endoscopic discectomy,PTED)治疗腰椎间盘突出症的临床疗效。方法:回顾性分析2009~2013年我院收治的明确诊断为腰椎间盘突出症且接受PTED治疗的194例患者的临床和随访资料,评价其Mac Nab疗效,比较手术前后患者的VAS疼痛评分、Lehmann腰椎功能评分及SF-36生存质量评分。结果:所有患者均至少随访至术后12月,患者术后当天及术后3月、12月的VAS评分、Lehmann腰椎功能评分、SF-36生存质量评分均较术前明显改善,差异均具有统计学意义(P0.05)。术后3月、12月,患者Macnab疗效的优良率分别为90.7%、92.3%。结论:采用PTED治疗腰椎间盘突出症的临床疗效较好,患者的疼痛明显缓解,腰椎功能和生活质量均明显改善,且安全方便。     

自膨式食管金属加膜支架治疗恶性食管狭窄和气管食管瘘

目的：探讨自膨式食管金属加膜支架治疗恶性食管狭窄和气管食管瘘的疗效和并发症。方法：2004年1月至2009年6月对63例恶性食管狭窄和气管食管瘘患者实施食管支架置入,男45例,女28例;年龄45～81岁,平均69.3岁。支架为MTN型形状记忆钛镍合金食管加膜支架（南京微创医学科技有限公司生产）,支架植入均在DSA监视下操作完成。结果：63例均一次性放置成功,即刻口服造影通过顺利剂。结论：自膨式食管金属加膜支架是治疗恶性食管狭窄和气管食管瘘的有效方法。     

Esophageal tone in patients with total aperistalsis: gastroesophageal reflux disease versus achalasia

We have evaluated esophageal tone in two different conditions that, in some cases, similarly impair phasic esophageal motility. Studies were performed in 14 healthy volunteers, 10 patients with total esophageal aperistalsis secondary to gastroesophageal reflux disease (GERD), and 25 untreated achalasia patients. We quantified esophageal compliance and relaxation induced by a nitric oxide donor using a barostat. Intraesophageal volume at a minimal distending pressure (2 mmHg) was not significantly different among all three groups (4.1 +/- 0.7, 3.8 +/- 0.7, and 4.2 +/- 1.2 ml for healthy, GERD, and achalasia groups, respectively). Esophageal compliance was significantly increased (P < 0.05 vs. healthy group) in the two groups of patients with aperistalsis (1.9 +/- 0.2, 3.0 +/- 0.2, and 3.1 +/- 0.3 ml/mmHg for healthy, GERD, and achalasia groups, respectively). Esophageal relaxation was decreased in GERD patients (Delta diameter: 0.4 +/- 0.1 cm) and increased in achalasia patients (Delta diameter: 1.3 +/- 0.4 cm) relative to healthy subjects (Delta diameter: 0.9 +/- 0.2 cm) (P < 0.05 for GERD vs. achalasia and healthy groups). Our results indicate that diseases that similarly impair phasic esophageal motility may affect esophageal tone differently.     

Diminished mechanosensitivity and chemosensitivity in patients with achalasia

The pathogenesis of achalasia involves the degeneration of enteric and autonomic nervous systems with resultant effects on esophageal motility. The neural degeneration could affect visceral sensation in achalasia. The aim of this study was to examine mechanosensitivity and chemosensitivity in patients with achalasia. Perceptual responses to esophageal distension and acid perfusion were assessed in nine achalasia patients and nine healthy subjects. Mechanosensitivity was evaluated using a barostat with a double-random staircase distension protocol. Responses were graded as follows: 0, no sensation; 1, initial sensation; 2, mild discomfort; 3, moderate discomfort; and 4, pain. Chemosensitivity was graded along a visual analog scale after perfusion of saline and 0.1 N HCl. Barostat pressure-volume relationships were used to report esophageal body compliance. Barostat pressures for initial sensation and mild discomfort were not significantly different for patients and controls. The pressures for moderate discomfort (37.9 +/- 3.5 vs. 25.7 +/- 2.4 mmHg; P < 0.05) and pain (47.8 +/- 2.3 vs. 32.2 +/- 3.5 mmHg; P = 0.002) were significantly higher in achalasics than controls. Seven of the eight achalasia patients never reached pain thresholds at the maximum distension pressure (50 mmHg). Sensation to acid perfusion was significantly lower in achalasics compared with controls (2.2 +/- 1.2 vs. 6.7 +/- 1.7 cm; P < 0.05). Compliance was significantly increased in patients with achalasia compared with controls. We conclude that both mechanosensitivity and chemosensitivity are significantly diminished in achalasia patients compared with controls. Also, initial sensation and pain sensation are differentially affected in achalasics. These findings suggest that neuropathic defects in achalasia may manifest themselves in visceral sensory and motor dysfunction.     

Complete lower esophageal sphincter relaxation observed in some achalasia patients is functionally inadequate

Generally accepted manometric criteria for the diagnosis of achalasia are absent peristalsis and incomplete lower esophageal sphincter (LES) relaxation. However, in some patients with otherwise typical features of achalasia, esophageal manometry shows complete LES relaxation during swallowing. To establish whether such apparently complete LES relaxations are functionally adequate, we quantified changes in resistance to flow at the esophagogastric junction (EGJ) during wet swallowing. We studied seven achalasia patients with manometrically complete (>80%) LES relaxation, eight achalasia patients with incomplete (<40%) LES relaxation, and eight healthy volunteers. Complete LES relaxation on standard manometry (open-tip catheters) was confirmed in five of the seven achalasia patients by a Dentsleeve. Changes in EGJ resistance to flow were quantified using a pneumatic resistometer. Manometrically, the relaxation time span was significantly longer in patients with complete LES relaxation than in those with incomplete relaxation (7. 3 +/- 0.5 vs. 4.4 +/- 0.7 s; P < 0.05). The fall in EGJ resistance from basal values during swallowing was markedly reduced in both achalasia groups (21 +/- 8% in those with manometrically complete relaxation and 4 +/- 2% in those with incomplete relaxation) by comparison with healthy individuals, in whom resistance fell by 90 +/- 3% (P < 0.05 vs. both achalasia groups). The duration of EGJ resistance drop was also much shorter in achalasia with (0.7 +/- 0.2 s) and without (0.2 +/- 0.1 s) complete LES relaxation compared with healthy control values (6.6 +/- 1.2 s). Our results reveal that the apparently complete LES relaxation observed manometrically in some patients with achalasia is functionally inadequate since it is not associated with the normal profound fall in EGJ resistance to flow.     

自膨式食管金属加膜支架治疗恶性食管狭窄和气管食管瘘

目的:探讨自膨式食管金属加膜支架治疗恶性食管狭窄和气管食管瘘的疗效和并发症。方法:2004年1月至2009年6月对63例恶性食管狭窄和气管食管瘘患者实施食管支架置入,男45例,女28例;年龄45～81岁,平均69.3岁。支架为MTN型形状记忆钛镍合金食管加膜支架(南京微创医学科技有限公司生产),支架植入均在DSA监视下操作完成。结果:63例均一次性放置成功,即刻口服造影通过顺利剂。结论:自膨式食管金属加膜支架是治疗恶性食管狭窄和气管食管瘘的有效方法。     

Achalasia: will genetic studies provide insights?

Despite increasing understanding of the pathophysiology of achalasia, the etiology of this esophageal motility disorder remains largely unknown. However, the occurrence of familial achalasia and its association with well-defined genetic syndromes suggest the involvement of genetic factors. Mutant mouse models display gastrointestinal disturbances that are similar to those observed in achalasia patients. The candidate gene approach has revealed some promising results; however, it has not established conclusive links to specific genes so far. The aim of this review was to summarize current knowledge of the genetics of achalasia. We also discuss the extent to which our understanding of achalasia is likely to be enhanced through future molecular genetic research.     

Airway and esophageal stenting in patients with advanced esophageal cancer and pulmonary involvement

Background

Most inoperable patients with esophageal-advanced cancer (EGC) have a poor prognosis. Esophageal stenting, as part of a palliative therapy management has dramatically improved the quality of live of EGC patients. Airway stenting is generally proposed in case of esophageal stent complication, with a high failure rate. The study was conducted to assess the efficacy and safety of scheduled and non-scheduled airway stenting in case of indicated esophageal stenting for EGC.

Methods and Findings

The study is an observational study conducted in pulmonary and gastroenterology endoscopy units. Consecutive patients with EGC were referred to endoscopy units. We analyzed the outcome of airway stenting in patients with esophageal stent indication admitted in emergency or with a scheduled intervention. Forty-four patients (58±\−8 years of age) with esophageal stenting indication were investigated. Seven patients (group 1) were admitted in emergency due to esophageal stent complication in the airway (4 fistulas, 3 cases with malignant infiltration and compression). Airway stenting failed for 5 patients. Thirty-seven remaining patients had a scheduled stenting procedure (group 2): stent was inserted for 13 patients with tracheal or bronchial malignant infiltration, 12 patients with fistulas, and 12 patients with airway extrinsic compression (preventive indication). Stenting the airway was well tolerated. Life-threatening complications were related to group 1. Overall mean survival was 26+/−10 weeks and was significantly shorter in group 1 (6+/−7.6 weeks) than in group 2 (28+/−11 weeks), p<0.001). Scheduled double stenting significantly improved symptoms (95% at day 7) with a low complication rate (13%), and achieved a specific cancer treatment (84%) in most cases.

Conclusion

Stenting the airway should always be considered in case of esophageal stent indication. A multidisciplinary approach with initial airway evaluation improved prognosis and decreased airways complications related to esophageal stent. Emergency procedures were rarely efficient in our experience.     

Achalasia in a sixty-four-year-old man.

Achalasia is an esophageal motility disorder characterized by increased lower esophageal sphincter pressure and absence of peristalsis in the lower esophagus. Patients typically present with complaints of progressive difficulty swallowing over a period of several years. Diagnosis is confirmed by esophageal manometry. Complications of achalasia include esophagitis, aspiration and possibly an increased risk of esophageal carcinoma. Medical treatment options include pneumatic dilatation, esophageal bougienage, nitrates, calcium channel blockers and botulinum toxin injections. The primary method of surgical treatment is the Heller myotomy, in which longitudinal incisions are made in the muscle fibers of the lower esophageal sphincter to reduce sphincter pressure. Frequently, a fundoplication is performed in addition to the myotomy to decrease the likelihood of development of gastroesophageal reflux. In recent years, the Heller myotomy has been performed both thoracoscopically and laparoscopically. An additional development has been the placement of an endoscope in the esophagus to provide transillumination during surgery; intraoperative endoscopy allows improved assessment of the depth of myotomy incisions and reduces the risk of esophageal perforation. The case report below describes a 64-year-old-man with achalasia who presented with persistent dysphagia despite multiple attempts at medical treatment. A laparoscopic Heller myotomy with Toupet fundoplication was performed with subsequent eradication of symptoms. A discussion of the epidemiology, etiology, clinical presentation, diagnosis and treatment of achalasia follows the case report.     

Dyschalasia: A Variant or Early Phase of Achalasia?: A Review of Motor Disturbances in Achalasia with Reference to Late Relaxation of the Lower Esophageal Sphincter

One of the characteristic motor abnormalities in achalasia of the esophagus is the lack of relaxation of the lower esophageal sphincter during swallowing. In a subject with a clinical history and radiologic evidence of early achalasia all the typical motor abnormalities of the disease were observed in the course of pressure studies, but the sphincter exhibited a fall of pressure in response to a contraction of the body of the esophagus. This relaxation occurred later than would be expected in the normal esophagus and, therefore, this unusual condition was named dyschalasia.The relationship of dyschalasia to classical achalasia is discussed and several theories are advanced. The authors believe that dyschalasia is possibly an early stage of achalasia.