贲门失弛缓症与麻醉

2020
06/15

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贲门失弛缓症与麻醉

贲门失弛缓症

英文名:

achalasia of cardia

esophageal achalasia

Achalasia

别称:

贲门痉挛、巨食管。

定义:

是由于食管贲门部的神经肌肉功能障碍所致的食管功能障碍引起食管下端括约肌弛缓不全,食物无法顺利通过而滞留,从而逐渐使食管张力、蠕动减低及食管扩张的一种疾病。

主要特征:

食管缺乏蠕动,食管下端括约肌(LES)高压和对吞咽动作的松弛反应减弱。

临床表现:

吞咽困难、胸骨后疼痛、食物反流以及误吸入气管所致咳嗽、肺部感染等症状。

下面这篇文献对这一疾病的诊断和治疗进行了综述,其摘要如下:

95961592089510041

食管失弛缓症是一种不明原因的原发性食管动力障碍,其特征是缺乏蠕动,吞咽时食管下括约肌松弛不完全或无松弛。治疗的目的是消除胃食管交界处的功能性梗阻。本综述将评估当前文献,阐述诊断进展,提供基于证据的治疗策略。专家点评:今天,我们有三种非常有效的治疗方法来治疗贲门失弛缓症-气动扩张术,经口内窥镜肌切开术,和腹腔镜海勒肌切开术伴胃底折叠术。治疗应针对患者个体,多学科协作。食道切除术应被视为先前治疗失败的患者的最后手段。

关键词:Dor胃底折叠术;食管失弛缓症;海勒肌切开术;吞咽困难;食管测压;经口内镜下肌切开术;充气扩张术。

原文摘要

Esophageal Achalasia: Current Diagnosis and Treatment

Esophageal achalasia is a primary esophageal motility disorder of unknown origin, characterized by lack of peristalsis and by incomplete or absent relaxation of the lower esophageal sphincter in response to swallowing. The goal of treatment is to eliminate the functional obstruction at the level of the gastroesophageal junction. Areas covered: This comprehensive review will evaluate the current literature, illustrating the diagnostic evaluation and providing an evidence-based treatment algorithm for this disease. Expert commentary: Today, we have three very effective therapeutic modalities to treat patients with achalasia - pneumatic dilatation, peroral endoscopic myotomy, and laparoscopic Heller myotomy with fundoplication. Treatment should be tailored to the individual patient, in centers where a multidisciplinary approach is available. Esophageal resection should be considered as a last resort for patients who have failed prior therapeutic attempts.

Keywords: Dor fundoplication; Esophageal achalasia; Heller myotomy; dysphagia; esophageal manometry; per oral endoscopic myotomy; pneumatic dilatation.

这类患者行经口内窥镜肌切开术时麻醉的注意事项有哪些呢?

可以参考下面这篇综述,其摘要如下:

89391592089510091

经内镜下肌切开术的麻醉:文献回顾

特发性贲门失弛缓症是一种食管运动障碍,对麻醉和围手术期处理有重要影响。随着新的和更复杂的治疗方案的发展,麻醉医生越来越多地介入到这些病人治疗中。贲门失弛缓症的主要症状有:吞咽困难、反流、胸痛和体重减轻。贲门失弛缓症也会增加误吸的风险。患者经常接受内镜肉毒杆菌毒素注射、食管下括约肌充气扩张、腹腔镜海勒肌切开术或经口内镜肌切开术(POEM)治疗。POEM手术是基于“自然口腔镜手术”的概念,由于POEM过程中故意中断食管壁的完整性,可能暴露纵隔和腹腔。因此,吸入的二氧化碳经常导致高碳酸血症、张力性腹膜透析、腹膜透析或气胸。一个跨学科的团队,能熟练的诊断和采取紧急措施,如治疗性过度通气,经皮腹针穿刺减压术,或胸膜引流,是成功的POEM围手术期处理的必要条件。POEM是一种需要全身麻醉的内镜手术。但目前这些患者既没有麻醉专用策略,也没有循证证据推荐。由于机构经验在全球范围内有很大差异,本文回顾了基于7个回顾性病例研究、1个前瞻性研究和我们的个人经验的POEM手术的麻醉建议和围手术期管理。

原文摘要

Anesthesia for Patients Undergoing Peroral Endoscopic Myotomy Procedures: A Review of the Literature

Idiopathic achalasia is a motility disorder of the esophagus with important implications on anesthesia and periprocedural management. As new and more complex treatment options develop, anesthesiologists are increasingly involved with these patients. The cardinal symptoms of achalasia are as follows: dysphagia, regurgitation, chest pain, and weight loss. Achalasia is also associated with an increased risk of aspiration. Patients are frequently treated by endoscopic botulinum toxin injections, pneumatic dilation of the lower esophageal sphincter, laparoscopic Heller myotomy, or peroral endoscopic myotomy (POEM). The POEM procedure is based on the concept of "natural orifice transluminal endoscopic surgery." Because the integrity of the esophageal wall is deliberately interrupted during POEM, the mediastinum and the peritoneal cavity may be exposed. Thus, the insufflated carbon dioxide frequently causes hypercapnia, tension capnoperitoneum, capnomediastinum, or pneumothoraces. An interdisciplinary team, skilled in diagnostics and emergency measures such as therapeutic hyperventilation, percutaneous abdominal needle decompression, or pleural drainage, is essential for the successful periprocedural management of POEM. POEM is one endoscopic procedure that requires general anesthesia. But neither anesthesia-specific care algorithms nor evidence-based recommendations are currently available for these patients. Because institutional experience varies broadly across the globe, this review examines anesthesia recommendations and perioperative management of POEM procedures based on 7 retrospective case series, 1 prospective study, and our personal experience.

牛津临床麻醉手册总结的

贲门失驰缓症的特征:

食管远端2/3运动异常、

不能松弛、

吞咽困难和反流,

恶性变风险。

麻醉要点:

胃反流的危险性增加。

参考文献

百度百科

牛津临床麻醉手册

原始文献:

1. Schlottmann F, Patti MG. Esophageal achalasia: current diagnosis and treatment. Expert Rev Gastroenterol Hepatol. 2018;12(7):711‐721. doi:10.1080/17474124.2018.1481748

2. Löser B, Recio Ariza O, Saugel B, et al. Anesthesia for Patients Undergoing Peroral Endoscopic Myotomy Procedures: A Review of the Literature. Anesth Analg. 2020;130(5):1331‐1340. doi:10.1213/ANE.0000000000004420

本文由作者自行上传,并且作者对本文图文涉及知识产权负全部责任。如有侵权请及时联系(邮箱:guikequan@hmkx.cn
关键词:
食管,治疗,麻醉

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