经口内镜下肌切开术治疗贲门失弛缓症的"中山规范"
Practice guideline of peroral endoscopic myotomy of achalasia: Zhongshan experience
经口内镜下肌切开术(POEM)是一种通过食管黏膜下隧道进行肌切开的内镜微创技术.自2010年问世以来,因其微创和良好的疗效,已广泛用于治疗贲门失弛缓症和食管动力障碍性疾病.针对POEM手术,复旦大学附属中山医院结合自身经验参考国内外文献,提出POEM治疗贲门失弛缓症诊疗的"中山规范",主要包括以下几点,谨与同道分享.(1)术前评估:根据临床症状评估、胃镜检查、高分辨率测压和上消化道造影进行诊断.(2)适应证选择:特发型贲门失弛缓症是绝对适应证,强调年龄不再是禁忌证.(3)手术开展要求:除限于有合法资质的医疗中心开展外,术者应是接受过规范化专业技术培训、有5年以上胃肠专科临床经验、超过30例食管内镜黏膜下剥离术治疗经验者.(4)手术操作:肌切开长度为8~10 cm,肌切开推荐位置是食管前壁或后壁,至于是全层肌切开还是环形肌切开,需根据患者病情制定个体化方案.(5)围手术期:如出现胸腔积液、肺不张及气胸情况,应行CT检查诊断;如出现呕血、高热等症状,及时复查胃镜和上消化道碘水造影,对症处理.(6)手术相关并发症:主要为黏膜损伤、穿孔、出血、气胸和胸腔积液.(7)疗效评估与随访:采用Eckardt评分系统进行症状评分,行胃镜检查进行客观评估.
更多Peroral endoscopic myotomy (POEM) is a novel clinical technique developed in 2010, and has been widely accepted for treating achalasia and esophageal motility disorders, because of its minimal invasiveness and good efficacy. Zhongshan Hospital has published the practice guideline (the "Zhongshan experience") of peroral endoscopic myotomy of achalasia (v1.2018) based on experience combined with literatures. (1) Preoperative evaluation includes clinical symptom assessment, gastroscopy, high?resolution manometry and upper gastrointestinal radiography. (2) Absolute indication is idiopathic achalasia, and age is no longer a contraindication. (3) The criteria include the medical centers with legal qualifications and the operators with over 5 years of clinical experience in gastroenterological surgery or gastroenterology and more than 30 cases of esophageal endoscopic submucosal dissection (ESD). (4) The length of the myotomy is 8 to 10 cm. The recommended location of the myotomy is the anterior or posterior wall. Whether a full?thickness or circular muscle myotomy is chosen is based on patient′s condition. (5) If pleural effusion, atelectasis or pneumothorax occurs, CT examination is recommended during the postoperative period. If patients presents with symptoms such as vomiting and high fever, endoscopic examination and upper gastrointestinal radiography should be performed. (6) Major adverse events include mucosal injury, perforation, bleeding, pneumothorax and pleural effusion. (7) The Eckardt score system and endoscopic examination are used for evaluating the effectiveness after POEM.
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