Značaj savremene radiološke dijagnostike u hirurškom lečenju pacijenata sa ahalazijom

Abstract

Ahalazija predstavlja hronični, neizlečivi primarni motorni premećaj jednjaka nepoznate etiologije koji se karakteriše odsustvom peristaltike tela jednjaka i nemogućnošću DES-a da se adekvatno relaksira tokom akta gutanja. Iako je etiologija ahalazije nepoznata, pretpostavlja se da je patofiziologija nastanka ovog oboljenja u osnovi autoimunog, virusnog, ili neurodegenerativnog porekla. Ahalazija se javlja sa prosečnom incidencom od oko 1 na 100.000 i prevalencom od oko 10 na 100.000 osoba. Osnovni simptomi bolesnika su: disfagija, regurgitacija i retrosternalni bol. I pored činjenice da manometrija jednjaka danas predstavlja “zlatni standard” u dijagnostici ahalazije, na raspolaganju je i čitav spektar konvencionalnih i savremenih radioloških metoda, čiju je vrednost u preoperativnoj dijagnostici i predikciji uspeha hirurškog lečenja potrebno ispitati. Cilj: Analizom simptomatološkog upitnika, kao i morfoloških i funkcionalnih karakteristika jednjaka vizualizovanih primenom sledećih radioloških metoda: rendgenskog pregleda sa vremenski definisanom barijumskom ezofagografijom (VDBE), multidetektorske kompjuterizovane tomografije (MDCT) i funkcionalne magnetne rezonance (fMR), pre i nakon operacije (kardiomiotomije), moguće je načiniti pouzdanu predikciju funkcionalnog i simptomatološkog ishoda hirurškog lečenja kod bolesnika sa ahalazijom. Metod: U kohortnoj grupi ispitanika koji su imali dokazanu ahalaziju manometrijskim ispitivanjem bilo je 60 bolesnika. Istraživanje je vršeno u periodu od oktobra 2015. do kraja 2016. godine u Odseku digestivne radiologije Centra za radiologiju i magnetnu rezonancu i Centru za hirurgiju jednjaka Klinike za digestivnu hirurgiju Kliničkog centra Srbije. Simptomatološki upitnik po metodi Vaezi-ja je korišćen pre pregleda i 3 meseca nakon operacije. Od radioloških dijagnostičkih metoda primenjivane su rendgenografija pluća i srca, rendgenski pregled jednjaka sa VDBE, CT i fMR. Stacionarna manometrija je predstavljala “zlatni standard” za preoperativno utvrđivanje tipa ahalazije (1, 2 ili 3). Po završenoj dijanostici svi bolesnici su operisani laparoskopskom ekstramukoznom longitudinalnom ezofagokardiomiotomijom po Heller-u (LHM) sa prednjom parcijalnom fundoplikacijom po Dor-u. . Rezultati: U postoperativnom praćenju došlo je značajnog smanjenja simptom-skora svih bolesnika, sa statistički značajnom razlikom između grupa (p=0.08) i najuočljivijim uspehom kod bolesnika sa ahalazijom tip 1. Na osnovu postoperativnog smanjenja simptom-skora procenjena je uspešnost LHM u intervalu od 96,4–99,5%. Postoperativno je došlo do značajne promene (smanjenja) u visini i širini stuba barijumskog kontrasta izmerenog na VDBE u vremenskom intervalu od 1, 2 i 5 minuta kod svih bolesnika (p˂0.001)...

Achalasia is a chronic, non-persistent primary motor disorder of the esophagus caused by unknown etiology, characterized by the absence of peristalsis of the esophageal body and the inability of DES to relax during swallowing. It is presumed that the pathophysiology of achalasia is basically autoimmune, viral or neurodegenerative. Achalasia occurs with an average incidence about 1 per 100.000 and a prevalence about 10 per 100.000 people. The main symptoms are: dysphagia, regurgitation and retrosternal pain. Despite the fact that manometry of the esophagus represents a "gold standard" in diagnostics, there is a numerous conventional and modern radiological methods, whose values in preoperative diagnostics and prediction of the success of surgical intervention needs to be examined in every pre-operative practice. Aim: With the analysis of the symptom questionnaire, as well as morphological and functional characteristics which are visualized using the following radiological methods: X-ray with time-defined barium esophagography (VDBE), multidetector computed tomography (MDCT) and functional magnetic resonance (fMR), before and after surgery (cardiomyotomy), is possible to provide a reliable predictor of the functional and symptomatic outcome of surgical treatment in patients with achalasia. Method: Achalasia was manometrically proven in the cohort group of 60 patients. The research was conducted in the period from October 2015 to the end of 2016, in the Department for digestive radiology, Center for radiology and magnetic resonance imaging and Center for esophageal surgery Clinic for digestive surgery, Clinical Center of Serbia. The symptom questionnaire was used before the investigation and 3 months after HLM. From radiological diagnostic methods: chest X-ray, X-ray esophagography with VDBE, MDCT and fMR were performed as well as endoscopy and manometry. The symptom questionnaire by Vaezi was used before the study and 3 months after surgery. Stationary manometry was used as a “gold standard” for the preoperative determination of the different achalasia types (1-3). All patients were operated by laparoscopic extramucosal longitudinal esophagocardiomyomtomy by Heller (LHM) with anterior partial fundoplication by Dor. Results: In the postoperative follow-up, there was a significant decrease in the symptom score in all patients, with statistically significant difference between the groups (p = 0.08) with the most pronounced success in patients with achalasia type 1. According to reduction in symptom score postoperatively, the success of LHM was estimated in the range from 96.4-99.5 %. In the postoperative follow-up there was a significant decrease in the height and width of the barium contrast column measured using VDBE during the time interval in 1, 2 and 5 minutes in all patients (p˂0.001)...