食道弛緩不能之新進展

Achalasia: An Update

蔡豐百(Feng-Pai Tsai) ； 黃俊輔(Chun-Fu Huang) ； 吳家豪(Chia-Hao Wu) ； 張善涵(Shan-Han Chang) ； 陳建全(Chien-Chuan Chen) ； 王秀伯(Hsiu-Po Wang) ； 曾屏輝(Ping-Huei Tseng)

《內科學誌》 31卷6期 (2020/12) Pp. 377-389

https://doi.org/10.6314/JIMT.202012_31(6).01

摘要

食道弛緩不能（achalasia）是一種少見的原發性食道蠕動異常疾病（primary esophageal motility disorder），主要造成患者吞嚥時中下段食道無法蠕動及下食道括約肌（lower esophageal sphincter, LES）無法正常放鬆，目前認為其神經節功能喪失與第一型單純疱疹病毒（herpes simplex virus, type 1, HSV-1）感染所引發的自體免疫反應有關，患者也被認為可能具有基因易感性（genetic susceptibility）。常見症狀包括吞嚥困難（dysphagia）、食道逆流（regurgitation）、胸痛及體重減輕等等。上消化道內視鏡檢查與鋇劑X光檢查皆能提供臨床診斷線索，高解析度食道壓力檢測（high resolution esophageal manometry, HRM）則是現今的黃金診斷工具，藉由HRM，食道弛緩不能又分為三種亞型，與治療反應及治療決策有關。除了目前傳統的氣球擴張術（pneumatic dilatation, PD）與腹腔鏡Heller氏賁門肌肉切開術（laparoscopic Heller myotomy, LHM）之外，經口內視鏡肌肉切開術（Per-oral endoscopic myotomy, POEM）是近年來蓬勃發展的新治療選擇，其不論是安全性或治療效果皆不亞於或甚至更優於其他的治療選項，因此為世界各醫學中心廣為採用且備受期待，然而其術後可能伴隨著胃食道逆流的發生，目前亦尚無治療成效長期追蹤的結果，期待未來有更多大型研究的驗證及進一步的發展。

關鍵字

食道弛緩不能（Achalasia） ； 經口內視鏡肌肉切開術（Per-oral endoscopic myotomy, POEM） ； 氣球擴張術（Pneumatic dilatation, PD） ； Heller氏賁門肌肉切開術（Laparoscopic Heller myotomy, LHM） ； 高解析度食道壓力檢測（High resolution manometry, HRM）

並列摘要

Achalasia is an uncommon primary esophageal motility disorder, which causes impaired relaxation of the lower esophageal sphincter and absent esophageal peristalsis. It is associated with functional loss of myenteric plexus ganglion cells in the distal esophagus and lower esophageal sphincter. The initiation of neuronal degeneration may be an autoimmune process triggered by latent Herpes simplex virus type 1 infection in conjunction with a genetically susceptible host. The cardinal symptoms include dysphagia, typically to solids and liquids, regurgitation, chest pain and weight loss. Both barium swallow and esophagogastroduodenoscopy (EGD) reveal some clues of achalasia, while they may be normal in early achalasia. Timed barium esophagogram (TBE) further helps to assess the esophageal emptying after treatment. High resolution esophageal manometry (HRM) is the diagnostic gold standard, which classify achalasia into 3 subtypes, and is considered mandatory before planning achalasia therapy. Per-oral endoscopic myotomy (POEM) is a revolutionizing achalasia therapy. A number of studies demonstrate that POEM produces comparable results compared to standard laparoscopic Heller myotomy (LHM) or pneumatic dilatation (PD). However, gastroesophageal reflux seemed to be more common among patients who underwent POEM; furthermore, few long-term follow-up studies are available. Longer duration of follow-up of patients who have undergone POEM is needed.