Zenker憩室及完全性咽食管梗阻腔内治疗的演变

文献信息

中文摘要

综述目的： 前肠手术的内镜方法，尤其是上食管括约肌（UES）的内镜方法，持续发展，为既往无法处理的疾病提供了治疗选择。本综述探讨用于治疗Zenker憩室及更为罕见的完全性食管狭窄的腔内手术隧道方法（第三空间内镜）。

近期发现： 针对UES的腔内手术方法，如利用胃镜和上消化道内镜器械进行的Z-POEM（经口内镜下肌切开术），正越来越多地用于UES功能障碍的治疗，具有良好的安全性和实用性。这些技术的优势包括：克服入路问题（牙关紧闭、骨赘和颈部僵硬）、能够在保留黏膜的同时处理隔膜至其基底部，以及通过术野注气获得更好的视野。目前已有多种这些技术的变体被报道，应用范围也在不断扩大。POETRE（经口内镜下隧道术用于食管重建）已被描述用于处理完全性食管腔闭塞，我们描述了将该技术作为“ rendezvous 手术”的一种变体应用，以成功重建下咽至食管和胃的通道。

总结： 针对上食管括约肌和食管的微创腔内“第三空间”方法提供了安全的入路、增强的视野，并能够在老年人群中处理UES和食管疾病，因为在这些人群中，解剖问题可能阻碍硬性内镜操作，而开放手术会增加并发症风险。Z-POEM和POETRE可成功应用于治疗Zenker憩室、环咽肌功能障碍和完全性下咽-食管梗阻。第三空间内镜促进了临床医生与各亚专科之间的合作，使患者获益。

英文摘要

PURPOSE OF REVIEW: Endoscopic approaches to surgery of the foregut, in particular, the upper oesophageal sphincter (UES), continue to develop, providing options for management that were previously unavailable. This review examines endoluminal surgical tunnelling approaches (third space endoscopy) to treat Zenker diverticulum and the more rare condition of complete oesophageal stenosis.
RECENT FINDINGS: Endoluminal surgical approaches to the UES such as Z-POEM (per-oral endoscopic myotomy) that utilize gastroscopes and upper gastrointestinal endoscopic instrumentation, are increasingly being utilized for management of UES dysfunction, with excellent safety and utility. Advantages of these techniques include overcoming access issues (trismus, osteophytes, and neck rigidity), ability to address the septum to its base whilst preserving mucosa, and enhanced visualization provided by insufflation in the surgical field. Multiple variations of these techniques are being reported, and the scope of application is expanding. POETRE (per-oral endoscopic tunnelling for restoration of the oesophagus) has been described to manage complete oesophageal luminal occlusion, and we describe application of this technique as a variation of the 'rendezvous procedure' to successfully reestablish communication from hypopharynx to oesophagus and stomach.
SUMMARY: Minimal access endoluminal 'third space' approaches to the upper oesophageal sphincter and oesophagus provide safe access, enhanced visualization and the ability to manage UES and oesophageal disease in the elderly population where anatomical issues may impede rigid endoscopy and open approaches contribute enhanced risk of complications. Z-POEM and POETRE can be successfully applied to treat Zenker diverticuli, cricopharyngeal dysfunction and complete hypopharyngeal-oesophageal obstruction. Third space endoscopy promotes increased collaboration between clinicians and subspecialities for the benefit of patients.