腹腔镜治疗食管裂孔疝术后吞咽困难的比较

目的:探讨食管裂孔疝行腹腔镜裂孔修补术加Nissen360°胃底折叠术和Toupet270°胃底折叠术后吞咽困难的发生率.方法:回顾分析天津市南开医院2012-02/2014-02采用腹腔镜技术治疗的64例食管裂孔疝患者资料,其中行腹腔镜Nissen360°胃底折叠术32例,行腹腔镜Toupet270°胃底折叠术32例.对两组术后吞咽困难的发生率、术后反酸发生率、手术时间、术中出血量、术后Demeester评分及术后住院时间进行观察,并进行统计学分析.结果:术后Nissen组有6例出现吞咽困难,这6例吞咽困难病例均未使用补片修补,予对症治疗3 mo后,4例吞咽困难仍不能缓解,行胃镜下扩张术后症状缓解;有1例术后出现轻度反酸,经抑酸治疗后症状缓解.术中Toupet组有1例巨大食管裂孔疝使用补片修补,术后Toupet组未出现吞咽困难病例,有2例患者出现轻度反酸,经抑酸、促进胃动力治疗后症状消失.术后吞咽困难的发生率Nissen组高于Toupet组,比较有统计学差异(P0.05).两组间手术时间、术中出血量、术后反酸的发生率、术后Demeester评分及术后住院时间差异无统计学意义(P0.05).结论:食管裂孔疝患者行Nissen360°胃底折叠术术后吞咽困难的发生率高于行Toupet270°胃底折叠术.     

聚丙烯补片在腹腔镜下食管裂孔疝修补联合胃底折叠术的临床应用

目的探讨聚丙烯补片在腹腔镜下食管裂孔疝修补联合胃底折叠术治疗食管裂孔疝合并胃食管反流病的临床疗效。 方法回顾性分析新疆维吾尔自治区人民医院2013年5月至2015年3月,住院治疗并使用聚丙烯补片(强生PHY补片)行腹腔镜下食管裂孔疝修补术联合胃底折叠术的38例患者临床资料,总结上述患者术前、术后6个月24 h食管pH监测、高分辨率食管测压、胃食管反流病调查问卷(GERD-Q)量表评分及术后并发症特点。 结果全部患者手术顺利无中转术式等情况,其中Nissen术式27例,Toupet术式8例,Dor术式3例。术后患者反流症状均较术前明显改善,术后反流时间、反流次数、DeMeester评分、GERD-Q量表评分等较术前明显降低,差异有统计学意义(P<0.05),术后出现吞咽困难3例,腹部胀气2例,随访过程中无严重并发症发生,无复发。 结论使用聚丙烯补片行腔镜食管裂孔疝修补联合胃底折叠术是治疗食管裂孔疝的有效方法,具有微创、恢复快、并发症少、复发率低等特点。     

腹腔镜Nissen胃底折叠术与腹腔镜前180°部分胃底折叠术后5年临床效果的比较

目的:随机对照研究腹腔镜Nissen胃底折叠术及镜前180°部分胃底折叠术2种手术方式在术后5年的临床效果.方法:2006-03/12共有107例接受腹腔镜抗反流手术的患者随机分入腹腔镜Nissen胃底折叠术组和腹腔镜前180°部分胃底折叠术组,各组均采用标准手术操作.术后定期随访,对随访记录包括有无烧心反酸、吞咽困难、胀气症状、嗳气、是否排气过多等症状及手术满意度等进行主观评分.临床数据进行统计分析.结果:两组之间烧心症状以及服用质子泵抑制剂的比例没有显著性差异.出现吞咽困难的比例无明显差异,但是前胃底折叠术组患者吞咽困难的程度比Nissen组患者明显较轻.Nissen组的患者出现上腹胀气、无法有效嗳气及排气过多的比例较高.两组的总体临床效果满意度基本相同.术后5年大多数患者没有或只有轻微的反流症状.结论:腹腔镜前180°部分胃底折叠术抗反流效果持久,术后出现并发症及不良反应的比例明显低于Nissen胃底折叠术.腹腔镜前180°部分胃底折叠术可以作为临床治疗胃食管反流性疾病的常规手术方式.     

腹腔镜食管裂孔疝修补联合胃底折叠术治疗食管裂孔疝合并胃食管反流的临床疗效观察

目的观察腹腔镜食管裂孔疝修补联合胃底折叠术治疗食管裂孔疝合并胃食管反流的临床疗效。方法选择2015-02~2016-04该院收治的80例食管裂孔疝合并胃食管反流患者,按随机数字表法分为两组,各40例。对照组实施常规开腹手术治疗,观察组实施腹腔镜食管裂孔疝修补联合胃底折叠术治疗。比较两组患者各项手术指标、生存质量、并发症发生情况以及术后病情状况。结果观察组术中出血量、胃肠道功能恢复时间、手术时间、住院时间均短于对照组,差异有统计学意义(P0.01);观察组胸痛、烧心感、反食、反酸评分均低于对照组,差异有统计学意义(P0.01);观察组GLQI评分与对照组相比有明显提高,差异有统计学意义(P0.01);观察组并发症发生率明显低于对照组,差异有统计学意义(P0.05)。结论对食管裂孔疝合并胃食管反流患者实施腹腔镜食管裂孔疝修补联合胃底折叠术治疗能有效优化各项手术指标,改善患者病情,提高患者生存质量,降低术后并发症发生率,安全性高,值得临床推广。     

腹腔镜胃底折叠术治疗胃食管反流性疾病

目的　探讨腹腔镜胃底折叠术治疗胃食管反流性疾病的可行性及安全性。方法　回顾性分析 2 0 0 1年 6月至 2 0 0 4年 3月对 4 2例行腹腔镜胃底折叠术的胃食管反流性疾病患者的临床资料。结果　 33例行腹腔镜Nissen胃底折叠术 ,9例行腹腔镜Toupet胃底折叠术。术后症状评分由11 5 6± 1 32降到 2 0 4± 1 36 ,食管下段压力由 (7 32± 1 34)mmHg提高到 (18 2 0± 3 4 3)mmHg ,2 4hpH值监测评分由 183 36± 96 76降低到 8 0 4± 2 12 ,均较手术前有明显改善 (P <0 0 1) ,并达到正常范围。无手术并发症 ,无中转开腹及死亡病例。结论　对于严重的胃食管反流性疾病 ,腹腔镜胃底折叠术是一种安全、有效的治疗方法     

食管裂孔疝合并胃食管反流病合并胃间质细胞瘤的外科治疗

目的探讨食管裂孔疝合并胃食管反流病合并胃间质细胞瘤患者的围手术期处理及安全性。 方法统计新疆维吾尔自治区人民医院2012年10月至2015年1月收治的17例食管裂孔疝合并胃食管反流病合并胃间质细胞瘤患者的病案资料,均采用腹腔镜下微创手术,其中单纯食管裂孔疝缝合者13例,生物补片修补者3例,强生PHY补片修补者1例。抗反流术式中行Nissen式胃底折叠术者8例,Dor式胃底折叠术者6例,Toupet式胃底折叠术者3例。病理结果提示极低危险度胃间质细胞瘤8例,低度危险度者4例,中度危险度者3例,高度危险度者1例,极高危险度者1例,回顾性总结分析该类患者围手术期的处理措施。 结果本组患者无围手术期死亡,术后无严重并发症发生,术后患者反流症状均较术前明显改善,反流时间、反流次数、酸反流时间百分比、长反流次数及DeMeester评分较术前明显降低(P<0.05),术后GERD Q量表评分较术前明显减低(P<0.05);LES压力较术前明显提高(P<0.05)。术后切口感染1例,慢性疼痛1例,给予换药、理疗后好转。2例患者术后出现进食哽噎,1例患者术后出现腹泻,嘱其少量多餐、细嚼慢咽,1个月后症状消失。合并贫血患者术后血红蛋白恢复至95 g/L,术后随访中位数10个月,无复发病例。 结论食管裂孔疝合并胃食管反流病合并胃间质细胞瘤患者病情较复杂使得手术风险大,难度高,但只要作好充分的术前准备,采用恰当的手术方式,术中谨慎、细致操作,针对性的处理术后出现的各种问题,仍是安全可行的。     

胃食管反流病合并食管裂孔疝动物实验手术配合体会

目的促使新一代的青年医师、器械护士能够更加熟练掌握胃食管反流病合并食管裂孔疝手术方式及术中能够紧密的配合。 方法新疆维吾尔自治区人民医院微创外科与科研技术部门合作,成功建立了腹腔镜下胃食管反流病合并食管裂孔疝手术小猪动物训练模型,通过动物模型手术训练熟悉手术操作要点及配合要点。 结果共完成腹腔镜食管裂孔疝修补术6次,Nissen胃底折叠术12次,Toupet胃底折叠术12次,Dor胃底折叠术12次,未发生麻醉意外、二氧化碳气栓、失血性休克等严重并发症。预期手术成功完成,没有发生因术中并发症导致实验动物死亡而终止训练等情况。 结论经过腹腔镜抗反流手术动物模型的手术训练可以使医护人员明显缩短学习时间、促进临床术中配合,可以减少手术相关并发症,是一种安全可行的最佳手术训练方法。     

腹腔镜食管裂孔疝修补联合胃底折叠术在西藏基层医院的临床应用

目的探讨在西藏基层医院开展腹腔镜食管裂孔疝修补联合胃底折叠术的疗效及可行性。 方法回顾分析2017年7月至2019年6月于林芝市人民医院普外科41例行腹腔镜食管裂孔疝修补联合胃底折叠术患者的临床资料。记录手术时间、术中出血量、术中并发症、术后住院时间以及术后并发症等情况。计量资料使用均数±标准差表示;计数资料以例数或百分比表示. 结果所有患者均顺利完成腹腔镜手术,平均手术时间为（108.0±33.3）min,平均出血量为（22.7±18.5）ml,术后平均住院时间为（3.5±2.1）d。平均随访14个月,未见复发病例。 结论在西藏基层医院开展腹腔镜食管裂孔疝修补联合胃底折叠术安全有效,适宜推广应用。     

腹腔镜抗反流手术联合胃大弯侧折叠术动物训练模型的建立

目的建立用猪腹腔镜下抗反流手术联合胃大弯侧折叠术的动物模型的经验与体会。 方法对6头健康猪做麻醉,用OLYMPUS公司的腹腔镜器械,分别行腹腔镜食管裂孔疝修补术＋ Nissen胃底折叠术＋胃大弯侧折叠术,腹腔镜食管裂孔疝修补术＋ Toupet胃底折叠术＋胃大弯侧折叠术,记录术中遇到的技术问题。 结果用6头猪开展的两种抗反流手术及胃大弯侧折叠术均成功,无术中大出血及脏器损伤等并发症。 结论经腹腔镜下食管裂孔疝修补＋胃底折叠术联合胃大弯侧折叠术的技术是安全可行的。     

胃食管吻合术联合Nissen胃底折叠术对食管中段癌患者术后胃食管反流的影响

目的探讨胃食管吻合术联合Nissen胃底折叠术对食管中段癌术后患者胃食管反流的影响。 方法选取2015年9月至2017年3月,新疆维吾尔自治区人民医院住院并行食管癌切除术31例食管中段癌患者的临床资料。根据手术方式分为2组,即接受胃食管吻合术联合Nissen胃底折叠术15例（观察组）,接受胃食管吻合术16例（对照组）,术后2周待患者恢复正常的胃肠道功能后采用pH动态监测仪对其进行24 h pH监测,术后1、3、6、12个月依据胃食管反流病调查问卷（GerdQ）对患者的胃食管反流相关症状进行评分,比较2组患者术后胃食管反流发生情况。 结果2组患者均未出现死亡病例,且术后均未发生有吻合口瘘及胸胃排空障碍等并发症;观察组患者术后2周24 h酸反流次数显著少于对照组、最长酸反流时间和pH值<4的总时间短于对照组,DeMeester评分显著低于对照组,组间比较均有统计学意义（P<0.05）;观察组术后3、6、12个月胃食管反流病调查问卷（GerdQ）评分显著低于对照组,组间比较均有统计学意义（P<0.05）。 结论胃食管吻合术联合Nissen胃底折叠术对食管癌切术后的胃食管反流病情起到更为理想的控制效果,为食管中段癌患者术中吻合术式的选择提供一定参考价值。     

Surgical treatment of the non-complicated gastroesophageal reflux: fundoplication without division of the short gastric vessels

BACKGROUND: There is today a significant greater number of laparoscopic antireflux procedures for the surgical treatment of gastroesophageal reflux disease and there are yet controversies about the necessity of division of the short gastric vessels and full mobilization of the gastric fundus to perform an adequate fundoplication. AIM: To verify the results of the surgical treatment of non-complicated gastroesophageal reflux disease performing Rossetti modification of the Nissen fundoplication. Patients and Methods - Fourteen patients were operated consecutively and prospectively (mean age 44.07 years); all had erosive esophagitis without Barrett's endoscopic signals (grade 3, Savary-Miller) and they were submitted to the Rossetti modification of the Nissen fundoplication. Endoscopy, esophageal manometry and pHmetry were performed before the procedure and around 18 months postoperatively. RESULTS: There was no morbidity, transient dysphagia average was 18.42 days; there was no register of dehiscence or displacement of the fundoplication and only one patient revealed a light esophagitis at postoperative endoscopy; the others presented a normal endoscopic view of the distal esophagus. All noticed a marked improvement of preoperative symptoms. Lower esophageal sphincter pressure changed from 5.82 mm Hg (preoperative mean) to 12 mm Hg (postoperative mean); lower esophageal sphincter relaxing pressure, from 0.38 mm Hg to 5.24 mm Hg and DeMeester score, from 16.75 to 0.8. CONCLUSION: Rossetti procedure (fundoplication without division of the short gastric vessels) is an effective surgical method to treat gastroesophageal reflux disease.     

Esophageal motility in reflux disease before and after fundoplication: a prospective, randomized, clinical, and manometric study.

BACKGROUND AND AIMS: The purpose of this study was to determine whether esophageal dysmotility affects symptoms of gastroesophageal reflux disease or clinical outcome after laparoscopic fundoplication and whether esophagus motor function changes postoperatively. METHODS: Two hundred patients with a history of long-standing gastroesophageal reflux disease were investigated by clinical assessment, upper gastrointestinal endoscopy, esophageal manometry, and 24-hour pH monitoring between May 1999 and May 2000. Patients were stratified according to presence or absence of esophageal dysmotility (each n = 100) and randomized to either 360 degrees (Nissen) or 270 degrees (Toupet) fundoplication. At a 4-month postoperative follow-up, preoperative tests were repeated. RESULTS: Preoperative esophageal dysmotility was associated with more severe reflux symptoms, more frequent resistance to medical treatment (64% vs. 49%; P < 0.05), and greater decrease in lower esophageal sphincter pressure (9.5 +/- 5.3 vs. 12.4 +/- 6.7 mm Hg; P < 0.0005) compared with normal motility. Postoperatively, clinical outcome and reflux recurrence (21% vs. 14%) were similar. Esophageal motility remained unchanged in 85% of patients and changed from pathologic to normal in 20 (10 Nissen/10 Toupet) and vice versa in 9 (8 Nissen/1 Toupet) patients. CONCLUSIONS: Esophageal dysmotility (1) reflects more severe disease; (2) does not affect postoperative clinical outcome; (3) is not corrected by fundoplication, independent of the surgical procedure performed; (4) may occur as a result of fundoplication; and (5) requires no tailoring of surgical management.     

Preoperative esophageal body motility does not influence the outcome of laparoscopic Nissen fundoplication for gastroesophageal reflux disease.

We evaluated a policy of performing laparoscopic antireflux surgery without tailoring the procedure to the results of preoperative esophageal motility tests. A total of 117 patients (82 with normal esophageal motility; 35 with ineffective motility, IEM) underwent laparoscopic Nissen fundoplication for symptomatic gastroesophageal reflux. There were no significant differences in preoperative symptom length, dysphagia, DeMeester symptom scores, acid exposure times or lower esophageal sphincter pressures between the two groups. Both groups showed postoperative improvements in DeMeester symptom scores, dysphagia and acid exposure, with no differences between groups. At 1 year after surgery, 95% of the normal motility group and 91% of the IEM group had a good/excellent outcome from surgery. None of the IEM group required postoperative dilatation or reoperation. Patients with IEM fare equally well from laparoscopic Nissen fundoplication as those with normal esophageal motility. There is no merit in tailoring antireflux surgery to the results of preoperative motility tests.     

Nissen fundoplication in infants and children: a long-term clinical study

BACKGROUND/AIMS: Infants and children who underwent open Nissen fundoplication for gastroesophageal reflux disease were retrospectively evaluated to assess the success and complications of this operation. METHODOLOGY: Twenty-six neurologically normal children (16 boys and 10 girls between 6 months and 11 years old) underwent Nissen fundoplication for intractable or complicated gastroesophageal reflux between October 1982 and February 2002. Before surgery and at follow-up visits, all children were subjected to thorough history, barium meal study and gastroscopy with multiple esophageal biopsies. The median follow-up period was 28 months (range: 11 months-19 years). RESULTS: Persistent vomiting or regurgitation since birth was the main symptom (24 patients, 92.3%), chest symptoms occurred in 5 patients (19.2%), malnutrition and retarded growth were found in 4 patients (15.4%), hematemesis and/or melena occurred in 2 patients (7.7%) and dysphagia due to esophageal stricture occurred in 4 patients (15.4%). There was no mortality. The mean hospital stay was 4.1 days. Twenty-two patients (84.6%) had no recurrent reflux. Reflux symptoms recurred in 4 cases (15.4%). One of these cases had no evidence of recurrent pathological reflux, 2 cases with preoperative stricture developed wrap disruption, recurrent reflux and re-stricture. Both refused a second operation. The fourth case developed melena and reflux esophagitis due to wrap herniation through the hiatus and was successfully managed by a second operation. CONCLUSIONS: Nissen fundoplication is an effective operation to correct gastroesophageal reflux in infants and children when the drug therapy fails. The operation should be done before occurrence of complications to decrease the recurrence of reflux.     

Antireflux surgery for symptomatic gastroesophageal reflux

To determine the effects of Nissen fundoplication upon the symptoms of reflux and the diagnostic tests employed to evaluate reflux and to examine the relationship between gastroesophageal reflux and lower esophageal sphincter pressure before and after fundoplication, 10 patients with symptomatic reflux were studied before and after operation. Clinical evaluation, barium esophagography, endoscopy with mucosal biopsy, esophageal manometry, acid-perfusion and acid-reflux testing, and gastroesophageal scintiscanning were performed on each patient before and after surgery. Following fundoplication, marked symptomatic, radiographic, endoscopic, and histologic improvement was observed. Serial acid-reflux tests at increasing gastroesophageal pressure gradients returned to normal after surgery. Lower-esophageal-sphincter (LES) pressure increased from 8.2±1.3 to 12.0±1.5 mm Hg (P<0.01). In addition, surgery resulted in a significant decrease in the gastroesophageal reflux index from 17.4±2.4 to 2.7±1.1% (P<0.001). Surprisingly, the pre- and postoperative resting LES pressures did not correlate significantly with corresponding gastroesophageal reflux indices for individual patients. We conclude that increased LES pressure alone does not explain adequately the functional and clinical improvement which follows fundoplication.     

Partial fundoplications for gastroesophageal reflux disease: indications and current status.

The Nissen fundoplication, and in particular the laparoscopic Nissen fundoplication, has received widespread acceptance as the most definitive therapy for gastroesophageal reflux disease. There remains, however, certain patients who do better with a less aggressive surgical augmentation of the lower esophageal sphincter. Partial fundoplications originated in the early 1960s as an alternative procedure to the Nissen, which was associated with moderately high rates of postoperative side effects. These "more physiologic" procedures have proved successful in the treatment of reflux disease in patients with poor or no esophageal motility. In particular, the use of partial fundoplications in association with Heller's myotomy for achalasia has been demonstrated to be well tolerated and to reduce the risk of late dysphasia resulting from uncontrolled gastroesophageal reflux (GER). The use of partial fundoplications in GER patients with normal motility, however, has been less successful. High recurrence rates are documented by many centers with the main cause appearing to be related to a less competent neo-lower esophageal sphincter and a higher rate of wrap herniation. This has led to the current practice of a "tailored approach" to reflux disease, in which all patients receive a thorough preoperative physiologic evaluation to determine the best antireflux procedure for the individual. This is generally a Nissen repair for those with normal motility and either an extrashort "floppy" Nissen or a partial wrap for those with impaired peristalsis.     

Outcome of floppy Nissen fundoplication with intraoperative manometry to treat sliding hiatal hernia

SUMMARY.  The aim of this study was to evaluate the effectiveness of floppy Nissen fundoplication with intraoperative esophageal manometry. Between February 1992 and July 2004, there were 102 patients with sliding hiatal hernia undergoing transabdominal Nissen fundoplication. They were divided into three groups: 27 patients were in the Nissen group (CNF), 44 in the floppy Nissen group (FNF, including 5 with laparoscopic Nissen fundoplication), and 31 in the intraoperative-esophageal-manometry group (INF, 13 with laparoscopic Nissen fundoplication). There were no operation-related deaths. Operation-related complications occurred in five patients within 1 month after operation: In CNF, two patients suffered from dysphagia and one from regurgitation; in FNF, one patient had slight dysphagia and two had regurgitation; in INF, there was no one who complained about dysphagia or regurgitation, but pneumothorax occurred in one case. After more than 2 years of follow-up, two patients, in CNF, suffered from severe dysphagia, one recurred and two with abnormal 24 h pH monitoring. In FNF, one patient had dysphagia, one recurred and three had abnormal 24 h pH monitoring; in INF, two patients had acid reflux on 24 h pH monitoring. The postoperative lower esophageal sphincter pressure was in the normal range in 30 of 31 patients (96.5%). The normal rate of postoperative tests in CNF, FNF and INF were 81.5%, 86.4% and 93.5%, respectively. Both the Nissen fundoplication and the floppy Nissen fundoplication are effective approaches to treat patients with sliding hiatal hernia. Intraoperative manometry is useful in standardizing the tightness of the wrap in floppy Nissen fundoplication and may contribute to reducing or avoiding the occurence of postoperative complications.     

Short-term symptom and quality-of-life comparison between laparoscopic Nissen and Toupet fundoplications

Laparoscopic antireflux surgery is an established method of treatment of gastroesophageal reflux disease (GERD). This study evaluates the efficacy of Nissen versus Toupet fundoplication in alleviating the symptoms of GERD and compares the two techniques for the development of post-fundoplication symptoms and quality of life (QOL) at 12 months post-surgery. In this prospective consecutive cohort study, 94 patients presenting for laparoscopic antireflux surgery underwent either laparoscopic Nissen fundoplication (LN) ( n  = 51) from February 2002 to February 2004 or a laparoscopic Toupet fundoplication (LT) ( n  = 43) from March 2004 to March 2006, performed by a single surgeon (G. S. S.). Symptom assessment, a QOL scoring instrument, and dysphagia questionnaires were applied pre- and postoperatively. At 12 months post-surgery, patient satisfaction levels in both groups were high and similar (LT: 98%, LN: 90%; P  = 0.21). The proportion of patients reporting improvement in their reflux symptoms was similar in both groups (LT: 95%, LN: 92%; P  = 0.68), as were post-fundoplication symptoms (LT: 30%, LN: 37%; P  = 0.52). Six patients in the Nissen group required dilatation for dysphagia compared with one in the Toupet group (LT: 2%, LN: 12%; P  = 0.12). One patient in the Nissen group required conversion to Toupet for persistent dysphagia ( P  = 0.54). In this series, overall symptom improvement, QOL, and patient satisfaction were equivalent 12 months following laparoscopic Nissen or Toupet fundoplication. There was no difference in post-fundoplication symptoms between the two groups, although there was a trend toward a higher dilatation requirement and reoperation after Nissen fundoplication.