Peroral endoscopic myotomy using the posterior approach in an 11-month-old girl with achalasia, severe malnutrition, and recurrent pneumonia
Peroral endoscopic myotomy using the posterior approach in an 11-month-old girl with achalasia, severe malnutrition, and recurrent pneumonia
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对一名患有贲门失弛缓症、严重营养不良和复发性肺炎的 11 个月大女孩采用后路经口内窥镜肌切开术
DOI：
10.1055/s-0034-1393156
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发表时间：
2015
期刊：
影响因子：
9.3
通讯作者：
Zhou Ping-Hong
中科院分区：
文献类型：
--
作者：
Zhang Xiao-Cen;Li Quan-Lin;Huang Ying;Miao Shi-Jian;Zhou Ping-Hong
经口内窥镜下肌切开术（POEM）已被广泛接受为治疗贲门失弛缓症的微创手术。在这里，我们报告一个11个月大的女婴失弛缓症，由POEM治疗。患者足月分娩，出生时体重2.95公斤。她的生长发育正常，直到5个月大时，她在喂食后出现非抛射性呕吐。3个月后开始间歇性咳嗽发热，怀疑吸入性肺炎。食管造影显示食管胃连接处（EGJ）狭窄（●图1a），经内镜检查证实。诊断为失弛缓症。由于患者年龄小，未进行测压。在向我们报告时，11个月大的患者体重仅为7.3公斤，低于其年龄的第3个百分位数。诗是有计划的。手术前她在医院住了9天，接受了鼻胃管喂养和肺炎抗生素治疗。然后由经验丰富的内窥镜医师（P.H.Z）进行POEM（●“图2，●”视频1）。采用成人患者的标准程序，使用标准胃镜（GIF-Q260J; Olympus, Tokyo, Japan），混合刀（ERBE; ERBE Elektromedizin, t<s:1>宾根，Germany）进行注射，粘膜剥离和肌切开，热活检钳（FD-410R; Olympus）进行止血，夹（HX-610-90; Olympus）进行粘膜闭合。在食管胃连接处（EGJ）上方约5cm的后食道5-6点钟位置（门牙-贲门距离25cm）进行初始粘膜切口。在EGJ上方4cm处开始肌切开术，并延伸至贲门1cm处。婴儿食管肌非常薄且脆弱。我们采用了一种我们称之为“推拉”技术的方法：在最初的部分厚度切割后，混合刀的尖端在5 - 6点钟插入肌肉-浆膜平面，在电解剖（“推”）的同时将全层肌肉束向食管腔抬起。在心脏，由于空间有限，肌肉纤维从管腔一侧被切断，以“扫地”的动作（“拉”）[1]拉动镜。手术过程很顺利，除了食管下部有一个小的粘膜损伤，后来被夹住了。出现腹胀，并通过针插入缓解。术后2天患者发热，白细胞计数高。她被保守地管理美罗培南，静脉注射免疫球蛋白和静脉高营养。术后第5天恢复喂养，术后第13天婴儿出院。术后第166天内镜随访显示粘膜完全愈合（●”图3a），轻度食管炎（●”图3b）。内窥镜可以无阻力通过。食管造影显示食管轻度扩张，造影剂通道通畅，伴有轻度胃食管反流（●“图1b”）。术后患者无反流或持续呕吐。1例11个月大的女婴患有贲门失弛缓症、严重营养不良和复发性肺炎。a经口内窥镜下肌切开术前（POEM），显示“鸟喙”外观。b第166天，造影剂顺利进入胃。案例和技术库（CTL） E480
Peroral endoscopic myotomy (POEM) has become widely accepted as a minimally invasive procedure for treatment of achalasia. Here we report a case of achalasia in an 11-month-old girl that was managed by POEM. The patient had been delivered at full term and weighed 2.95kg at birth. Her growth and development were normal until she was 5 months old, when she developed nonprojectile vomiting after feeding. She began to have intermittent cough with fever 3 months later and aspiration pneumonia was suspected. Esophagography showed narrowing of the esophageal gastric junction (EGJ) (●" Fig.1a), that was confirmed by endoscopy. A diagnosis of achalasia was made. Manometry was not performed because of the young age of the patient. At presentation to us the 11-month-old patient weighed only 7.3kg, below the 3rd percentile for her age. POEM was planned. She stayed in hospital for 9 days before the procedure, undergoing nasogastric tube feeding and antibiotic treatment for pneumonia. POEM was then performed by an experienced endoscopist (P.H.Z) (●" Fig.2, ●" Video 1). The standard procedure for adult patients was used, with a standard gastroscope (GIF-Q260J; Olympus, Tokyo, Japan), a hybrid knife (ERBE; Erbe Elektromedizin, Tübingen, Germany) for injection, mucosal dissection, and myotomy, hot biopsy forceps (FD-410R; Olympus) for hemostasis, and clips (HX-610-90; Olympus) for mucosal closure. An initial mucosal incision was done in the 5–6 o’clock position on the posterior esophagus about 5cm above the esophagogastric junction (EGJ) (incisor–cardia distance 25cm). Myotomy was begun 4cm above the EGJ and extended 1cm into the cardia. The infant esophageal muscle was extremely thin and fragile. We applied a method that we call the “push and pull” technique: after an initial partial-thickness cut, the tip of the hybrid knife was inserted into the muscle–serosa plane at 5– 6 o’clock and the full-thickness muscle bundle was lifted towards the esophageal lumen while being electrically dissected (the “push”). At the cardia, because of the limited space, muscle fibers were cut from the luminal side, pulling the scope with a “floor-sweeping” action (the “pull”) [1]. The procedure was uneventful, with the exception of a small mucosal injury at the lower esophagus, which was later clipped. Abdominal bloating occurred and was relieved by needle insertion. The patient had fever and a high white cell count for 2 days after the procedure. She was managed conservatively with meropenem, intravenous immunoglobulin, and intravenous hyperalimentation. Feeding was resumed at postoperative day 5 and the infant was discharged from hospital at postoperative day 13. Endoscopic follow-up at postoperative day 166 showed complete healing of the mucosa (●" Fig.3a), and low grade esophagitis (●" Fig.3b). The endoscope could be passed without resistance. Esophagography showed a slightly dilated esophagus and smooth passage of contrast with mild gastroesophageal reflux (●" Fig.1b). The patient experienced no regurgitation or persistent vomiting following the procedure. There were 2 episodes of upper Fig.1 Esophagography in an 11-month-old girl with achalasia, severe malnutrition, and recurrent pneumonia. a Before peroral endoscopic myotomy (POEM), showing the “bird beak” appearance. b At day 166 postPOEM showing smooth passage of contrast into the stomach. Cases and Techniques Library (CTL) E480
经口内镜下肌切开术治疗贲门失弛缓症的观点：中山经验。
影响因子：
3.4
作者：
Li QL;Zhou PH
通讯作者：
Zhou PH