【作者】 李亮；

【导师】 周平红；

【作者基本信息】 复旦大学 ， 外科学， 2012， 硕士

【摘要】 研究目的1.探讨食管下括约肌中的肠道间质细胞及一氧化氮在贲门失弛缓症发病中的作用。2.评价经口内镜下肌切开术治疗贲门失弛缓症的临床价值。研究方法1.随机选取2011年8月～2011年12月在中山医院收治的责门失弛缓症16例作为实验组。男9例,女7例,中位年龄45岁(22岁～71岁)。术前依据临床症状、食管造影、胃镜检查及食管测压明确诊断为贲门失弛缓症,POEM术中活检食管下括约肌作为实验组标本。另外选取非食管动力障碍性疾病手术标本15例作为对照组,男8例,女7例,中位年龄48岁(38岁～65岁),切取食管下括约肌作为对照组标本。采用免疫组化染色法,在镜下随机选取3个视野观察ICC和NOS在两组LES中的分布和表达情况：计算肠间质细胞的个数和半定量判定一氧化氮合酶的表达强度,数据用SPSS19.0软件处理分析。2.2011年7月～2011年12月间,对50例依据临床症状、食管造影、内镜检查和食管测压诊为责门失弛缓症纳入研究。采用POEM术治疗,总结手术情况、手术并发症及术后不良反应,比较手术前后患者的症状评分和食管动力学的变化。研究结果1.光镜下观察,食管下括约肌中有肠间质细胞分布,其呈梭形,有两端细长突起,弥散分布在肌层中,与肌束平行走向,有些肠间细胞间突起相互连接。而在实验组中肠间质细胞数量明显减少,且细胞突起不明显,与对照组比较有统计差异性(P=0.01)；食管下括约肌中也可见一氧化氮合酶染色阳性神经纤维,对照组染色神经纤维粗大,染色深,而病例组中可见神经纤维纤细,染色淡,分布稀疏,两组在染色强度上比较也有统计差异性(P=0.13)。2.入选的50例贲门失弛缓症患者中,曾行扩张治疗10例(1例扩张12次、1例扩张2次、其余均1次),外科手术1例,药物治疗6例,内镜下局部注射肉毒杆菌毒素治疗4例；乙状结肠型食管10例。1例有扩张史2次的患者手术失败,另有1例被超声内镜诊断为贲门肿瘤而除外手术,共48例成功完成手术,手术成功率97.9%。术中2例出血(4.2%),热活检钳成功止血；术中6例出现皮下气肿(12.5%),保守治疗好转。术后少量胸腔积液16例(33.3%)、气腹14例(29.2%)、气胸7例(14.5%),仅3例气胸需行胸腔闭式引流治疗,其余保守治疗好转。术后不良反应主要为腹部隐痛不适14例(29.2%),胸闷2例(4.2%),气急者1例(2.1%),上述症状经对症处理,2天后自行消失,对病人无明显影响。手术时间为10-60min,平均33±12.4min。住院时间为1-5天,平均2.9±1.2天。手术48例中,临床症状评分由术前6.9±1.6降至术后2.1±1.9,两者相比P<O.05。随访1月、3月及6月的症状缓解率分别为87.5%(42/48)、85%(34/40)和84.2%(16/19)。20例患者术前食管下段括约肌静息压为(29.1±17.0)mmHg,术后1周为(14.6±4.9)mmHg,P<0.05；而术前后食管下端括约肌松弛压和松弛率无显著变化；食管未恢复蠕动。研究结论1.肠间质细胞和一氧化氮合酶在食管下括约肌中分布和表达异常,两者可能与贲门失弛缓症发病有关。2.经口内镜下肌切开术治疗贲门失弛缓症,成功率高,围术期短,无严重并发症,临床疗效满意。更多还原

【Abstract】 ObjectiveTo investigate the role of nitric oxide(NO) and interstitial cell of Cajal (ICC) on the pathogenesis of AC.To evaluate the clinical outcome and value of per-oral endoscopic myotomy (POEM) for treatment of AC.Methods1. Between August2011and December2011,16patients with AC enrolled in endoscopy center of the Zhongshan Hospital were the experimental group. Of them,there were9males and7females, the median age45years old (ranged from22years～71years). All of them were diagnosed by clinical symptoms, chest radiography, endoscopy and manometry. The experimental group specimens were gotten by biopsying lower esophageal sphincter during POEM procedure. The15LES surgical specimens of non-esophageal motility disorders were obtained as controll group. There were8males and7females, with the median age48years old (ranged form38years～65years). All specimens were made into paraffin sections and were examined by immunohistochemical staining method. Under light microscope,we observed the distribution of ICC and expression of NOS:ICC was calculated and the staining intensity of NOS was Semi-quantitativly evaluated to select field of vision at random.2. The50cases of patients with AC diagnosed by clinical symptoms, chest radiography, endoscopy and manometry between July2011and December2011were enrolled in the study. All patients were treated by POEM technique. The surgical complications and postoperative adverse was observed, and compare the changes of patients’ clinical symptom score and esophageal motility before and after surgery。Results1. Observed under light microscope, ICC was distributed and NOS was expressed in the LES. ICC was fusiform with two elongated apophysis. ICC was linked by apophysis and parallel distributed with smooth muscle cells. The density of ICC in the experimental group was reduced and apophysis was less obvious compared to that in control group showed the defference between AC and normal control (P=0.01). Likewise, NOS positive nerve fibers was visible in LES,.NOS positive nerve fibers were absent and the strength of staining was weaker in AC group compared to that in control group showed the defference (P=0.13)2. A total of50patients were recruited into the present study. Among them,10cases were treated by balloon dilation(1case treated with12times,1case with2times),1case treated with Heller operation,6case with durgs and4with botulinumpoisonous injected; and10cases had sigmoid esophageal.Only one case with2-time balloon dilation was failed to POEM. Another case was diagnosed as tumor by endoscopic ultrasound and was exculated from the study. The POEM success rate is97.9%.2case(4.2%) was bled with successfully treated by hot biopsy forceps coagulation and6cases(12.5%) got subcutaneous emphysema without necessary treatment during operation. Postoperative, there were16cases(33.3%) of little small amout pleural effusion,14cases(29.2%) of pneumoperitoneum and7cases(14.5%) of pneumothorax with only3cases treated by closed thoracic drainage treatment. Postoperative adverse events were abdominal dull pain discomfort in14patients(29.2%), chest tightness in2cases(4.2%) and shortness of breath in1case(2.1%). The discomfort symptoms had no apparent effect for patients and disappeared in two days. The average operative time was33±12.4min(ranged10min to60min) and average hospital stay was2.9±1.2days (ranged1to5days),them were shorten compared to thoracoscopic and laparoscopic Heller myotomy. The clinical symptom score decreased from preoperative6.9±1.6to2.1±1.9in48cases,P<0.05.The follow-up symtomy remission rate was87.5%(42/48),85%(34/40) and84.2%(16/19) respectively in first, third and sixth month after the operation. The LESP of20patients decreased from preoperative(29.1±17.0)mmHg to1-week postoperative (14.6±4.9)mmHg, P<0.05.But IRP, LESRR and esophageal motion mode were no significant changed.Conclusions1. These findings suggest an abnormal distribution and of ICC and NOS in LES be responsible for AC.2. There was a high success rate, shorten perioperative time,no serisous complications and satisfactory clinical effect using POEM for treatment to AC.更多还原