腹腔镜食管下段贲门肌层切开联合Dor胃底折叠术治疗贲门失弛缓症

目的:探讨腹腔镜食管下段贲门肌层切开联合Dor胃底折叠术治疗贲门失弛缓症的临床应用价值。方法:回顾性分析31例行腹腔镜食管下段贲门肌层切开联合Dor胃底折叠术治疗的贲门失弛缓症患者术前与术后3个月的临床数据。结果:31例均成功行腹腔镜手术,27例术前与术后3个月吞咽困难评分(1.10±0.18与0.91±0.12,P<0.01)、术前与术后胸骨后疼痛评分(0.38±0.04与0.36±0.03,P<0.05)症状得到有效缓解,体质量指数(21.32±1.26与20.47±1.34,P<0.05)及生活质量指数(85.69±7.78与80.43±9.19,P<0.05)明显优于术前。结论:腹腔镜食管下段贲门肌层切开联合Dor胃底折叠术对于改善贲门失弛缓症患者临床症状及提高生活质量具有重要的意义。     

经脐单孔腹腔镜手术治疗贲门失弛缓症及食管裂孔疝的临床体会

目的：总结经脐单切口腹腔镜手术治疗贲门失弛缓症及食管裂孔疝的经验,提高腹腔镜临床应用的水平。方法：2010年3月—2011年10月分别对3例贲门失迟缓症进行单切口腹腔镜食管Heller肌切开、Dor胃底折叠术,对4例食管裂孔疝患者进行单切口腹腔镜食管裂孔疝修补、Nissen胃底折叠术。结果：7例手术均顺利完成。手术时间115～180 min;出血量50～110 mL;住院时间5～7 d。所有患者均无术后出血、食管漏、发热感染等并发症。患者术后脐部切口愈合良好,美容效果明显。结论：对于有经验的腹腔镜外科医生,单切口腹腔镜手术治疗贲门失弛缓症及食管裂孔疝是安全可行的,并具有极佳的美容效果。     

免气腹辅助3D腹腔镜改良Heller肌切开联合Dor胃底折叠治疗贲门失弛缓症

目的探讨免气腹辅助3D腹腔镜改良Heller肌切开联合Dor胃底折叠治疗贲门失弛缓症的临床价值。方法 2013年7月~2015年11月对32例贲门失弛缓症行免气腹辅助3D腹腔镜下贲门食管肌层切开,联合Dor胃底折叠术(前部180°胃底折叠缝合术)。结果 32例均成功完成免气腹腹腔镜手术,手术时间(71.6±36.8)min,术中出血量(23.6±18.4)ml,住院时间(8.2±2.6)d,无食管漏等并发症及死亡。32例术后随访6~34个月,平均15.3月,Eckardt评分Ⅰ级20例(62.5%),Ⅱ级9例(28.1%),Ⅲ级3例(9.4%);手术有效29例(90.6%),失败3例(9.4%)。23例术后6个月复查食管吞钡造影,食管最大横径(31.1±5.2)mm,较术前(45.3±8.0)mm明显改善(t=11.064,P=0.000)。结论免气腹辅助3D腹腔镜改良Heller联合Dor胃底折叠术治疗贲门失弛缓症疗效满意。     

腹腔镜Heller手术治疗贲门失弛缓症的初步临床经验

目的总结腹腔镜Heller手术治疗贲门失弛缓症的初步临床经验。方法2005年2～8月，对肺功能较差、合并肾功能不全或怀疑存在胸膜腔粘连的8例贲门失弛缓症行腹腔镜下Heller联合Dor胃底折叠手术，并进行随访。结果手术时间70～184min，平均103．8min；1例术中食管穿孔改开腹手术修补成功；术后住院3～10d，平均5．1d。术后随访1～6个月，平均3．8月，7例症状缓解，1例轻度吞咽困难。全组无手术死亡。结论腹腔镜具有刨伤小、术中暴露较佳、术后恢复快、术后住院时间短等优点，腹腔镜下Heller术可作为贲门失弛缓症的首选治疗方法，但是否附加胃底折叠术仍需进一步探讨。     

改良三孔法腹腔镜下Heller肌切开联合胃底折叠治疗贲门失弛缓症

目的探讨三孔法腹腔镜下Heller肌切开联合胃底折叠治疗贲门失迟缓症的效果及优势。方法回顾性分析我院2006年7月～2011年10月完成的26例腹腔镜下Heller肌切开联合胃底折叠术的临床资料。手术采用三孔法,术中使用自制简易拉钩,行Heller肌切开联合Dor胃底折叠,观察术中及术后相关指标并随访。结果所有手术均获得成功,无中转开腹,手术时间65—260min,平均110．6rain。出血量25～100ml,平均53．2ml。术后住院时间3～7d,平均5．8d。1例术中食管黏膜破裂,修补后无食管漏。术后随访18～72个月,平均34．7月,无复发,饮食无明显不适。结论三孑L法腹腔镜下Heller肌切开联合胃底折叠治疗贲门失弛缓症具有手术部位显露效果好,创伤小,恢复快,治疗效果确切,安全,并发症少等优点,术后病人腹部美观,是治疗贲门失弛缓症的良好微创途径。     

腹腔镜手术治疗胃食管反流病和贲门失弛缓症

目的:探索三种腹腔镜胃底折叠术治疗胃食管反流病及Heller肌切开术治疗贲门失弛缓症的安全性与可行性。方法:1995年12月至2004年9月,经腹腔镜手术治疗了胃食管反流病人45例和贲门失弛缓病人5例。术前常规行胃镜与上消化道钡餐检查者50例,加行食管测酸、测压检查者39例。腹腔镜单纯胃底折叠术10例(Nissen式1例,Toupet式9例);腹腔镜食管裂孔疝修补加胃底折叠术35例(Nissen式11例,Toupet式24例)。Heller肌切开术加Dor胃底折叠术5例。结果:全组病人的平均手术时间为120(60～360)min,术中平均出血量15(10～100)ml,术后日平均引流量20(10～100)ml,平均住院7(5～12)d。其中前10例使用电刀者平均用时210(180～360)min,中转开腹1例;后40例使用超声刀者平均用时100(60～180)min。术中脾被膜划破出血2例,12例Nissen式胃底折叠术后有1例出现吞咽困难,1月后缓解。42例获随访的病人中40例不再需要服药。其中5例Heller肌切开术Dor胃底折叠术病人术后第2天即可顺畅进食,且无反流。结论:与传统的经胸或经腹手术相比,腹腔镜抗反流手术治疗胃食管反流病和Heller肌切开贲门失弛缓症的病人具有心肺干扰小、麻醉难度低、创伤小、痛苦轻、并发症少、住院时间短、康复快、疗效好等突出优点。经过不断改进手术设计和加强训练可使?     

经腹腔镜改良Heller手术加胃底折叠术治疗贲门失弛缓症

目的:探讨腹腔镜治疗贲门失弛缓症的方法及其优势。方法:经腹腔镜行食管贲门括约肌切开术(改良Heller手术)加胃底折叠术治疗贲门失弛缓症1例。结果:手术顺利,手术时间140m in,术中出血量30m l。患者术后第3天进软食无异常后出院。术后3个月食管下括约肌(LES)残留压、松弛率以及食管基础压均恢复正常,钡餐结果显示为正常食管影像,24h食管pH值测定正常,未见返流。随访6个月,症状无反复。结论:经腹腔镜改良Heller手术加胃底折叠术治疗贲门失弛缓症具有创伤小,术后康复快,疗效确切等优点。     

腹腔镜联合胃镜微创治疗贲门失弛缓症26例分析

目的 探讨采用腹腔镜联合胃镜微创手术治疗贲门失弛缓症的可行性及临床价值。方法 2005年12月至2009年3月,天津市南开医院对26例贲门失弛缓症病人实施腹腔镜Heller括约肌切开加Dor胃底折叠术,术中联合胃镜进行定位、检查,对围手术期相关指标进行分析,并随访观察治疗效果。结果 26例均完成腹腔镜手术,无中转开腹病例,术后无严重并发症。1例术中食管黏膜破损,经胃镜证实后行腹腔镜下修补术,随访观察4～42个月无吞咽困难,1例术后1年内出现轻度胃食管反流及胸骨后疼痛症状,术后3个月复查食管测压、胃镜、上消化道造影提示均基本恢复正常。结论 腹腔镜治疗贲门失弛缓症具有手术创伤小、恢复快、疗效可靠的特点,术中联合胃镜操作可提高手术安全性,减少并发症的发生。     

小儿贲门失弛缓症的外科诊治

目的:探讨小儿贲门失弛缓症的诊疗方法。方法:回顾性分析2001年9月—2011年9月收治的34例贲门失弛缓症患儿的临床资料,患儿均有吞咽困难,进食后呕吐胃内容物,上消化道钡餐检查可见食管下端鸟嘴样狭窄等典型征象。患儿均经腹行改良Heller术和Dor胃底前壁折叠术。结果:34例均于手术后7~14 d顺利出院,出院前均可进半流食。1例失访,33例患儿随访2个月至9年7个月。均无吞咽困难、进食后呕吐和反流性食管炎的症状,术后上消化道钡餐复查,食管腔光滑,狭窄段变粗,钡剂通过顺畅,且无胃食管反流征象。除1例21三体综合征患儿外,其余患儿生长发育与同龄儿相仿。结论:改良Heller术治疗小儿贲门失弛缓症具有良好的效果,附加Dor胃底前壁折叠术能够有效防止改良Heller术后的胃食管反流。     

腹腔镜胃镜联合手术治疗贲门失弛缓症25例报道

目的探讨腹腔镜胃镜联合手术治疗贲门失弛缓症的临床价值。方法2003年10月～2006年4月，采用腹腔镜胃镜联合Heller肌切开Dor胃底折叠治疗贲门失弛缓症25例。结果手术均获成功，手术时间60～240min，平均107min。术中出血量5—60ml，平均22ml。术中4例分破食管或胃黏膜。术后8h下床活动，1—3d（平均1．5d）排气、拔胃管进流食。术后7d复查食管测压食管下括约肌（lower esophageal sphincter，LES）功能压均降至正常；24h食管pH监测3例酸反流指数高于正常，但无症状。术后8d复查上消化道钡餐，扩张的食管最大横径平均缩小18mm（8～26mm）。术后8～11d出院，平均8．5d。25例随访1—30个月，平均5．4月，术前症状均消失。2例因进食不当出现间断吞咽困难。结论腹腔镜胃镜联合手术治疗贲门失弛缓症具有定位准确、创伤小、痛苦轻、疗效好等突出优点，同时可以提高手术质量，减少并发症。     

腹腔镜手术治疗食管裂孔疝45例

目的探讨腹腔镜食管裂孔疝修补联合抗反流手术治疗食管裂孔疝的疗效。方法 2004年5月~2008年11月45例食管裂孔疝行腹腔镜食管裂孔疝修补联合抗反流手术。采用视觉模拟积分(visual analogue scales,VAS)评价术前及术后1、6、12个月胃食管反流症状,包括烧心、吞咽梗阻、反酸、胸痛、嗳气等。结果在缝合缩小食管裂孔的同时,行改良Nissen术9例,Toupet术10例,Dor术26例。无中转开腹。手术时间92~203min,平均118min。术后住院2~8d,平均2.7d。术后发生胃潴留3例,吞咽梗阻2例。术后随访1~48个月,平均21.5月,2例分别在术后1、12个月复发。胃食管反流综合症状VAS评分术前中位数5分(4~8分),术后1、6、12个月中位数均为1分,术前后比较均有统计学意义(P=0.000)。结论腹腔镜食管裂孔疝修补联合抗反流手术是治疗食管裂孔疝的有效方法 ,具有创伤小、恢复快的特点。     

腹腔镜手术治疗胃食管结合部良性疾病的疗效评估

Benign diseases of gastroesophageal junction include gastroesophageal reflux disease,hiatal hernia and achalasia of the cardia.Surgical intervention is superior in the treatment of moderate to severe cases.With the rapid development of laparoseopic technology,minimally invasive surgical procedures,such as laparoscopic fundoplication,laparoscopic rear of hiatal hernia and laparoscopic cardiamyotomy are widely applied with excellent efficacy.According to our experience and clinical study,laparoscopic surgery,with advantages of minimal trauma,rapid recovery,safety and reliable efficacy,could be the first-line treatment for benign diseases of gastroesophageal junction.     

Pseudoachalasia occurring after laparoscopic Nissen fundoplication and crural mesh repair

Background Benign esophageal pseudoachalasia is a rare condition. Discussion We report the case of a 70-year-old man who complained of severe dysphagia after laparoscopic Nissen fundoplication and crural mesh repair performed for long-standing gastroesophageal reflux disease. Severe dysphagia and nocturnal aspiration developed soon after the operation. A marked dilatation of the esophageal body and a manometric pattern resembling achalasia was documented. Results Endoscopic balloon dilatation was ineffective. Five months after the initial operation, the patient underwent revisional laparoscopic surgery that consisted of Nissen’s wrap takedown, enlargement of the hiatus with partial resection of the mesh, Heller myotomy, and Dor fundoplication. After a 2-year follow-up, the patient is doing well and is free of symptoms.     

Laparoscopic heller cardiomyotomy either combined with a Dor or Toupet procedure in the treatment of achalasia

INTRODUCTION: The treatment of achalasia has undergone a dramatic evolution over the past ten years with the introduction of advanced laparoscopic techniques beside the use of balloon dilatation and injections of botulinumtoxin. With the introduction of the laparoscopic Heller cardiomyotomy the question was raised again whether and if so which antireflux measures are meaningful in combination with the cardiomyotomy. PATIENTS AND METHOD: Since 1998, 51 patients underwent laparoscopic cardiomyotomy in the surgical department of the Marienhospital Herne, Ruhr University Bochum. To prevent postoperative gastroesophageal reflux we performed a Dor fundoplication in 13 patients and a Toupet fundoplication in 38 patients. The mean period of observations was 17 months (3-45 months). All patients were evaluated through a symptoms score. 16 patients could be clinically and objectively followed-up. RESULTS: The mean operation time was 170 min. (80-290 min). The intraoperative complications were 8 mucosal disruptions without further morbidity and 1 pneumothorax. Postoperative complications were 1 scarring restenosis and 1 wrap dislocation. Improvement of symptoms was reported in 94.2 % of patients with good or excellent results. In 5.8 % of patients symptoms of reflux were claimed. There was no significant difference in results between Dor- and Toupet-fundoplication. CONCLUSION: Laparoscopic Heller cardiomyotomy with either a Dor or Toupet fundoplication are equivalent with respect to short- and middle-term outcome and efficient procedures with low rate of morbidity and mortality in the treatment of achalasia. A long-term observation period is necessary for determining which type of fundoplication has to be performed particularly regarding restenosis and reflux rate.     

Improved outcome after extended gastric myotomy for achalasia

HYPOTHESIS: There is general agreement that a Heller myotomy should extend 6 to 7 cm above the gastroesophageal junction. Results of most previous studies have recommended that the myotomy extend 1 to 1.5 cm below the gastroesophageal junction. We speculated that the effectiveness of the operation could be improved if a longer, 3-cm myotomy was carried out below the gastroesophageal junction, as it would more completely obliterate the lower esophageal sphincter. We, therefore, changed our technique in 1998. Concurrently, we converted from a Dor fundoplication to a Toupet fundoplication. This study analyzes the results of our new strategy. DESIGN: A case series using a prospectively maintained database. SETTING: Tertiary referral center. PATIENTS: One hundred ten consecutive patients with achalasia undergoing laparoscopic Heller myotomy. INTERVENTION: We analyzed the course of 52 patients treated with a standard laparoscopic esophagogastric myotomy (1.5 cm in the stomach) and a Dor fundoplication between September 1, 1994, and August 31, 1998, and 58 treated with an extended gastric myotomy (3 cm below the gastroesophageal junction) and a Toupet fundoplication between September 1, 1998, and August 31, 2001. MAIN OUTCOME MEASURES: Esophageal function testing (esophageal manometry and 24-hour pH monitoring), symptom questionnaire (frequency and severity), and postoperative interventions required. RESULTS: Postoperatively the lower esophageal sphincter pressure was significantly lower after extended gastric myotomy and a Toupet fundoplication vs standard myotomy and a Dor fundoplication (9.5 vs 15.8 mm Hg). Dysphagia was both less frequent (1.2 vs 2.1) and less severe (visual analog scale, 3.2 vs 5.3) after extended gastric myotomy and Toupet fundoplication. In the standard laparoscopic esophagogastric myotomy and a Dor fundoplication group, 9 patients (17%) had recurrent, severe dysphagia, which was treated by dilation in 5 patients and by reoperation in 4 patients. In the extended gastric myotomy and Toupet fundoplication group, 2 patients (3%) developed recurrent dysphagia that resolved with dilatation. There were no reoperations in the extended gastric myotomy and Toupet fundoplication group. No difference was noted in the frequency of heartburn (1.3 vs 1.7), regurgitation (0.3 vs 0.8), and chest pain (0.3 vs 0.6), nor was there a difference between the 2 groups in proximal (1.7% vs 2.3%) and distal (6.0% vs 5.9%) esophageal acid exposure. CONCLUSION: An extended gastric myotomy (3 cm) more effectively disrupts the lower esophageal sphincter, thus improving the results of surgical therapy for achalasia for dysphagia without increasing the rate of abnormal gastroesophageal reflux provided that a Toupet fundoplication is added.     

How I Do It: Laparoscopic Heller Myotomy with Toupet Fundoplication for Achalasia

Achalasia, an esophageal motility disorder characterized by aperistalsis and failure of lower esophageal sphincter (LES) relaxation, is most effectively treated by surgical ablation of the LES. In this report, we describe our technique of laparoscopic extended Heller myotomy with Toupet partial posterior fundoplication. The technical details of this procedure include careful division of the longitudinal and circular muscle fibers of the LES anteriorly, including extension of the myotomy 3 cm distal to the esophagogastric junction onto the gastric cardia. The Toupet procedure, involving a posterior wrap of the gastric fundus which is secured to both edges of the myotomy as well as to the crura of the hiatus, is added to prevent post-myotomy gastroesophageal reflux. From a recently published report, mean dysphagia scores remained low (3 out of 10 severity on a visual analog scale) and symptoms of reflux were reported minimally in a series of 63 patients followed for a median of 45 months. This technique provides excellent and durable relief of dysphagia associated with achalasia while minimizing post-myotomy acid reflux symptoms.     

Comparison of thoracoscopic and laparoscopic heller myotomy for achalasia

For more than three decades experts have debated the relative merits of thoracoscopic Heller myotomy (no antireflux procedure) vs. laparoscopic Heller myotomy plus Dor fundoplication for treatment of achalasia. The aim of this study was to compare the results of these two methods with respect to (1) relief of dysphagia, (2) incidence of postoperative gastroesophageal reflux, and (3) hospital course. Sixty patients with esophageal achalasia were operated on between 1991 and 1996. Thirty underwent a thoracoscopic Heller myotomy and 30 had a laparoscopic Heller myotomy with a Dor fundoplication. The two groups were similar with respect to demographic characteristics, clinical findings, and extent of manometric abnormalities. Preoperative pH monitoring showed abnormal reflux in two patients in the laparoscopic group. Average hospital stay was 84 hours for the thoracoscopic group and 42 hours for the laparoscopic group. Excellent (no dysphagia) or good (dysphagia less than once a week) results were obtained in 87% of patients in the thoracoscopic group and in 90% of patients in the laparoscopic group. Postoperative pH monitoring showed abnormal reflux in 6 (60%) of 10 patients in the thoracoscopic group and in 1 (10%) of 10 patients in the laparoscopic group. The two patients in the laparoscopic group who had reflux preoperatively had normal reflux scores postoperatively. Laparoscopic Heller myotomy with Dor fundoplication was found to be superior to thoracoscopic Heller myotomy. Both operations relieved dysphagia, but the laparoscopic approach avoided postoperative reflux and even corrected reflux present preoperatively. In addition, the patients were more comfortable and left the hospital earlier following a laparoscopic myotomy. Whether it is truly possible to perform a Heller myotomy without an antireflux procedure in a way that relieves dysphagia and regularly avoids reflux remains questionable. Presented at the Thirty-Eighth Annual Meeting ofThe Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14, 1997 (poster presentation).     

Laparoscopic reoperation as management of severe gastroesophageal reflux following laparoscopic Heller myotomy for achalasia: a case report

Achalasia is a rare disorder of the esophagus. Nonsurgical management includes oral medication, pneumatic dilatation, and injections of botulinum toxin. Surgical intervention was traditionally limited to patients with residual dysphagia after nonsurgical treatment. With the popularization of minimally invasive surgery, myotomy was increasingly performed via a laparoscopic approach. The procedure was found to be safe and efficient and is now used with increasing frequency as a primary therapeutic option. We report the case of a 17-year-old patient with achalasia in whom symptoms of gastroesophageal reflux developed following laparoscopic Heller myotomy without an antireflux procedure. Five years after surgery, the patient underwent reoperation with Toupet fundoplication. Five months after surgery, we found a normal De Meester Score and no pathologic gastroesophageal reflux. The authors conclude that laparoscopic Heller myotomy is the treatment of choice for achalasia and recommend that an antireflux procedure be included routinely.     

Laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia in children

BACKGROUND/PURPOSE: In the past, surgical treatment in achalasia usually has been reserved for patients whose dysphagia does not respond to pneumatic dilatation. The success of minimally invasive myotomy, however, has resulted in a shift in practice in adult patients, whereby laparoscopic surgery is becoming preferred as primary treatment by most gastroenterologists and surgeons. The aim of this study was to assess the efficacy of laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia in children. METHODS: Thirteen patients with esophageal achalasia (median age, 15 years; 6 boys and 7 girls; median duration of symptoms, 24 months) underwent laparoscopic Heller myotomy and Dor fundoplication between 1996 and 1999. Two patients had been treated previously by pneumatic dilatation, and 1 patient had received intrasphincteric Botulinum toxin injections. RESULTS: Median duration of the operation was 130 minutes. The patients were fed after an average of 33 hours, and they all left the hospital within 2 days. At a median follow-up of 19 months, there was no residual dysphagia in any patient. CONCLUSIONS: Laparoscopic Heller myotomy and Dor fundoplication were effective and safe for children with esophageal achalasia. Hospital stay and recovery time was short, and the functional results were excellent. These data support the notion that laparoscopic Heller myotomy should become the primary treatment of esophageal achalasia in children.