伴有无效食管动力的胃食管反流病用药和手术治疗的效果对比

doi:10.3877/cma.j.issn.1674-0793.2024.01.004

目的

探讨伴有无效食管动力（IEM）的胃食管反流病（GERD）患者进行腹腔镜胃底折叠术和药物治疗的效果。

方法

依据选择标准纳入57例伴有IEM的GERD患者，应用倾向性评分匹配（PSM）进行1∶2匹配。对比两组患者治疗前后的胃食管反流病问卷（GerdQ）评分、GERD-HRQL生活质量评分、食管动力和治疗后消化道症状。

结果

（1）经PSM匹配后纳入39例患者，其中手术组13例（腹腔镜胃底折叠术治疗），药物组26例（艾司奥美拉唑+莫沙必利方案），两组基线年龄、性别、体质指数、食管裂孔疝伴发情况和病程达到均衡。（2）手术组治疗后1、6个月分别比药物组GerdQ评分值低（均P<0.05）。（3）手术组治疗后6个月的GERD-HRQL评分改善值比药物组大（均P<0.001）。（4）药物组患者远端收缩积分（DCI）较基线增大（P<0.05）。手术组患者食管下括约肌（LES）静息压、松弛压4 s中值、LES残余压与术前相比增大，且均高于同期药物组（均P<0.05）。（5）手术组治疗后1个月时吞咽困难发生率高于药物组（P<0.001），6个月后缓解且与药物组差异无统计学意义（P=0.593）。

结论

LES低压的GERD患者存在IEM，如果多次快速吞咽试验有吞咽储备，腹腔镜胃底折叠术可以有较好的短期效果，长期效果有待进一步随访。与药物治疗相比，腹腔镜胃底折叠术能较好地改善伴有IEM的GERD患者症状和生活质量，但要防范术后短期出现的吞咽困难。

关键词: 胃食管反流病, 无效食管动力, 腹腔镜胃底折叠术, 药物治疗, 倾向性评分匹配

Objective

To compare the effects of surgical and medical therapy on ineffective esophageal motility (IEM) in patients with gastroesophageal reflux diseases (GERD).

Methods

According to the inclusion and exclusion criteria, a total of 57 GERD patients with IEM met the study criteria were selected. They were 1∶2 matched by applying propensity score matching. The gastroesophageal reflux disease questionnaire (GerdQ) score, GERD-health related quality of life questionnaire (GERD-HRQL) score, esophageal dynamics before and after treatment and digestive symptoms after treatment between the two groups were compared.

Results

(1) After PSM matching, 39 patients were finally included in the study, including 13 patients undergoing laparoscopic fundoplication surgery in the operation group and 26 patients undergoing esomeprazole+mosapride regimen in the medication group. Baseline data of the two groups were balanced. (2) The GerdQ scores of patients in the operation group 1 month and 6 months after treatment were lower than those of patients in the medication group, respectively (both P<0.05). (3) The improvement in GERD-HRQL scores in the operation group at 1 month and 6 months after treatment was greater than that in the medication group (P<0.001). (4) Distal contractile integral (DCI) in the medication group was higher than the baseline value before treatment (P<0.05). Lower esophageal sphincter (LES) resting pressure, median integrated relaxation pressure 4 s (IRP4) and LES residual pressure were increased in the operation group compared to the preoperative level, with statistically differences, and the levels of which were also higher than those of the medication group during the same period (all P<0.05). (5) The incidence of dysphagia in operation group was more common than that in the medication group 1 month after treatment (P<0.001), while there was no statistical difference between the two groups in incidence of dysphagia 6 months later (P=0.593).

Conclusions

IEM exists in GERD patients with lower LES pressure and if multiple rapid swallowing tests have swallowing reserve, laparoscopic fundoplication surgery can have good short-term effect, while the long-term effect needs to be further followed up. Compared with medication treatment, laparoscopic fundoplication surgery can better improve the symptoms and quality of life of GERD patients with IEM, but it is necessary to prevent the short-term postoperative dysphagia.

Key words: Gastroesophageal reflux diseases, Ineffective esophageal motility, Laparoscopic fundoplication surgery, Drug therapy, Propensity score matching

图1 患者纳入及分配流程图　高分辨率食管测压（HRM）；无效食管动力（IEM）；胃食管反流病（GERD）；倾向性评分匹配（PSM）

表1 匹配后的伴有无效食管动力的胃食管反流病患者基线资料

组别	例数	年龄(岁, ±s)	性别(男, %)	体质指数(kg/m²)	食管裂孔疝[例(%)]	病程(年)
药物组	26	53.62±15.05	16(61.5)	23.14±2.78	8(30.7)	4.22±4.20
手术组	13	53.46±13.64	8(61.5)	22.96±3.09	6(46.1)	4.70±3.85
t值		0.027	0.828	-0.163	-0.784	-0.305
P值		0.978	0.416	0.872	0.420	0.763

表1 匹配后的伴有无效食管动力的胃食管反流病患者基线资料

组别	例数	年龄(岁, ±s)	性别(男, %)	体质指数(kg/m²)	食管裂孔疝[例(%)]	病程(年)
药物组	26	53.62±15.05	16(61.5)	23.14±2.78	8(30.7)	4.22±4.20
手术组	13	53.46±13.64	8(61.5)	22.96±3.09	6(46.1)	4.70±3.85
t值		0.027	0.828	-0.163	-0.784	-0.305
P值		0.978	0.416	0.872	0.420	0.763

表2 两组伴有无效食管动力的胃食管反流病患者治疗前后GerdQ评分比较(分，±s)

组别	例数	治疗前基线值	治疗后1个月	治疗后6个月
手术组	13	12.31±2.09	6.54±1.66^a	5.69±1.43^a
药物组	26	10.92±2.32	9.69±2.65^b	8.23±3.00^a
t值		-1.594	3.626	2.404
P值		0.216	0.001	0.014

表2 两组伴有无效食管动力的胃食管反流病患者治疗前后GerdQ评分比较(分，±s)

组别	例数	治疗前基线值	治疗后1个月	治疗后6个月
手术组	13	12.31±2.09	6.54±1.66^a	5.69±1.43^a
药物组	26	10.92±2.32	9.69±2.65^b	8.23±3.00^a
t值		-1.594	3.626	2.404
P值		0.216	0.001	0.014

表3 两组伴有无效食管动力的胃食管反流病患者治疗前后GERD-HRQL评分比较(分，±s)

组别	例数	治疗前基线值	治疗后1个月	改善值	治疗后6个月	改善值
手术组	13	11.00±2.79	4.85±2.30^a	6.15±2.94	1.08±1.03^a	9.92±2.98
药物组	26	7.15±3.82	9.54±9.06^b	-2.15±6.08	8.92±9.46^b	-0.85±8.03
t值				-4.435		-4.553
P值				<0.001		<0.001

表3 两组伴有无效食管动力的胃食管反流病患者治疗前后GERD-HRQL评分比较(分，±s)

组别	例数	治疗前基线值	治疗后1个月	改善值	治疗后6个月	改善值
手术组	13	11.00±2.79	4.85±2.30^a	6.15±2.94	1.08±1.03^a	9.92±2.98
药物组	26	7.15±3.82	9.54±9.06^b	-2.15±6.08	8.92±9.46^b	-0.85±8.03
t值				-4.435		-4.553
P值				<0.001		<0.001

表4 两组伴有无效食管动力的胃食管反流病患者治疗前后HRM比较(±s)

项目	手术组	药物组	t值	P值
例数	13	26
治疗前
UES长度(cm)	2.66±0.68	3.18±0.96	1.567	0.130
UES静息压(mmHg)	48.59±33.59	42.60±34.38	-0.449	0.658
UES残余压(mmHg)	9.86±12.37	6.75±9.36	-0.724	0.476
LES长度(cm)	2.58±0.66	2.93±0.53	1.501	0.146
LES静息压(mmHg)	9.42±4.44	9.17±4.20	-0.145	0.886
IRP4中值(mmHg)	2.59±1.96	2.83±2.49	0.271	0.789
LES残余压(mmHg)	3.54±2.15	3.74±2.94	0.198	0.845
无效收缩(%)	71.54±31.05	91.54±13.44	2.131	0.054
失败收缩(%)	33.85±37.75	45.38±36.65	0.791	0.437
蠕动中断(cm)	5.91±4.00	6.90±4.27	0.606	0.550
最大蠕动中断(cm)	4.67±2.76	4.98±3.70	0.240	0.812
远端潜伏期(s)	7.53±1.30	8.13±1.64	1.030	0.313
DCI(mmHg·s·cm)	365.00(203.00,782.00)	211.00(123.00,376.00)	-2.004	0.061
治疗后
UES长度(cm)	2.51±0.49	5.72±8.44	1.368	0.184
UES静息压(mmHg)	51.12±39.04	35.57±20.31	-1.273	0.215
UES残余压(mmHg)	8.33±9.87	10.80±16.61	0.461	0.649
LES长度(cm)	2.76±0.76	3.42±1.04	1.846	0.077
LES静息压(mmHg)	12.35±5.32	7.44±5.66	-2.278	0.032
IRP4中值(mmHg)	5.43±3.20	1.93±5.21	-2.061	0.040
LES残余压(mmHg)	6.55±3.53	2.35±5.49	-2.318	0.029
无效收缩(%)	66.15±37.09	77.31±29.09	0.844	0.407
失败收缩(%)	23.08±31.72	32.69±25.05	0.858	0.400
蠕动中断(cm)	6.19±4.50	5.30±3.71	-0.536	0.597
最大蠕动中断(cm)	4.46±3.33	4.36±3.21	-0.078	0.939
远端潜伏期(s)	7.97±1.12	7.93±4.41	-0.030	0.976
DCI(mmHg·s·cm)	376.00(196.00,701.50)	401.00(192.00,718.5)	-0.592	0.559

表4 两组伴有无效食管动力的胃食管反流病患者治疗前后HRM比较(±s)

项目	手术组	药物组	t值	P值
例数	13	26
治疗前
UES长度(cm)	2.66±0.68	3.18±0.96	1.567	0.130
UES静息压(mmHg)	48.59±33.59	42.60±34.38	-0.449	0.658
UES残余压(mmHg)	9.86±12.37	6.75±9.36	-0.724	0.476
LES长度(cm)	2.58±0.66	2.93±0.53	1.501	0.146
LES静息压(mmHg)	9.42±4.44	9.17±4.20	-0.145	0.886
IRP4中值(mmHg)	2.59±1.96	2.83±2.49	0.271	0.789
LES残余压(mmHg)	3.54±2.15	3.74±2.94	0.198	0.845
无效收缩(%)	71.54±31.05	91.54±13.44	2.131	0.054
失败收缩(%)	33.85±37.75	45.38±36.65	0.791	0.437
蠕动中断(cm)	5.91±4.00	6.90±4.27	0.606	0.550
最大蠕动中断(cm)	4.67±2.76	4.98±3.70	0.240	0.812
远端潜伏期(s)	7.53±1.30	8.13±1.64	1.030	0.313
DCI(mmHg·s·cm)	365.00(203.00,782.00)	211.00(123.00,376.00)	-2.004	0.061
治疗后
UES长度(cm)	2.51±0.49	5.72±8.44	1.368	0.184
UES静息压(mmHg)	51.12±39.04	35.57±20.31	-1.273	0.215
UES残余压(mmHg)	8.33±9.87	10.80±16.61	0.461	0.649
LES长度(cm)	2.76±0.76	3.42±1.04	1.846	0.077
LES静息压(mmHg)	12.35±5.32	7.44±5.66	-2.278	0.032
IRP4中值(mmHg)	5.43±3.20	1.93±5.21	-2.061	0.040
LES残余压(mmHg)	6.55±3.53	2.35±5.49	-2.318	0.029
无效收缩(%)	66.15±37.09	77.31±29.09	0.844	0.407
失败收缩(%)	23.08±31.72	32.69±25.05	0.858	0.400
蠕动中断(cm)	6.19±4.50	5.30±3.71	-0.536	0.597
最大蠕动中断(cm)	4.46±3.33	4.36±3.21	-0.078	0.939
远端潜伏期(s)	7.97±1.12	7.93±4.41	-0.030	0.976
DCI(mmHg·s·cm)	376.00(196.00,701.50)	401.00(192.00,718.5)	-0.592	0.559

表5 两组伴有无效食管动力的胃食管反流病患者治疗后消化道症状[例(%)]

组别	例数	吞咽困难		腹痛		恶心		嗳气
组别	例数	1个月	6个月	1个月	6个月	1个月	6个月	1个月	6个月
手术组	13	12(92.3)	1(7.7)	0(0)	0(0)	1(7.7)	0(0)	1(7.7)	1(7.7)
药物组	26	3(11.5)	3(11.5)	8(30.8)	8(30.8)	6(23.1)	9(34.6)	4(15.4)	5(19.2)
P值		<0.001	0.593	0.025	0.025	0.388	0.018	0.648	0.643

表5 两组伴有无效食管动力的胃食管反流病患者治疗后消化道症状[例(%)]

组别	例数	吞咽困难		腹痛		恶心		嗳气
组别	例数	1个月	6个月	1个月	6个月	1个月	6个月	1个月	6个月
手术组	13	12(92.3)	1(7.7)	0(0)	0(0)	1(7.7)	0(0)	1(7.7)	1(7.7)
药物组	26	3(11.5)	3(11.5)	8(30.8)	8(30.8)	6(23.1)	9(34.6)	4(15.4)	5(19.2)
P值		<0.001	0.593	0.025	0.025	0.388	0.018	0.648	0.643

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Effects of medical versus surgical therapy on ineffective esophageal motility in patients with gastroesophageal reflux diseases

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Effects of medical versus surgical therapy on ineffective esophageal motility in patients with gastroesophageal reflux diseases