經(jīng)口內(nèi)鏡下肌切開術(shù)治療賁門失弛緩癥的長期有效性及安全性的單中心回顧性分析
發(fā)布時間：2019-07-01 17:37
【摘要】：目的:(1)探討經(jīng)口內(nèi)鏡下肌切開術(shù)(peroral endoscopic myotomy,POEM)治療AC(achalasia,AC)的長期有效性及安全性;(2)評估影響術(shù)后發(fā)生胃食管反流和手術(shù)失敗的相關(guān)因素;(3)了解POEM術(shù)的學(xué)習(xí)曲線,為即將開展該技術(shù)的內(nèi)鏡醫(yī)師提供借鑒。方法:回顧性分析2011年4月至2016年12月由山東大學(xué)齊魯醫(yī)院消化內(nèi)科內(nèi)鏡醫(yī)師完成的POEM術(shù)治療AC患者的臨床資料。分別在手術(shù)前,手術(shù)后1個月,6個月,1年,2年,3年,4年,5年,6年對AC患者進行Eckardt癥狀評分,評估POEM術(shù)的療效。統(tǒng)計患者術(shù)中發(fā)生并發(fā)癥及術(shù)后隨訪發(fā)生胃食管反流的情況,判斷POEM術(shù)的安全性。采用多因素logistic回歸方程分析影響術(shù)后2年發(fā)生胃食管反流和手術(shù)失敗的相關(guān)因素。利用曲線擬合回歸分析方法了解基于手術(shù)時間的POEM術(shù)學(xué)習(xí)曲線。結(jié)果:自2011年4月至2016年12月共有142例(男/女:59/83;平均年齡,42歲)AC患者接受了POEM治療�；颊咂骄〕踢_5年,41例患者在接受手術(shù)之前進行過其他治療。平均手術(shù)操作時間93.6min。平均肌切開長度食管部分為9.4cm,胃部分為2.3cm�；颊咂骄≡簳r間10天,平均住院花費25079元。術(shù)后115例(80.9%)患者完成了隨訪,平均隨訪時間2年(2～68個月)。在術(shù)后1個月,6個月,1年,2年,3年,大于3年的隨訪中相對應(yīng)的臨床成功率為99.1%(114/115),95.5%(107/112),92.4%(85/92),91.8%(79/86),88.6%(31/35),86.7%(13/15)。手術(shù)過程中有2例出現(xiàn)術(shù)中出血,其中1例手術(shù)失敗。術(shù)后住院期間35%(50/142)的患者出現(xiàn)胸前區(qū)不適或疼痛;7%(10/142)的患者出現(xiàn)皮下氣腫,12.7%(18/142)的患者出現(xiàn)體溫升高。在長期隨訪過程中,有41(35.7%)例患者出現(xiàn)胃食管反流的癥狀。分別于2012年,2013年,2014年,2015年,2016年進行手術(shù)的患者平均手術(shù)時間為122.5min,111.2min,82.3min,90.8min,88.3min;術(shù)后平均住院花費分別為33673.6元,28290.9元,23429元,23290.3元和24885元;術(shù)后平均住院時間為13天,12天,10天,9天和10天。在影響術(shù)后2年手術(shù)失敗的多因素回歸分析中,手術(shù)時間(OR值,1.03;95%置信區(qū)間,1.01～1.05;P=0.01)和肌切開的程度(OR值,0.003;95%置信區(qū)間,0.80～1.19;P=0.01)與手術(shù)失敗有關(guān)。在影響術(shù)后2年發(fā)生胃食管反流的多因素回歸分析中,年齡,性別,飲酒,手術(shù)切口的位置與術(shù)后胃食管反流的發(fā)生均無明顯的相關(guān)性。通過對數(shù)擬合回歸方程得出POEM術(shù)學(xué)習(xí)曲線在23～27例時手術(shù)時間變化趨于平緩,將患者分為A組(n=25)和B組(n=38)。兩組的平均年齡,性別,BMI,病史,術(shù)后胃食管反流的發(fā)生及手術(shù)成功率等之間相比無明顯的統(tǒng)計學(xué)差異,而在手術(shù)時間,住院時間及住院花費上,B組比A組顯著性減少。結(jié)論:POEM能夠安全有效的治療AC,有效率達85%以上,且術(shù)中及術(shù)后均無嚴重并發(fā)癥發(fā)生。除此之外,術(shù)后觀察時間及住院天數(shù)逐步縮短,住院費用不斷降低。手術(shù)時間為手術(shù)失敗的獨立危險因素;環(huán)形肌切開為手術(shù)失敗的保護性因素。內(nèi)鏡醫(yī)師基于手術(shù)時間的學(xué)習(xí)曲線為25例,此后患者至少可以從減少手術(shù)時間,住院時間及住院花費方面獲益。
[Abstract]:Objective: (1) To investigate the long-term effectiveness and safety of the oral endoscopic mytotomy (POEM) in the treatment of AC (achalasia, AC); (2) to assess the related factors that affect the postoperative gastroesophageal reflux and the failure of the operation; and (3) to understand the learning curve of POEM. Provide a reference for an endoscopic physician who is about to carry out the technique. Methods: The clinical data of the treatment of patients with AC from April 2011 to December 2016 by endoscopic physician of Qilu Hospital of Shandong University were analyzed retrospectively. Eckhardt's symptom score was evaluated in 1 month,6 months,1 year,2,3,4,5 and 6 years before and after operation, and the efficacy of POEM was evaluated. The safety of POEM was determined by the occurrence of complications during the operation of the patients and the occurrence of gastroesophageal reflux in the follow-up. A multi-factor logistic regression equation was used to analyze the factors affecting gastroesophageal reflux and operation failure in 2 years after operation. The learning curve of POEM based on the time of operation was studied by the curve fitting regression analysis method. Results:142 patients (male/ female:59/83; mean age,42 years) were treated with POEM from April 2011 to December 2016. The mean duration of the patient was 5 years, and 41 patients had undergone additional treatment prior to the procedure. The mean operative time was 93.6 min. The average myotomy length was 9.4 cm in length and 2.3 cm in the stomach. The average hospital stay was 10 days and the average hospital stay was 25079 yuan. The follow-up was completed in 115 (80.9%) patients and the mean follow-up time was 2 years (2-68 months). The clinical success rate was 99.1% (114/115), 95.5% (107/112), 92.4% (85/92), 91.8% (79/86), 88.6% (31/35) and 86.7% (13/15) at 1,6,1,2, and 3 years after the operation. There were 2 cases of intraoperative bleeding during the procedure, one of which failed. 35% (50/142) of the patients in the post-operative hospitalization showed discomfort or pain in the chest region;7% (10/142) of the patients had subcutaneous emphysema and 12.7% (18/142) of the patients had a higher body temperature. In the long-term follow-up,41 (35.7%) patients had symptoms of gastroesophageal reflux. The mean operative time of the patients in 2012,2013,2014,2015 and 2016 was 122.5 min, 111.2 min, 82.3 min, 90.8 min, and 88.3 min. The average hospital cost after operation was 33673.6, 28290.9,23429, 23290.3 and 24885. The average hospital stay was 13 days,12 days,10 days,9 days and 10 days. The operative time (OR value, 1.03;95% confidence interval, 1.01-1.05; P = 0.01) and the degree of myotomy (OR value, 0.003;95% confidence interval, 0.80-1.19; P = 0.01) were related to the failure of the operation in the multi-factor regression analysis that affected the 2-year operation failure. In the multi-factor regression analysis of gastroesophageal reflux in 2 years after operation, there was no significant correlation between the age, sex, alcohol consumption, the location of the surgical incision and the occurrence of postoperative gastroesophageal reflux. By means of the log-fitting regression equation, the learning curve of POEM was gradually changed in 23-27 cases, and the patients were divided into group A (n = 25) and group B (n = 38). There was no significant difference in the mean age, sex, BMI, history of the two groups, the occurrence of postoperative gastroesophageal reflux and the success rate of operation. Conclusion: POEM is safe and effective in the treatment of AC, with an effective rate of more than 85% and no serious complications in the operation and after operation. In addition, the post-operative observation time and the number of days of hospitalization were gradually shortened, and the hospitalization expenses decreased. The operative time is an independent risk factor for the failure of the procedure; the annular myotomy is a protective factor for the failure of the procedure. The patient's learning curve based on the time of surgery is 25, and the patient can then at least benefit from the reduction of the operative time, the hospital stay and the cost of the hospital stay.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R655.4
本文編號：2508674
[Abstract]:Objective: (1) To investigate the long-term effectiveness and safety of the oral endoscopic mytotomy (POEM) in the treatment of AC (achalasia, AC); (2) to assess the related factors that affect the postoperative gastroesophageal reflux and the failure of the operation; and (3) to understand the learning curve of POEM. Provide a reference for an endoscopic physician who is about to carry out the technique. Methods: The clinical data of the treatment of patients with AC from April 2011 to December 2016 by endoscopic physician of Qilu Hospital of Shandong University were analyzed retrospectively. Eckhardt's symptom score was evaluated in 1 month,6 months,1 year,2,3,4,5 and 6 years before and after operation, and the efficacy of POEM was evaluated. The safety of POEM was determined by the occurrence of complications during the operation of the patients and the occurrence of gastroesophageal reflux in the follow-up. A multi-factor logistic regression equation was used to analyze the factors affecting gastroesophageal reflux and operation failure in 2 years after operation. The learning curve of POEM based on the time of operation was studied by the curve fitting regression analysis method. Results:142 patients (male/ female:59/83; mean age,42 years) were treated with POEM from April 2011 to December 2016. The mean duration of the patient was 5 years, and 41 patients had undergone additional treatment prior to the procedure. The mean operative time was 93.6 min. The average myotomy length was 9.4 cm in length and 2.3 cm in the stomach. The average hospital stay was 10 days and the average hospital stay was 25079 yuan. The follow-up was completed in 115 (80.9%) patients and the mean follow-up time was 2 years (2-68 months). The clinical success rate was 99.1% (114/115), 95.5% (107/112), 92.4% (85/92), 91.8% (79/86), 88.6% (31/35) and 86.7% (13/15) at 1,6,1,2, and 3 years after the operation. There were 2 cases of intraoperative bleeding during the procedure, one of which failed. 35% (50/142) of the patients in the post-operative hospitalization showed discomfort or pain in the chest region;7% (10/142) of the patients had subcutaneous emphysema and 12.7% (18/142) of the patients had a higher body temperature. In the long-term follow-up,41 (35.7%) patients had symptoms of gastroesophageal reflux. The mean operative time of the patients in 2012,2013,2014,2015 and 2016 was 122.5 min, 111.2 min, 82.3 min, 90.8 min, and 88.3 min. The average hospital cost after operation was 33673.6, 28290.9,23429, 23290.3 and 24885. The average hospital stay was 13 days,12 days,10 days,9 days and 10 days. The operative time (OR value, 1.03;95% confidence interval, 1.01-1.05; P = 0.01) and the degree of myotomy (OR value, 0.003;95% confidence interval, 0.80-1.19; P = 0.01) were related to the failure of the operation in the multi-factor regression analysis that affected the 2-year operation failure. In the multi-factor regression analysis of gastroesophageal reflux in 2 years after operation, there was no significant correlation between the age, sex, alcohol consumption, the location of the surgical incision and the occurrence of postoperative gastroesophageal reflux. By means of the log-fitting regression equation, the learning curve of POEM was gradually changed in 23-27 cases, and the patients were divided into group A (n = 25) and group B (n = 38). There was no significant difference in the mean age, sex, BMI, history of the two groups, the occurrence of postoperative gastroesophageal reflux and the success rate of operation. Conclusion: POEM is safe and effective in the treatment of AC, with an effective rate of more than 85% and no serious complications in the operation and after operation. In addition, the post-operative observation time and the number of days of hospitalization were gradually shortened, and the hospitalization expenses decreased. The operative time is an independent risk factor for the failure of the procedure; the annular myotomy is a protective factor for the failure of the procedure. The patient's learning curve based on the time of surgery is 25, and the patient can then at least benefit from the reduction of the operative time, the hospital stay and the cost of the hospital stay.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R655.4
【參考文獻】
相關(guān)期刊論文 前2條
1 Yalini Vigneswaran;Michael B Ujiki;;Peroral endoscopic myotomy: An emerging minimally invasive procedure for achalasia[J];World Journal of Gastrointestinal Endoscopy;2015年14期
2 Vivek Kumbhari;Mouen A Khashab;;Peroral endoscopic myotomy[J];World Journal of Gastrointestinal Endoscopy;2015年05期
，本文編號：2508674
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