经口内镜下肌切开术治疗贲门失弛缓症的长期有效性及安全性的单中心回顾性分析
发布时间：2019-07-01 17:37
【摘要】：目的:(1)探讨经口内镜下肌切开术(peroral endoscopic myotomy,POEM)治疗AC(achalasia,AC)的长期有效性及安全性;(2)评估影响术后发生胃食管反流和手术失败的相关因素;(3)了解POEM术的学习曲线,为即将开展该技术的内镜医师提供借鉴。方法:回顾性分析2011年4月至2016年12月由山东大学齐鲁医院消化内科内镜医师完成的POEM术治疗AC患者的临床资料。分别在手术前,手术后1个月,6个月,1年,2年,3年,4年,5年,6年对AC患者进行Eckardt症状评分,评估POEM术的疗效。统计患者术中发生并发症及术后随访发生胃食管反流的情况,判断POEM术的安全性。采用多因素logistic回归方程分析影响术后2年发生胃食管反流和手术失败的相关因素。利用曲线拟合回归分析方法了解基于手术时间的POEM术学习曲线。结果:自2011年4月至2016年12月共有142例(男/女:59/83;平均年龄,42岁)AC患者接受了POEM治疗。患者平均病程达5年,41例患者在接受手术之前进行过其他治疗。平均手术操作时间93.6min。平均肌切开长度食管部分为9.4cm,胃部分为2.3cm。患者平均住院时间10天,平均住院花费25079元。术后115例(80.9%)患者完成了随访,平均随访时间2年(2～68个月)。在术后1个月,6个月,1年,2年,3年,大于3年的随访中相对应的临床成功率为99.1%(114/115),95.5%(107/112),92.4%(85/92),91.8%(79/86),88.6%(31/35),86.7%(13/15)。手术过程中有2例出现术中出血,其中1例手术失败。术后住院期间35%(50/142)的患者出现胸前区不适或疼痛;7%(10/142)的患者出现皮下气肿,12.7%(18/142)的患者出现体温升高。在长期随访过程中,有41(35.7%)例患者出现胃食管反流的症状。分别于2012年,2013年,2014年,2015年,2016年进行手术的患者平均手术时间为122.5min,111.2min,82.3min,90.8min,88.3min;术后平均住院花费分别为33673.6元,28290.9元,23429元,23290.3元和24885元;术后平均住院时间为13天,12天,10天,9天和10天。在影响术后2年手术失败的多因素回归分析中,手术时间(OR值,1.03;95%置信区间,1.01～1.05;P=0.01)和肌切开的程度(OR值,0.003;95%置信区间,0.80～1.19;P=0.01)与手术失败有关。在影响术后2年发生胃食管反流的多因素回归分析中,年龄,性别,饮酒,手术切口的位置与术后胃食管反流的发生均无明显的相关性。通过对数拟合回归方程得出POEM术学习曲线在23～27例时手术时间变化趋于平缓,将患者分为A组(n=25)和B组(n=38)。两组的平均年龄,性别,BMI,病史,术后胃食管反流的发生及手术成功率等之间相比无明显的统计学差异,而在手术时间,住院时间及住院花费上,B组比A组显著性减少。结论:POEM能够安全有效的治疗AC,有效率达85%以上,且术中及术后均无严重并发症发生。除此之外,术后观察时间及住院天数逐步缩短,住院费用不断降低。手术时间为手术失败的独立危险因素;环形肌切开为手术失败的保护性因素。内镜医师基于手术时间的学习曲线为25例,此后患者至少可以从减少手术时间,住院时间及住院花费方面获益。
[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.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R655.4
本文编号：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.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R655.4
【参考文献】
相关期刊论文 前2条
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
，本文编号：2508674
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