Gastroesophageal Reflux Disease and Obesity. Pathophysiology and Implications for Treatment

Although the etiology of gastroesophageal reflux disease (GERD) is multifactorial, the pathophysiology of the disease in morbidly obese patients remains incompletely understood. The aims of this study were to compare in morbidly obese (body mass index (BMI) ≥35) and nonmorbidly patients (BMI <35) with GERD: (a) lower esophageal sphincter (LES) profile; (b) esophageal body function; and (c) esophageal acid exposure. We reviewed esophageal manometry and ambulatory 24-hour pH monitoring studies of 599 consecutive patients with GERD (DeMeester score >14.7). Patients were divided into two groups according to the BMI: (1) 520 patients (86.8%) with BMI <35 and (2) 79 patients (13.2%) with BMI ≥35. While the DeMeester score was not different between the two groups, morbidly obese patients had higher LES pressure and higher amplitude of peristalsis in the distal esophagus (DEA). Among these patients, LES and DEA pressures were often hypertensive. A linear regression model showed that BMI, LES pressure, LES abdominal length, and DEA were independently associated with the DeMeester score. These data showed that: (a) BMI was independently associated to the severity of GERD; and (b) in most morbidly obese patients with GERD, reflux occurred despite normal or hypertensive esophageal motility. These findings show that the pathophysiology of GERD in morbidly obese patients might differ from that of nonobese patients, suggesting the need for a different therapeutic approach. Presented at the 47th Annual Meeting of the Society for Surgery of the Alimentary Tract, Los Angeles, CA, May 22–24, 2006.     

The real value of lower esophageal sphincter measurement for predicting acid gastroesophageal reflux or barrett’s esophagus

The study goal was to ascertain the true value of lower esophageal sphincter measurement in order to establish the risk of presenting gastroesophageal reflux or Barrett’s esophagus. Of 671 patients assessed for symptoms of gastroesophageal reflux, 459 were included in a prospective study, practicing esophagogastroscopy, esophageal manometry, and 24-hour pH-metry. The risks of presenting a pathologic DeMeester score or Barrett’s esophagus were estimated according to different values for the lower esophageal sphincter parameters. The risk of a pathologic DeMeester score only increased when pressure was less than 6 mm Hg, total length was less than 2 cm, or abdominal length was less than 1 cm; regardless of which parameter was affected, the risk being greater when the three parameters were altered (odds ratio = 2.4, 3.1, and 4 for one, two, and three altered parameters). Male sex, sphincter pressure, and DeMeester score were associated with Barrett’s esophagus (P < 0.05) but not total or abdominal length. Pressure and total and abdominal lengths have a similar influence over establishing the risk of pathologic acid reflux, but only pressure may indicate the risk of Barrett’s esophagus.     

Prevalence of gastroesophageal reflux after laparoscopic Heller myotomy

Background: There is still some controversy over the need for antireflux procedures with Heller myotomy in the treatment of achalasia. This study was undertaken in an effort to clarify this question. Methods: To determine whether Heller myotomy alone would cause significant gastroesophageal reflux (GER), we studied 16 patients who had undergone laparoscopic Heller myotomy without concomitant antireflux procedures. Patients were asked to return for esophageal manometry and 24-h pH studies after giving informed consent for the Institutional Review Board (IRB)-approved study at a median follow-up time of 8.3 months (range, 3–51). Results are expressed as the mean ± SEM. Results: Fourteen of the 16 patients reported good to excellent relief of dysphagia after myotomy. They were subsequently studied with a 24-h pH probe and esophageal manometry. These 14 patients had a significant fall in lower esophageal sphincter (LES) pressure from 41.4 ± 4.2 mmHg to 14.2 ± 1.3 mmHg, after the myotomy (p < 0.01, Student's t-test). The two patients who reported more dysphagia postoperatively had LES pressures of 20 and 25 mmHg, respectively. Two of 14 patients had DeMeester scores of >22 (scores = 61.8, 29.4), while only one patient had a pathologic total time of reflux (percent time of reflux, 8%). The mean percent time of reflux in the other 13 patients was 1.9 ± 0.6% (range, 0.1–4%), and the mean DeMeester score was 11.7 ± 4.6 (range, 0.48–19.7). Conclusions: Laparoscopic Heller myotomy is effective for the relief of dysphagia in achalasia if the myotomy lowers the LES pressure to <17 mmHg. If performed without dissection of the entire esophagus, the laparoscopic Heller myotomy does not create significant GER in the postoperative period. Clearance of acid refluxate from the aperistaltic esophagus is an important component of the pathologic gastroesophageal reflux disease (GERD) seen after Heller myotomy for achalasia. Furthermore, GERD symptoms do not correlate with objective measurement of GE reflux in patients with achalasia. Objective measurement of GERD with 24 h pH probes may be indicated to identify those patients with pathologic acid reflux who need additional medical treatment. Received: 12 May 1998/Accepted: 15 December 1998     

腹腔镜食管裂孔疝修补术联合改良DOR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

目的探讨腹腔镜食管裂孔疝修补术联合改良DOR胃底折叠术治疗食管裂孔疝（HH）合并胃食管反流病患者的临床疗效。 方法选择2016年1月至2019年1月河北北方学院附属第二医院收治的108例食管裂孔疝合并胃食管反流病患者开展回顾性研究，按照不同手术方式将患者分为2组，每组患者54例。对照组行常规开腹手术，联合组行腹腔镜食管裂孔疝修补术联合改良DOR胃底折叠术，比较2组患者术前及术后6个月反流时间、反流次数、DeMeester评分、食管下括约肌压力及Gerd Q量表评分。 结果2组术前反流时间、反流次数、DeMeester评分、食管下括约肌压力及Gerd Q量表评分比较，差异无统计学意义（P>0.05）；2组患者术后6个月反流症状与术前比较，均得到明显改善，差异有统计学意义（P<0.05）；2组术后反流时间、反流次数、DeMeester评分、食管下括约肌压力及Gerd Q量表评分比较，差异有统计学意义（P<0.05）。联合组患者的手术时间、术中出血量及术后住院时长均明显优于对照组，差异有统计学意义（P<0.05）。 结论腹腔镜食管裂孔疝修补术联合改良DOR胃底折叠术对HH合并胃食管反流病患者效果显著，有利于患者身体快速恢复，微创、安全且近期疗效满意。     

Effect of partial and total laparoscopic fundoplication on esophageal body motility

Background Abnormal esophageal body motility often accompanies gastroesophageal reflux disease (GERD). Although the effect of surgery on the pressure and behavior of the lower esophageal sphincter (LES) has been extensively studied, it still is unclear whether a successful fundoplication improves esophageal peristalsis. Methods The pre- and postoperative esophageal manometries of 71 patients who underwent a successful laparoscopic fundoplication (postoperative DeMeester score < 14.7) were reviewed. The patients were grouped according to the type of fundoplication (partial vs total) and preoperative esophageal peristalsis (normal vs abnormal): group A (partial fundoplication and abnormal esophageal peristalsis; n = 16), group B (total fundoplication and normal peristalsis; n = 41), and group C (total fundoplication and abnormal peristalsis; n = 14). Results The LES pressure was increased in all the groups. A significant increase in amplitude of peristalsis was noted in groups A and C. Normalization of peristalsis was achieved in 31% of the group A patients and 86% of the group C patients. No changes occurred in group B. Conclusions Laparoscopic fundoplication increased LES pressure and the strength of esophageal peristalsis in patients with abnormal preoperative esophageal motility. A total fundoplication resulted in normalization of peristalsis in the majority of patients. Presented at the Annual Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Dallas, Texas, 27–29 April 2006     

Gastro-Esophageal Reflux and Esophageal Motility Disorders in Morbidly Obese Patients before and after Bariatric Surgery

Background Obesity is a predisposing factor to gastro- esophageal reflux disease (GERD), but esophageal function remains poorly studied in morbidly obese patients and could be modified by bariatric surgery. Methods Every morbidly obese patient (BMI ≥40 kg/m² or ≥35 in association with co-morbidity) was prospectively included with an evaluation of GERD symptoms, endoscopy, 24-hour pH monitoring and esophageal manometry before and after adjustable gastric banding (AGB) or Roux-en-Y gastric bypass (RYGBP). Results Before surgery, 100 patients were included (84 F, age 38.4 ± 10.9 years, BMI 45.1 ± 6.02 kg/m2), of whom 73% reported GERD symptoms. Endoscopy evidenced hiatus hernia in 39.4% and esophagitis in 6.4%. The DeMeester score was pathological in 53.3%; 69% of patients had lower esophageal sphincter (LES) pressure <15 mmHg and 7 had esophageal dyskinesia. BMI was significantly related to the DeMeester score (P = 0.018) but not to LES tone or esophageal dyskinesia. Postoperative data were available in 27 patients (AGB n = 12/60, RYGBP n = 15/36). The DeMeester score (normal <14.72) was significantly decreased after RYGBP (24.8 ± 13.7 before vs 5.8 ± 4.9 after; P < 0.001) but tended to increase after AGB (11.5 ± 5.1 before vs 51.7 ± 70.7 after; P = 0.09), with severe dyskinesia in 2 cases. Conclusion: GERD and LES incompetence are highly prevalent in morbidly obese patients. Preliminary postoperative data show different effects of RYGBP and AGB on esophageal function, with worsening of pH-metric data with occasional severe dyskinesia after AGB.     

Factors predictive of dysphagia after laparoscopic Nissen fundoplication

Background: Persistent postoperative dysphagia occurs in up to 24% of patients who undergo a laparoscopic Nissen fundoplication for reflux disease [7]. We hypothesized that patient history, pH testing, and esophageal manometry could be used to preoperatively identify patients at risk for this complication. Methods: Of 156 laparoscopic Nissen fundoplications performed over a 27-month period, we identified 19 patients (12%) who suffered from postoperative dysphagia longer than 3 months. The presenting complaint of preoperative swallowing difficulty was noted as was the presence of a known esophageal stricture. Preoperative pH testing and esophageal manometry were performed for all subjects. We compared the following parameters to an age and gender-matched control group: history of esophageal stricture, presence of preoperative dysphagia, DeMeester reflux score, upper esophageal sphincter pressure and relaxation, esophageal body motility, location of respiratory inversion point, and lower esophageal sphincter length, resting pressure, and relaxation. Data were compared via t-test and Fisher's exact test. Results: Patients who presented before surgery with complaints of difficulty swallowing were more likely to suffer from postoperative dysphagia (p= 0.029). Incidence of stricture, DeMeester score, and manometric measurements did not differ between the dysphagia and control groups (p > 0.05 for all parameters). Conclusions: Although preoperative studies are not helpful in identifying patients at risk for persistent dysphagia after laparoscopic Nissen fundoplication, patients presenting with the preoperative complaint of difficulty swallowing are at increased risk for this complication. Received: 1 April 1999/Accepted: 22 July 1999     

Esophageal motility disorders in the morbidly obese population

Background Most studies investigating esophageal motility among the morbidly obese have focused on the relationship between lower esophageal sphincter (LES) pressure and gastroesophageal reflux disease (GERD). Very few studies in the literature have examined motility disorders among the morbidly obese population in general outside the context of GERD. This study aimed to determine the prevalence of esophageal motility disorders in obese patients selected for bariatric surgery. Methods A total of 116 obese patients (81 women and 35 men) selected for laparoscopic gastric banding underwent manometric evaluation of their esophagus from January to March 2003. Tracings were retrospectively reviewed for the end points of LES resting pressure, LES relaxation, and esophageal peristalsis. Results The study patients had a body mass index (BMI) of 42.9 kg/m², and a mean age of 48.6 years. The following abnormal manometric findings were demonstrated in 41% of the patients: nonspecific esophageal motility disorders (23%), nutcracker esophagus (peristaltic amplitude >180 mmHg) (11%), isolated hypertensive LES pressure (>35 mmHg) (3%), isolated hypotensive LES pressure (<12 mmHg) (3%), diffuse esophageal spasm (1%), and achalasia (1%). Only one patient with abnormal esophageal motility reported noncardiac chest pain. Conclusions Despite a high prevalence of esophageal dysmotility in our morbidly obese study population, there was a conspicuous absence of symptoms. Although the patients in this study were not directly questioned with regard to esophageal symptoms, several studies in the literature support our conclusion. Podium presentation at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), 26–29 April 2006, Dallas, TX, USA     

The role of esophageal motility and hiatal hernia in esophageal exposure to acid

Background: The pathogenesis of gastroesophageal reflux disease (GERD) is multifactorial. This study evaluates the relationship between esophageal exposure to acid, the presence or absence of a hiatal hernia, and manometric indicators of esophageal motility. Methods: A total of 51 patients with foregut symptoms were evaluated with upper gastrointestinal series or endoscopy, 24-h pH testing, and esophageal manometry. The DeMeester score was used to distinguish patients with physiologic reflux (DeMeester score <14.72) FROM PATIENTS WITH PATHOLOGIC REFLUX (DEMEESTER SCORE >14.72). Results: Patients with physiologic reflux had fewer hypotensive contractions and a smaller percentage of uncoordinated and hypotensive contractions combined, as compared to patients with pathologic reflux. The amplitude of distal esophageal contractions was greater in patients with physiologic reflux. Also, patients with a hiatal hernia had a higher incidence of pathologic reflux, regardless of the lower esophageal sphincter pressure. Conclusion: Patients with pathologic reflux have abnormal acid exposure associated with pump failure of the esophagus and/or a mechanical defect of the cardia associated with a hiatal hernia.     

Laparoscopic toupet fundoplication for gastroesophageal reflux disease with poor esophageal body motility

Impaired esophageal body motility is a complication of chronic gastroesophageal reflux disease (GERD). In patients with this disease, a 360-degree fundoplication may result in severe postoperative dysphagia. Forty-six patients with GERD who had a weak lower esophageal sphincter pressure and a positive acid reflux score associated with impaired esophageal body peristalsis in the distal esophagus (amplitude <30 mm Hg and >10% simultaneous or interrupted waves) were selected to undergo laparoscopic Toupet fundoplication. They were compared with 16 similar patients with poor esophageal body function who underwent Nissen fundoplication. The patients who underwent Toupet fundoplication had less dysphagia than those who had the Nissen procedure (9% vs. 44%;P=0.0041). Twenty-four-hour ambulatory pH monitoring and esophageal manometry were repeated in 31 Toupet patients 6 months after surgery. Percentage of time of esophageal exposure to pH <4.0, DeMeester reflux score, lower esophageal pressure, intra-abdominal length, vector volume, and distal esophageal amplitude all improved significantly after surgery. Ninety-one percent of patients were free of reflux symptoms. The laparoscopic Toupet fundoplication provides an effective antireflux barrier according to manometric, pH, and symptom criteria. It avoids potential postoperative dysphagia in patients with weak esophageal peristalsis and results teria. It avoids potential postoperative dysphagia in patients with weak esophageal peristalsis and results in improved esophageal body function 6 months after, surgery. Presented at the Thirty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, Calif., May 19–22, 1996.     

One-year follow-up after laparoscopic Heller-Dor operation for esophageal achalasia

Background: The Heller-Dor operation has recently been proposed for the treatment of esophageal achalasia even via a laparoscopic approach. Methods: To measure the medium-term effectiveness of this new minimally invasive technique, an evaluation of pre- and postoperative symptoms, esophagogram, endoscopic findings, esophageal manometry, and pH monitoring was prospectively designed in 43 patients with primary esophageal achalasia. The mean clinical follow-up for all the patients is 12 months (range 3–43), while the mean radiological follow-up is 11 months (range 1–23). Endoscopic data 1 year after surgery are currently available for 27 patients (63%), whereas a 12-month (range 1–26) functional follow-up (including manometric and pH-monitoring studies of the esophagus) is currently available for 35 patients (81.4%). Results: No dysphagia was reported in 38 cases (88.4%); two (4.6%) complained of occasional swallowing discomfort which regressed spontaneously; two (4.6%) had persistent dysphagia which regressed with pneumatic dilatation. One patient (2.8%) reported mild occasional dysphagia after a 1-year asymptomatic period. Preoperatively, esophagograms showed an average maximum diameter of 40.6 ± 9.1 mm which decreased to 24.1 ± 6.0 mm after operation. Mean lower esophageal sphincter (LES) resting and residual pressures decreased significantly from 28.6 ± 10.7 mmHg to 8.8 ± 4.1 mmHg and from 17.0 ± 9.7 mmHg to 4.7 ± 4.0 mmHg, respectively (p < 0.0001). These effects on esophageal diameter and LES function seem to persist over time. The complete absence of any peristaltic contractions recorded preoperatively in all cases remained unchanged after surgery in all but four patients. However, this rare recovery of peristalsis proved to be transient, and patients revealed a manometric impairment of their esophageal body function, but without complaining of dysphagia. Twenty-four-hour pH monitoring showed abnormal gastroesophageal reflux episodes in two (5.7%) of the 35 patients who were monitored: one was asymptomatic; the other had heartburn and endoscopically demonstrated grade II esophagitis. Conclusions: Laparoscopic Heller-Dor operation achieves excellent medium-term results which, together with the already-demonstrated advantages of a minimal surgical trauma and rapid convalescence, validate the use of such a minimally invasive approach to treat patients with primary achalasia of the esophagus. Received: 19 March 1996/Accepted: 15 May 1996     

Cervical esophageal dysphagia: indications for and results of cricopharyngeal myotomy

Twenty patients with cervical esophageal dysphagia were treated by cricopharyngeal myotomy. Of these 20 patients, ten had pharyngoesophageal diverticula, four had a hypertensive upper esophageal sphincter (UES), four had bulbar palsy, and two has miscellaneous forms of cricopharyngeal dysfunction. Preoperative esophageal manometric examination revealed mean UES pressures of 37.2 mmHg +/- 4.8 SEM in patients with diverticula-markedly lower (p = 0.01) than in normal patients (55.9 mmHg +/- 5.0 SEM). In patients with hypertensive UES the mean pressure was 166.2 mmHg +/- 13.4, significantly higher (p less than 0.001) than normal. Incoordination of the deglutitive response of the UES characterised by premature relaxation and contraction was present in all patients with diverticula and in one other patient. Another patient exhibited incomplete sphincteric relaxation (achalasia). A 4-5 cm myotomy of the cricopharyngeus muscle and adjacent esophageal muscle was performed in all patients. On the patients with diverticula two also had diverticulectomy. No patient with bulbar palsy was benefited. All other patients were relieved of dysphagia by the operation, with the exception of one patient with a diverticulum. A subsequent diverticulectomy was required in this patient. Postoperative manometric examination revealed an average decrease in UES pressure of 63% and an average decreased in length of the high pressure zone of 1.4 cm.     

Laparoscopic toupet fundoplication is an inadequate procedure for patients with severe reflux disease

Recently we have shown that laparoscopic Toupet fundoplication is associated with a high degree of late failure when employed as a primary treatment for gastroesophageal reflux disease (GERD). This study defines preoperative risk factors that predispose patients to failure. Data from 48 patients with objective follow-up performed as part of a prospective long-term outcomes project (24-hour pH monitoring, manometry, and esophagogastroduodenoscopy [EGD] at 6 months, 3 years, and 6 years) was analyzed. Preoperative studies of patients with documented postoperative failure (n = 22), defined as an abnormal 24-hour pH study (DeMeester score >14.9), were compared to preoperative studies of patients with normal 24-hour pH studies (n = 26). Outcomes were assessed at a mean of 22 months (range 18 to 37 months) postoperatively. Of the 22 patients in the failure group, 16 (77%) were symptomatic and the majority (64%) had resumed proton pump inhibitor therapy. Preoperative indices of severe reflux were significantly more prevalent in the failure group including a very low or absent lower esophageal sphincter (LES) pressure on manometry, biopsy-proved Barrett’s metaplasia, presence of a stricture, grade III or greater esophagitis, and a DeMeester score greater than 50 with ambulatory 24-hour pH testing. Comparison of pre- and postoperative manometric analysis of the LES revealed adequate augmentation of the LES in both groups and there were no wrap disruptions documented by postoperative EGD or manometry, indicating that reflux was most likely occurring through an intact wrap in the failure group. Esophageal dysmotility was present before surgery in four of the nonrefluxing patients and in three of the failures. Intact wraps were noted to have herniated in eight patients, all of whom had postoperative reflux. Laparoscopic Toupet fundoplication is associated with a high rate of failure both clinically and by objective testing. Surgery is more likely to fail in patients with severe GERD than in patients with uncomplicated or mild disease. A preoperative DeMeester score greater than 50 was 86% sensitive for predicting failure in our patient population. Laparoscopic Toupet fundoplication should not be used as a standard antireflux procedure particularly in patients with severe or complicated reflux disease. Presented at the Thirty-Ninth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, La., May 17–20, 1999.     

Laparoscopic Fundoplication in Patients with a Hypertensive Lower Esophageal Sphincter

Background  A small proportion of patients evaluated with manometry prior to a fundoplication have a high-pressure lower esophageal sphincter (LES). This paper examines the outcome of laparoscopic fundoplication for these patients. Material and Methods  Between October 1991 and December 2006, 1,886 patients underwent primary laparoscopic fundoplication. Those with a high-pressure LES on preoperative manometry (LESP ≥30 mm Hg at end expiration) were identified from a prospective database. Long-term outcomes were determined using analogue symptom scores (0–10) for heartburn, dysphagia, and patient satisfaction and compared to those of a matched control group. Results  Thirty patients (1.6%), nine men and 21 women, median age 51 years, had a hypertensive LES (mean, 36 mmHg; range, 30–55). Median follow-up after fundoplication was 99 (12–182) months. These patients had similar mean symptom scores to 30 matched controls for heartburn (2.3 vs. 2.2, P = 0.541), dysphagia (2.7 vs. 3.1, P = 0.539), and satisfaction (7.4 vs. 7.6, P = 0.546). Five patients required revision for dysphagia compared to no control patients (P = 0.005). These patients had a higher preoperative dysphagia score (6.6 vs. 3.1, P = 0.036). Conclusion  Laparoscopic fundoplication can be performed with good long-term results for patients with reflux and a hypertensive LES. However, those with preoperative dysphagia have a higher failure rate.     

Is laparoscopic refundoplication feasible in patients with failed primary open antireflux surgery?

Background: Due to the widespread availability and acceptance of minimal-access surgery, laparoscopic antireflux surgery has become the standard procedure for the treatment of severe gastroesophageal reflux disease (GERD). However, open and laparoscopic antireflux procedures sometimes result in failure, so that redosurgery is required in some cases. The aim of this prospective study was to evaluate the surgical outcome and quality of life of patients who underwent refundoplication after the failure of primary open antireflux surgery. Methods: Twenty patients with a mean age of 52 years (range, 33–69) underwent laparoscopic refundoplication after primary open antireflux surgery. Four of them had undergone surgery twice previously. Preoperative and postoperative data, including esophageal manometry, 24-h pH monitoring, and assessment of quality of life, were reviewed prospectively. Quality of life was evaluated using the Gastrointestinal Quality of Life Index (GIQLI). Results: In 18 patients (90%), the reoperation was completed successfully laparoscopically. Two others (10%) required conversion to an open procedure. One of them had an injury of the gastric wall; in the other case, severe bleeding of the spleen necessitated the conversion. The average operating time was 245 min. Preoperatively, the main symptoms were recurrent reflux in 14 cases and a combination of re-reflux and dysphagia in six cases. The anatomic findings were telescope phenomenon (n = 6), hiatal disruption (n = 10), and wrap breakdown (n = 4). Postoperatively, two patients suffered from dysphagia and required pneumatic dilatation. The lower esophageal sphincter (LES) pressure increased significantly from a preoperative value of 6.08 mmHg to 12.2 mmHg at 3 months and 11.9 mmHg at 1 year after surgery. The DeMeester score decreased from a preoperative value of 69.8 to 17.1 at 3 months and 14.6 at 1 year postoperatively. The GIQLI score increased from a preoperative value of 84.9 points to 119.6 points at 3 months and 120.1 points at 1 year. Conclusion: Laparoscopic refundoplication after the failure of a primary open intervention is an effective procedure that can be performed safely by experienced laparoscopic surgeon. The procedure yields excellent functional results and leads to significant improvement in the patient's quality of life.     

Myenteric plexus in spastic motility disorders

Previous studies have often revealed an absence or reduction of ganglia in Auerbach’s plexus in many patients with achalasia, which has been postulated to be related to the elevated lower esophageal sphincter pressure in these patients. We undertook a prospective study to determine whether microscopic changes were present in the myenteric plexus of patients with hypertensive lower esophageal sphincter, nutcracker esophagus, and diffuse esophageal spasm and if there was a correlation with lower esophageal sphincter pressure. Nine patients (3 men and 6 women; ages 49 to 72 years, mean 58 years) underwent a laparoscopic esophagomyotomy with fundoplication for symptomatic spastic motility disorder. A 10 mm X 5 mm segment of esophageal muscle was removed from the border of the myotomy incision, fixed in formalin, and examined under light microscopy for the presence or absence of ganglia and inflammation. Correlation between the presence of ganglia and lower esophageal sphincter pressure was tested by Pearson’s bivariant correlation. Manometry revealed three patients with hypertensive lower esophageal sphincter, four patients with nutcracker esophagus, and two patients with diffuse esophageal spasm. All three patients with a hypertensive lower esophageal sphincter revealed an absence of ganglia, whereas the six patients with nutcracker esophagus and diffuse esophageal spasm exhibited ganglia despite an elevated lower esophageal sphincter pressure in four. Hypertensive lower esophageal sphincter resembled achalasia in its absence of ganglia in Auerbach’s plexus, whereas nutcracker esophagus and diffuse esophageal spasm exhibited ganglia. There was no significant correlation in our series between the presence of ganglia and an elevated lower esophageal sphincter pressure in spastic motility disorders.     

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及长期疗效的评估

目的观察分析腹腔镜下食管裂孔疝修补联合Nissen/Dor胃底折叠术治疗食管裂孔疝临床疗效及食管测压与pH值监测对长期疗效的预估意义。 方法回顾性分析2018年1月至2020年1月于河北北方学院附属第二医院收治的120例食管裂孔疝患者的临床资料,其中64例行腹腔镜下食管裂孔疝修补联合Nissen胃底折叠术（Nissen组）,56例行腹腔镜下食管裂孔疝修补联合Dor胃底折叠术（Dor组）。术后随访1年,对比观察2组患者手术情况、住院时间、术后并发症、记录食管测压及pH检测等指标变化情况、Gerd Q、DeMeester评分等。 结果Nissen组术程以及术中出血量明显高于Dor组（P<0.05）,2组总住院时间差异无统计学意义（P>0.05）。2组患者术后总并发症发生率比较,差异无统计学意义（P>0.05）;2组患者术后1年食管反流情况与DeMeester评分较术前均得到明显改善。Nissen组在减少反流次数、长反流次数和最长反流时间方面均优于Dor组（P<0.05）。2组在反流时间、酸反流时间百分比与DeMeester评分比较,差异均无统计学意义（P>0.05）;术后2组患者食管下括约肌压力、静息呼吸平均值、食管残余压较术前均显著提升（P<0.05）,但2组间术后比较无明显差异（P>0.05）。术后2组患者食管松弛率、无效吞咽与Gerd Q评分均较术前也均明显降低,但2组间差异无统计学意义（P>0.05）。 结论腹腔镜疝修补术联合Nissen或Dor胃底折叠术治疗食管裂孔疝均有明显效果,临床应根据患者自身情况选择合适的手术方式。     

胃食管反流病的外科手术治疗（附84例分析）

目的：探讨腹腔镜 Nissen 胃底折叠术治疗胃食管反流病的安全性及临床效果。方法对84例胃食管反流病患者行腹腔镜 Nissen 胃底折叠术,合并食管裂孔疝患者行 Nissen 胃底折叠术的同时行疝修补术。结果84例患者均成功实施腹腔镜 Nissen 胃底折叠术,无中转开腹,无严重并发症及死亡病例。手术时间55～250 min,平均96．4 min,术中出血量20～420ml,平均60．6 ml,术后住院时间5～12 d,平均8．7 d。84例患者术后随访1～24个月,平均15个月。84例患者于术后3个月行24小时食管 pH 值监测与食管测压,DeMeester 评分由87．35±2．81降低到8．72±4．15（P ＜0．05）,食管下段括约肌压力由（6．58±2．97）mmHg 上升到（21．27±5．74）mmHg,均较术前明显改善。术后6个月80例烧心、反酸、胸痛等症状完全消失,无需口服 PPI 制剂者,4例经口服PPI 制剂2个月后停药症状缓解。其中16例伴随夜间睡眠时呛咳均获缓解。32例术后有吞咽梗阻感,经饮食训练4～6周后症状消失。结论腹腔镜 Nissen 胃底折叠术是治疗胃食管反流病一种有效、安全、微创的方法,值得临床广泛推广。     

Severely disordered esophageal peristalsis is not a contraindication to laparoscopic Nissen fundoplication

Background Laparoscopic Nissen fundoplication (LNF) is the preferred operation for the control of gastroesophageal reflux disease (GERD). The use of a full fundoplication for patients with esophageal dysmotility is controversial. Although LNF is known to be superior to a partial wrap for patients with weak peristalsis, its efficacy for patients with severe dysmotility is unknown. We hypothesized that LNF is also acceptable for patients with severe esophageal dysmotility. Methods A multicenter retrospective review of consecutive patients with severe esophageal dysmotility who underwent an LNF was performed. Severe dysmotility was defined by manometry showing an esophageal amplitude of 30 mmHg or less and/or 70% or more nonperistaltic esophageal body contractions. Results In this study, 48 patients with severe esophageal dysmotility underwent LNF. All the patients presented with symptoms of GERD, and 19 (39%) had preoperative dysphagia. A total of 10 patients had impaired esophageal body contractions, whereas 32 patients had an abnormal esophageal amplitude, and 6 patients had both. The average abnormal esophageal amplitude was 24.9 ± 5.2 mmHg (range, 6.0–30 mmHg). The mean percentage of nonperistaltic esophageal body contractions was 79.4% ± 8.3% (range, 70–100%). There were no intraoperative complications and no conversions. Postoperatively, early dysphagia occurred in 35 patients (73%). Five patients were treated with esophageal dilation, which was successful in three cases. One patient required a reoperative fundoplication. Overall, persistent dysphagia was found in two patients (4.2%), including one patient with severe preoperative dysphagia, which improved postoperatively. Abnormal peristalsis and/or distal amplitude improved postoperatively in 12 (80%) of retested patients. There were no cases of Barrett’s progression to dysplasia or carcinoma. During an average follow-up period of 25.4 months (range, 1–46 months), eight patients (16%) were receiving antireflux medications, with six of these showing normal esophageal pH study results. Conclusion The LNF procedure provides low rates of reflux recurrence with little long-term postoperative dysphagia experienced by patients with severely disordered esophageal peristalsis. Effective fundoplication improved esophageal motility for most of the patients. A 360° fundoplication should not be contraindicated for patients with severe esophageal dysmotility.     

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。