腹腔镜Nissen胃底折叠术对胃食管反流病患者食管动力学的影响

目的通过食管高分辨率测压（high resolution manometry，HRM）对比胃食管反流病（gastroesophageal reflux disease，GERD）患者腹腔镜下Nissen胃底折叠术（laparoscopic Nissen fundoplication，LNF）前后食管动力学的改变情况，探讨手术的抗反流原理。 方法选取2014年6月至2016年7月，火箭军总医院73例连续住院的GERD患者，LNF术前1周内行包括HRM在内一系列术前评估，术后GERD症状明显缓解且吞咽困难等并发症已经消失时复查HRM。对手术前后2次HRM的9个食管动力学参数进行对比分析，并按术前是否存在食管裂孔疝进一步分组分析。 结果术后患者食管长度平均延长了（0.43±1.72）cm，腹腔内下食管括约肌长度平均延长了（1.20± 0.94）cm，术后患者下食管括约肌静息压平均增加了（5.99±7.79）mmHg（1 mmHg=0.133 kPa），综合松弛压平均增加了（3.41±5.43）mmHg；远端收缩分数平均增加了（157.26±596.01）mmHg·s·cm，远端收缩延迟时间平均增加了（0.93±2.30）s；上述6个动力学参数与术前比较差异均有统计学意义（P=0.04，<0.01，<0.01，<0.01，0.03，<0.01）。而术后下食管括约肌长度、食管上括约肌压力和收缩前沿速度与术前相比差异无统计学意义（P=0.83，0.43，0.73）。食管长度、下食管括约肌长度和远端收缩分数在食管裂孔疝患者中较无食管裂孔疝患者改善更为显著（P<0.01，<0.01，<0.01）。 结论LNF主要通过延长腹腔内食管长度，增强下食管括约压力，增强食管的廓清功能，从而到达有效的抗反流作用。其中合并食管裂孔疝的患者较无食管裂孔疝患者术后上述食管动力学改善更为显著。

Effect of laparoscopic Nissen fundoplication on esophageal motility in GERD patients

ObjectiveTo compare the esophageal dynamic changes before and after laparoscopic Nissen fundoplication (LNF) in patients with gastroesophageal reflux disease (GERD) by high resolution manometry (HRM) and to explore the anti-reflux mechanism of the procedure. MethodsA total of 73 consecutive hospitalized patients with GERD were included. A series of preoperative evaluations including HRM were performed within 1 weeks before LNF. After the GERD symptoms were significantly relieved and dysphagia and other complications disappeared, the HRM was rechecked. The 9 esophageal motility parameters of the HRM before and after operation were compared and analyzed, and further analysis was made on whether or not there were hiatus hernia before the operation. ResultsThe average length of esophagus was prolonged by (0.43±1.72) cm after operation, and the length of intra-abdominal and lower esophageal sphincter was prolonged by (1.20±0.94) cm. Postoperative resting pressure of the lower esophageal sphincter increased by an average of (5.99±7.79) mmHg and the integrated relaxation pressure increased by (3.41±5.43) mmHg. The distal contractile integral increased by an average of (157.26±596.01) mmHg?s?cm, the distal latency increased by an average of (0.93±2.30) s, the above 6 motility parameters compared with preoperative had significant difference (P=0.04, <0.01, <0.01, <0.01, 0.03, <0.01). There were no significant differences in the length of the lower esophageal sphincter, the pressure of the upper esophageal sphincter and the contractile front velocity after operation (P=0.83, 0.43, 0.73). The length of the esophagus, the length of the lower esophageal sphincter, and the distal contractile integral were significantly improved in the patients with hiatal hernia comparing with those without hiatal hernia (P<0.01, <0.01, <0.01). ConclusionThe effective anti-reflux effect is mainly achieved by prolonging the length of the intraperitoneal esophageal, enhancing the lower esophageal sphincter pressure and enhancing the esophageal clearance function by LNF. Patients with esophageal hiatal hernia had better esophageal motility improvement than those without esophageal hiatal hernia.