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1、经胃镜腔内折叠术治疗胃食管反流病经胃镜腔内折叠术治疗胃食管反流病经胃镜腔内折叠术治疗胃食管反流病的临床研究摘要 目的 探讨治疗胃食管反流病(GERD)的新方法经胃镜腔内折叠术(ELGP)的操作方法、治疗效果、适应证及禁忌症等问题。方法 选择无服药情况下出现每周3次以上烧心或胃酸、食物反流,并且24h食管pH监测证实胃酸异常者26例进行ELGP, 其中2例为贲门切除术后的胃食管反流病患者。缝合器为美国BARD公司二代缝合器。术前检查、常规胃镜观察后,辅助静脉麻醉,在齿状线下或吻合口下1-3cm缝合,采用环行、纵行或两种方法结合治疗。记录手术前后食管裂口大小、缝合位置、针间距、缝合皱褶数、术中不良
2、反应等。结果 26例GERD患者食管下端裂口直径1.5-3.5cm,平均2.6cm;并食管裂孔疝20例,达77%。共缝合32例次,其中环行缝合17例次,纵行缝合11例次,纵行和环行结合缝合4例次。两针间距1-3cm,两褶间距约1.5-2cm。每例次1-4个褶,平均每例2.3个褶、每例次1.88个皱褶。缝合后食管裂口平均约1.5cm。烧心及反流症状改善总有效率76%(完全缓解36%,部分缓解40%),无效24%。1例感冒患者术中出现呼吸困难,余无严重并发症。结论 胃镜下环行、纵行或环行纵行结合缝合均能明显改善胃食管反流病的症状,2cm以上的食管裂孔疝及贲门切除术后胃食管反流均可应用该方法进行治疗
3、,术程安全。关键词 胃食管反流病;经胃镜腔内折叠术Clinical utility of endoluminal gasrtroplication in gastroesophageal reflux disease.Yang Yunsheng, Linghua Enqiang, Sun Gang, Wang Xiangdong, Meng Jiangyun, Guo Rongbin, Wang Zhiqiang, Cheng Liufang and Wang HongzhiDepartment of Gastroenterology, Chinese PLA General Hospital
4、, Beijing 100853,China.Abstract Objective The transoral endoluminal gasrtroplication (ELGP) is a new endoscopic therapy in gastroesophageal reflux disease (GERD) and appealing. We studied the treatment for its procedures, safety, indications, contraindications and the primary efficacy. Methods 26 pa
5、tients with GERD were performed by routin endoscopic examination followed ELGP, including 2 patients with resection of cardiac orifice. These patients suffered from 3 or more heartburn or regurgitation episodes per week while taking no medicine, and the acid reflux was verified by 24-hour pH monitor
6、ing. The ELGP was performed with a linear pattern in 8 patients, circumferential in 14 cases and the combination of both patterns in 4 patients. The suturing device was available of the BARD Suturing System. Results The esophageal hiatus was 1.5-3.5cm of diameter, with average of 2.5cm in 26 patinet
7、s, and 20 patients were identifed to suffer from hiatus hernia. The plicae were within 3cm from the squamocolumnar junction or gastroesophageal stoma, sutured on the lesser curve with linear configuration in 11 patients, around the cardiac orifice with circumferential configuration in 17 cases and w
8、ith the combinatin of both configurations in 4 patients. The distance was 1-3cm between two stitchs and 1.5-2cm between two folds. 32 procedures were finished in 26 patiensts with total of 60 plicae, a repeat procedure was performed on 6 patients. Each patient was sutured for 1-4 plicae with a avera
9、ge of 2.3 plicae. The hearburn and regurgitation was improved in 76% of patients, resolved completely in 36% of patients and remitted partly in 40% of patients. One patient occurred dyspnoea during operation as having suffered a cold and the others were free of serious complications. Conclusion The
10、symptoms of GERD can be significantly improved with ELGP which indicated in GERD with 3 or more heartburn or regurgitation episodes per week,1-3cm hiatus hernia or resection of cardiac orifice. The procedures generally show convenient and safety,but it is not indication for the patients with acut co
11、ld, serious pulmonary or heart diseases.Key Words Gastroesophageal reflux disease; Endoluminal gasrtroplication; Endoscopic gastroplasty.胃食管反流病(gastroesophageal reflux disease, GERD)是常见的消化病,目前主要依靠抑酸剂和胃肠动力药物治疗,部分病例反复发作、无法停药或无法控制其症状。经胃镜缝合治疗又称经胃镜腔内折叠术(endoluminal gastroplication, ELGP),是近来开展治疗GERD的一项新技
12、术,国外目前仅见一篇全文报道,显示疗效显著1。国内我们首先开展该技术,本文中我们对ELGP的操作方法、治疗效果、不良反应、适应证、禁忌症等进行初步的总结。资料与方法1.对象:胃食管反流病(GERD)患者共26例,其中2例为贲门切除术后引起的胃食管反流病。男性16例,女性10例,年龄30-78岁,平均54.5岁。病史2个月52年,平均11.8年。26例均有烧心感,其中感觉每日烧心者21例,每周3次以下2例;24例感胃酸反流,其中每日有胃酸反流者15例,每周3次以下者9例;10例有食物反流,其中每日有食物反流者2例,每周3次以下者8例。22例服药(奥美拉唑)缓解、停药复发或加重,2例服药无明显疗效
13、。3例并发哮喘及慢性咽炎。2.材料:特制富士能450HR或Olympus240电子胃镜,美国BARD二代缝合器,Sandhill食管pH检测仪,Bonston Microvasive 可变球囊扩张器。3.方法:参照Savary-Miller评分系统,术前评估GERD症状积分;并均经食管24h pH监测及常规胃镜检查,评价食管24h酸反流、食管炎、食管裂口大小、裂孔疝状况、有无静脉曲张、严重狭窄等,食管炎诊断参照Savary-Miller分级。入选患者均为无服药情况下出现每周3次以上烧心或胃酸(或食物)反流,24h 食管pH监测证实胃酸异常反流。并发食管狭窄者先行可变球囊扩张治疗,口服抑酸剂,解
14、除狭窄后方行ELGP。缝合治疗术前检查包括凝血功能、血型、心电图检测,术前准备包括手术签字,吸引、吸氧及心肺监护设备等。手术步骤包括静脉辅助麻醉,内镜下放置食管套管,缝合器安装,胃镜下缝合、打结,术后复查等。缝合部位一般选择齿状线下或吻合口下1-3cm内的胃壁组织。环行缝合沿贲门四周呈环形折襞,如图1所示,纵行缝合沿小弯侧进行线形折叠,如图2所示,两者结合即环行和纵行两种折叠方式同时应用。每皱褶2针或3针,针间距一般约1.5-2cm;两褶间距一般约1.5-2cm。结 果26例GERD患者术前食管下端裂口直径1.5-3.5cm,平均2.5cm,并发食管裂孔疝20例,占77%。其中反流性食管炎0级
15、6例、1级6例、2级5例、3级4例,4级5例(狭窄2例,Barretts食管3例)。共缝合32例次,6人缝合2次。采用环行缝合17例次,纵行缝合11例次,环行和纵行结合缝合4例次。采用3针法折叠6个褶,其余均为2针折叠法。32例次共折叠60个皱褶(或襞),每例次1-4个褶,平均每例次1.88个褶,平均每例2.3个褶。缝合后食管裂口平均约1.5cm。手术时间20-90min,平均35min(不包括准备工作)。术后平均4h进流质饮食,活动无限制,平均住院日4d。烧心及反流症状改善总有效率76%,完全缓解36%,部分缓解40%,症状无改善24%。三种缝合方式均能改善患者的烧心及反流症状。 应详细补充
16、例数积分情况及24h 监测等情况术中多数病例可见针孔处少量渗血,数分钟自凝。出现缝合组织撕裂1次,局部喷洒肾上腺素止血。1例感冒患者术中出现呼吸困难,拔除食管套管后缓解。术后出现上腹轻微疼痛6例,上腹有牵拉感5例,均在2 d 后缓解;21例出现咽喉部轻痛,持续1-3d;呃逆5例,平均持续2-3d。讨 论GERD指胃或十二指肠内容物过多反流入食管引起烧心等症状,严重影响生活质量,往往引起食管炎。GERD的治疗目前主要依靠抑酸剂和胃肠动力药物控制症状,但部分病例反复发作、无法停药,甚至少数患者药物治疗症状无法缓解。对于严重或顽固的GERD以往需外科或腹腔镜下手术治疗,但存在创伤大、术后难以修改及部分病例效果不满意等难题。经胃镜腔内折襞术是近来开展的一项新技术,是将缝合器安装在胃镜前端,于直视下在齿状线附近缝合胃壁组织形成皱褶,增加贲门口附近紧张度、“延长腹内食管长度”,使皱褶阻挡反流,发挥治疗作用,具有创伤小,手术效果可以在术后进行反复修改等优点,显著优于外科和腹腔镜下手术疗法。据我们的体会目前该技术操作仍较复杂,步骤较多,操作6-8 例次以上后(包括动物实验),一次性