アカラシアに対する口腔内視鏡下筋切除術後の下部食道括約筋の遮断と嚥下障害の緩和との関係

The relationship between the interruption of the lower esophageal sphincter and relief of dysphagia after per-oral endoscopic myotomy for achalasia.

• Sheng Wang
• Xiang Liu
• Nan Ge
• Guoxin Wang
• Jintao Guo
• Wen Liu
• Jinlong Hu
• Siyu Sun

抄録

背景と目的:

口腔周囲内視鏡下筋切開術（POEM）で治療した食道アカラシア患者を対象に，EUSで測定した下部食道括約筋突起（LES）の遮断と嚥下障害の軽減との関係を検討した．

Background and Objectives: We investigated the relationship between the interruption of the muscularis propria of the lower esophageal sphincter (LES) measured by EUS and the relief of dysphagia in patients with esophageal achalasia treated by per-oral endoscopic myotomy (POEM).

患者と方法:

2015年1月から2016年8月までの間に当院内視鏡センターでPOEMにより治療を受けたアカラシア患者を対象とした。術前の臨床的特徴、嚥下障害とEckardtスコア、術後合併症、術後3ヶ月と7ヶ月の嚥下障害とEckardtスコア、術後胃食道逆流症（GERD）の発症率を記録した。患者は、EUSで測定されたLESでの前庭筋分離の程度によって2群に分けられ、A群は分離距離2～5mm、B群は分離距離5～9mmで比較された。

Patients and Methods: Patients with achalasia treated by POEM at our endoscopy center between January 2015 and August 2016 were included in the study. Preoperative clinical characteristics and dysphagia and Eckardt scores, operative and postoperative complications, dysphagia and Eckardt scores at 3- and 7-months postoperatively, and the incidence of postoperative gastroesophageal reflux disease (GERD) were recorded. Patients were divided into two groups according to the degree of separation of the muscularis propria at the LES, as measured by EUS: Group A, separation distance 2-5 mm and Group B, separation distance 5-9 mm, for comparison.

結果:

術前の臨床的特徴、Eckardtスコア、嚥下障害スコアは両群で同程度であった。両群とも術後の症状は有意に軽減し、Eckardtスコアと嚥下障害スコアは有意に減少した。両群間の比較では、術後のEckardtスコアに有意差はなかったが、嚥下障害スコアはB群がA群に比べて統計学的に有意に低かった（P < 0.05）。ガス関連合併症の発生率、術後GERDの発生率には両群間に有意差はなかった。

Results: Preoperative clinical characteristics, Eckardt scores, and dysphagia scores were similar in the two groups. Patients in both groups had significant symptom relief postoperatively, with significant decreases in Eckardt scores and dysphagia scores. On the comparison between the groups, there was no significant difference in postoperative Eckardt score, but the dysphagia score was statistically significantly lower in Group B as compared to Group A (P < 0.05). There was no significant difference between the groups in the incidence of gas-related complications or in the incidence of postoperative GERD.

結論:

本研究では、POEMは食道アカラシアの治療に概ね有効であった。筋腫切開後の大脳小脳前庭筋の欠損が大きい患者では、術後合併症の発生率を増加させることなく、より大きな嚥下障害の緩和が得られた。

Conclusions: POEM was largely effective in the treatment of esophageal achalasia in this study. Patients with larger defects of the muscularis propria at the LES after myotomy had greater relief of dysphagia without an increased incidence of postoperative complications.