经腹腔镜行食管贲门括约肌切开术和经口内镜下肌层切开术治疗儿童贲门失弛缓症的临床分析

doi:10.3877/cma.j.issn.2095-8765.2020.02.004

目的

探讨经腹腔镜食管贲门括约肌切开术（Heller）及经口内镜下肌层切开术（POEM）治疗儿童贲门失弛缓症的可行性及安全性。

方法

回顾性分析2014年6月至2018年6月于山东大学齐鲁医院（青岛）儿外科收治的10例儿童贲门失弛缓症的临床资料。其中，男童6例，女童4例；年龄1.3~12岁，平均年龄4.5±2.3岁。收集并记录患儿的病史、手术方式、并发症、随访结果。计量资料使用均数±标准差表示。

结果

10例患儿均行手术治疗。其中，腹腔镜Heller术治疗7例，POEM术治疗3例，治疗过程顺利。腹腔镜Heller术中1例合并先天性食道闭锁病史患儿术中黏膜层破裂，术后发生食道胸腔瘘，给予胸腔闭式引流及抗生素治疗2个月后瘘管闭合。腹腔镜Heller术组的平均手术时间为84.2±15.2 min；POEM术组的平均手术时间为67±4.8 min。术后随访9个月~4年，所有患儿均无食管狭窄及胃食管反流。

结论

腹腔镜Heller术及POEM术均可用于儿童贲门失弛缓症的治疗，手术疗效确切，并发症可控，其中POEM术在手术时间及出血量方面有一定优势，但应根据患儿的病情和临床条件选择合适的手术方案。

关键词: 腹腔镜Heller术, 经口内镜下肌层切开术, 儿童, 贲门失弛缓症

Objective

Analysis of feasibility and safety of laparoscopic Heller and POEM in the treatment of pediatric achalasia of cardia.

Methods

The clinical data of 10 cases of pediatric achalasia of cardia admitted to Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University from June 2014 to June 2018 were analyzed retrospectively. Among them, there were 6 boys and 4 girls, with an average age of 4.5±2.3 years. Collect and record the patient's history, operation mode, complications and follow-up results. The measurement data is expressed by mean ± standard deviation.

Results

All the 10 cases were underwent surgical treatment. Among them, laparoscopic Heller operation was performed in 7 cases and POEM in 3 cases. One case with congenital history of esophageal atresia had rupture of mucous membrane during operation, and esophageal thoracic fistula occurred after operation, and the fistula closed after 2 months by using drainage of thoracic cavity and antibiotic treatment. The average operation time of laparoscopic Heller group was 84.2±15.2 minutes, while that of POEM group was 67±4.8 minutes. No esophageal stricture and gastroesophageal reflux were found in all the cases after follow-up for 9 months to 4 years.

Conclusions

Laparoscopic Heller and POEM can be used in the treatment of pediatric achalasia of cardia. The curative effect is accurate and the complications can be controlled. POEM have some advantages in terms of operation time and blood loss, but the appropriate surgical scheme should be selected according to the condition and clinical conditions of the children.

Key words: Laparoscopic Heller Myotomy, POEM, Children, Achalasia of cardia

表1 贲门失弛缓症临床症状评分系统（Eckardt评分）

评分	症状
评分	体重减轻（Kg）	吞咽困难	胸骨后疼痛	反流
0	无	无	无	无
1	＜5	偶尔	偶尔	偶尔
2	5~10	每天	每天	每天
3	＞10	每餐	每餐	每餐

表1 贲门失弛缓症临床症状评分系统（Eckardt评分）

评分	症状
评分	体重减轻（Kg）	吞咽困难	胸骨后疼痛	反流
0	无	无	无	无
1	＜5	偶尔	偶尔	偶尔
2	5~10	每天	每天	每天
3	＞10	每餐	每餐	每餐

图1A.胃镜下见贲门狭窄，明确诊断；图1B.黏膜下注射抬举黏膜；图1C.取倒T型切口；图1D.建立黏膜下隧道；图1E.切开贲门环肌层；图1F.切开至显露贲门纵肌层；图1G切开后松弛的贲门，可通过胃镜；图1H.钛夹夹闭黏膜隧道开口

图2A.患儿2术后食管胸腔瘘，造影剂外泄至胸腔内；图2B.术后2月瘘管关闭；图2C.术后4年随访无术区狭窄及胃食管反流

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Clinical analysis of laparoscopic Heller and POEM in the treatment of pediatric achalasia of cardia

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Clinical analysis of laparoscopic Heller and POEM in the treatment of pediatric achalasia of cardia