Modern management of achalasia.
Modern management of achalasia.
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DOI：
10.1007/s11938-005-0020-1
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发表时间：
2005-08-01
期刊：
影响因子：
--
通讯作者：
Richter, Joel E
中科院分区：
文献类型：
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作者：
Richter, Joel E
贲门失弛缓症的治疗目标有三个：1）缓解症状，特别是吞咽困难和轻微反流； 2）通过破坏松弛不良的食管下端括约肌（LES）来改善食管排空； 3) 预防巨食道的发展。虽然贲门失弛缓症无法永久治愈，但超过 90% 的患者可以获得良好的姑息治疗，特别是那些接受气动扩张和腹腔镜 Heller 肌切开术的患者。由专家进行的短期和长期治疗的疗效似乎相似。门诊手术中进行的气动扩张通过使用直径逐渐变大（3.0、3.5 和 4.0 厘米）的球囊从内部破坏 LES 肌肉。可能需要重复扩张；继发性严重胃食管反流病 (GERD) 很少见，但大约 2% 的患者会出现食管穿孔。现在正在通过腹腔镜通过腹部进行海勒肌切开术，切割 LES 并将肌切开术延伸到胃部 2 至 3 厘米。通常需要住院2天，患者通常可以在1至2周内恢复工作。严重胃食管反流病（GERD）伴有食管炎和消化道狭窄是常见的并发症；因此，大多数外科医生将肌切开术与不完全胃底折叠术结合起来。药物治疗的效果远不如这些侵入性手术。饭前立即服用平滑肌松弛剂（硝酸盐和钙通道阻滞剂）可以改善吞咽困难，但副作用和药物耐受性很常见。通过内窥镜将肉毒杆菌毒素（100 至 200 单位）注射到 LES 中，可短期缓解症状并改善食管排空。这种治疗对老年人最有效，因为单次注射症状缓解可持续长达 1 至 2 年。多项研究表明，贲门失弛缓症最具成本效益的治疗方法是气动扩张初始治疗。
The goals in the treatment of achalasia are threefold: 1) relieving the symptoms, particularly dysphagia and bland regurgitation; 2) improving esophageal emptying by disrupting the poorly relaxing lower esophageal sphincter (LES); and 3) preventing the development of megaesophagus. Although achalasia cannot be permanently cured, excellent palliation is available in over 90% of patients, especially those with pneumatic dilation and laparoscopic Heller myotomy. The efficacy for short- and long-term therapy seems to be similar when performed by experts. Pneumatic dilation done as an outpatient surgery disrupts the LES muscle from within by using balloons of progressively larger diameter (3.0, 3.5, and 4.0 cm). Repeat dilations may be required; secondary severe gastroesophageal reflux disease (GERD) is rare, but approximately 2% of patients will have an esophageal perforation. A surgical Heller myotomy is now being done laparoscopically through the abdomen that cuts the LES and extends the myotomy 2 to 3 cm onto the stomach. Usually 2 days of hospitalization is required, and patients can normally return to work in 1 to 2 weeks. Severe GERD with esophagitis and peptic stricture is a common complication; therefore, most surgeons combine the myotomy with an incomplete fundoplication. Medical therapy is much less effective than these invasive procedures. Smooth muscle relaxants (nitrates and calcium channel blockers) taken immediately before meals improve dysphagia, but side effects and drug tolerance are common. The injection of botulinum toxin (100 to 200 units) endoscopically into the LES gives short-term relief of symptoms and improves esophageal emptying. This treatment is most effective in the elderly, as symptom relief can last up to 1 to 2 years with a single injection. Several studies suggest the most cost-effective management of achalasia is initial treatment with pneumatic dilation.