抗胃食管返流手术的探讨

胃食管返流病是上消化道最常见的疾患之一，发生并发症的部分病人需外科治疗。作从1988年7月至1996年12月用各种抗返流手术方法治疗87例胃食管返流病人，其中包括77例滑动型食管裂孔症，8例短食管，2例食管旁疝。48例用Nissen胃底折叠术，11例用Belsey4号手术，3例用Collis-Nissen手术，1例用Thor手术，24例用作自己设计的贲门斜行套叠术。3例Nisson手术术后复发，全组术后复发率和并发症发生率为.9%（6/87）。从1993年开始施行贲门斜行套叠术，全部病人术后24h食管pH监测证明手术成功。结论：Nissen手术虽应用广泛，但难于操作和并发症多；相反，贲门斜行套叠术易于传播，疗效确实，有效地建立了肮返流屏障。     

腹腔镜下或胃镜下胃食管反流手术的疗效观察

目的探讨腹腔镜下或胃镜下胃食管反流(gastroesophageal reflux d isease,GERD)手术的疗效、手术方法及适应证。方法总结2005年8月~2006年1月施行腹腔镜下N issen手术52例和胃镜下胃壁折叠术28例的一般资料、手术结果,以及术后1、3个月的随访资料。结果两组的症状指数及反流时间均明显下降。腹腔镜组灼心感指数和反流指数分别从72.2±7.3和1.80±0.45下降至14.5±4.8和0.26±0.15(P均<0.05);胃镜组该两指数分别从70.6±9.4和1.80±0.32下降至28.2±7.6和0.30±0.12(P均<0.05)。腹腔镜组食管下段反流时间百分比从11.2%±6.2%下降至2.5%±0.4%(P<0.05);胃镜组从10.2%±5.7%下降至7.6%±1.2%(P<0.05)。腹腔镜手术中1例中转开腹手术,近期并发症3例,远期并发症2例,术后完全缓解率93.9%(46/49)。胃镜手术近期并发症3例,无远期并发症,术后完全缓解率58.3%(14/24)。结论腹腔镜下N issen手术是治疗严重GERD的理想术式,胃镜下胃折叠术则适用于治疗病情轻的GERD以减少其对药物的依赖,但疗效尚待进一步提高。     

抗胃食管返流手术的探讨

胃食管返流病是上消化道最常见的疾患之一,发生并发症的部分病人需外科治疗。作者从1988年7月至1996年12月用各种抗返流手术方法治疗87例胃食管返流病人,其中包括77例滑动型食管裂孔疝,8例短食管,2例食管旁疝。48例用Nissen胃底折叠术,11例用Belsey 4号手术,3例用Collis-Nissen手术,1例用Thor手术,24例用作者自己设计的贲门斜行套叠术。3例Nissen手术术后复发,全组术后复发率和并发症发生率为6.9％(6/187)。从1993年开始施行贲门斜行套叠术,全部病人术后24h食管pH监测证明手术成功。结论:Nissen手术虽应用广泛,但难于操作和并发症多;相反,贲门斜行套叠术易于传授,疗效确实,有效地建立了抗返流屏障。     

贲门斜行套叠术─——种新的抗反流手术

作者设计了一种新的抗反流手术─—贲门斜行套叠术，在动物实验成功的基础上应用于临床，共施行１７例。方法为贲门部胃大弯侧食管与胃套叠缝合４ｃｍ，小弯侧２ｃｍ，再缝合食管胃连接部全周。术后患者仅流症状均消失，食管测压显示高压带压力较术前升高，２４小时食管ｐＨ监测无异常反流。理论上，此手术建立了食管腹段、Ｈｉｓ角和玫瑰花结，并符合ＬａＰｌａｃｅ定律。此手术经腹操作，方法简单，近期疗效确实。     

食管肌层切开术联合胃底折叠术治疗食管运动功能障碍性疾病的远期疗效

目的 比较食管肌层切开术加不同胃底折叠术式治疗贲门失弛缓症或弥漫性食管痉挛的远期效果.方法 1978年1月至1998年10月,共64例贲门失弛缓症或弥漫性食管痉挛患者经左胸行Heller手术+抗反流手术.其中21例加行Nissen全胃底折叠术(Nissen组),43例加行BelseyⅣ式部分胃底折叠术(Belsey组).患者于手术前后行影像学、食管核素排空、食管压力测定和内窥镜检查及24 h pH值监测.结果 全组无手术死亡及严重并发症.术后6年随访,Nissen组吞咽困难(P=0.025)及核素潴留(P=0.044)的发生率高于Belsey组.两种术式均可降低食管下括约肌的压力梯度.Nissen组术后食管直径较术前增加(P=0.012),而Belsey组增加不明显(P=0.695).两组烧心与反酸症状均少见.Nissen组有8例患者、Belsey组有1例患者因复发性吞咽困难需行二次手术(P＜0.01).结论 在治疗贲门失弛缓症或弥漫性食管痉挛患者时,加行全胃底折叠术可能并不适宜,而部分胃底折叠术可以提供满意的抗反流效果,且不会显著影响食管排空功能.     

腹腔镜治疗食管裂孔疝的初步临床经验

目的总结腹腔镜手术治疗食管裂孔疝的初步经验。方法2004年5月~2005年4月,食管裂孔疝15例行腹腔镜食管裂孔疝修补加抗反流手术。Ⅰ型4例均伴有严重的胃食管反流,Ⅱ型10例,Ⅲ型1例。在缝合缩小食管裂孔的同时,行N issen术9例,Toupet术4例,Dor术2例。采用视觉模拟积分(visual analogue scales,VAS)评价术前及术后1、6个月胃食管反流症状,包括烧心、吞咽梗阻、反酸、胸痛、嗳气等。结果全组无中转开腹。手术时间100~187 m in,平均125 m in。术后住院2~5 d,平均2.8 d。术后随访1~12个月,平均8.5月,无疝复发。胃食管反流综合症状VAS评分术前5.0±3.9,术后1个月降至0.9±1.3(t=3.823,P<0.05),术后6个月降至0.8±1.6(t=3.549,P<0.05)。术后并发胃潴留2例,吞咽梗阻1例,3个月后缓解。结论采用腹腔镜技术手术治疗食管裂孔疝具有创伤小、恢复快的特点,其短期临床效果满意。     

贲门斜行套叠术—一种新的抗反流手术

作者设计了一种新的抗反流手术－贲门斜行套叠术，在动物实验成功的基础上应用于临床，共施行７例。方法为贲门总胃大弯侧食管与胃套叠缝合４ｃｍ，小弯侧２ｃｍ，再缝合食管胃连接部全周。术后患者仅流症状均消失，食管测压显示高压带压力较术前升高，２４小时食管ＰＨ监测无异常反流。理论上，此手术建立了食管腹段、Ｈｉｓ角和玫瑰花结，并符合ＬａＰｌａｃｅ定律。此手术经腹操作，方法简单，近期疗效确实。     

腹腔镜下以Crurasoft重建食管裂孔在老年GERD患者中的应用研究

目的 探讨腹腔镜下以Crurasoft补片重建食管裂孔并行Nissen胃底折叠术在老年胃食管反流(GERD)中的应用效果.方法 2006年7月至2009年7月3年期间我科共收治老年(≥65岁)GERD患者22例,其中行Nissen胃底折叠术并以Crurasoft补片无张力重建食管裂孔者10例(直径≥5 cm者2例,<5 cm者8例),行Nissen胃底折叠术并以间断缝合方式重建食管裂孔者12例(直径≥5 cm者2例,<5 cm者10例).对2组患者手术资料以及术前和术后3个月及1年的症状变化(烧心、反酸、吞咽困难、呼吸道疾患)、胃镜检查情况、食管下段压力(LESP)及24 h pH检查(DeMeester评分)结果进行对比分析.结果 补片组手术时间长于缝合组(P<0.05),缝合组有2例术后发生折叠胃底移位致症状复发.两种手术方式均可改善患者症状,与术前比较其GERD症状评分明显降低(P<0.05),补片组的GERD症状评分又低于缝合组(P<0.05);缝合组术后1年其烧心及反酸症状较术后3个月有所加重(P<0.05).2组患者术后的胃镜、LESP及pH复查情况较术前均有所改善,胃黏膜改变评分及24 h食管pH评分明显降低,LESP明显升高(P<0.05);其中补片组的改善情况优于对应时间的缝合组(P<0.05);缝合组组内术后1年时的LESP及24 h食管pH评分较术后3个月又明显降低或升高(P<0.05).结论 腹腔镜下Crurasoft补片重建食管裂孔并行Nissen胃底折叠术是治疗老年GERD的一种安全有效的方法.     

腹腔镜Nissen胃底折叠术治疗老年胃食管反流病

目的:对比腹腔镜Nissen 胃底折叠术在老年组和非老年组胃食管反流病(GERD)的疗效,评价其在老年人应用的可行性.方法:回顾分析因GERD行腹腔镜Nissen胃底折叠术治疗的老年病人28例,随机选取同时期非老年GERD病人40例作为对照组,分析不同年龄组患者的治疗效果.结果:术后两组症状完全消失.食管下段压力由(8.8±2.6)mmHg(1mmHg =0.133 kPa)提高到(18.23±3.6)mmHg(P＜ 0.01),24 h pH值检测评分由105.4±3.7降低到8.12±2.1(P＜ 0.01),较术前明显改善,并达到正常范围.平均随访4.5年,非老年组症状复发2例,老年组1例.远期吞咽困难老年组发生8例,非老年组为1例,差异有统计学意义(P＜ 0.05).结论:在老年GERD病人中实施腹腔镜Nissen 胃底折叠术与在非老年病人中实施一样安全、有效,但远期吞咽困难发生率较非老年人为高.     

抗胃食管反流手术对大鼠胃排空功能影响的实验研究

目的 观察不同抗胃食管反流手术对大鼠胃排空功能的影响。方法 将大鼠随机分为5组，A组为贲门肌层切开组，B组为贲门肌层切开后行Nissen手术，C组为贲门肌层切开后行Nissen手术并加行幽门肌层切开，D组为贲门肌层切开加贲门斜行套叠术，E组为对照组。于第4周行放射性核素胃排空功能检查，观察手术对大鼠胃排空功能的影响。结果 （1）半胃排空时间C组较B、D组快（P＜0．05），B、C、D组较E组快（P＜0．05），A组与E组无差别（P＞0．05）。（2）2h胃内放考元素潴留率测定表明，A组与E组无差别（P＞0．05），B、C、D组较E组少（P＜0．05），B、C、D组间无差别（P＞0．05）。结论 （1）抗反流手术（Nissen手术、贲门斜行套叠术）可以使半胃排空时间增快，2h胃内放射性元素潴留率减少。（2）Nissen手术加做幽门肌层切开可使半胃排空时间增快，但2h胃内放射性元素潴留率较单纯Nissen术无变化，综合考虑，行抗反流手术不必同时加行幽门肌层切开术。     

Laparoscopic partial posterior fundoplication provides excellent intermediate results in GERD patients with impaired esophageal peristalsis.

BACKGROUND: Gastroesophageal reflux disease (GERD) is frequently associated with impaired esophageal peristalsis, and many authorities consider this condition not suitable for Nissen fundoplication. METHODS: To investigate the outcome of antireflux surgery in the presence of impaired esophageal peristalsis, 78 consecutive GERD patients with poor esophageal contractility who underwent laparoscopic partial posterior fundoplication were studied. A standardized questionnaire, upper gastrointestinal endoscopy, esophageal manometry, and 24-hour pH monitoring were performed preoperatively and at a median of 31 months (range 6-57 months) postoperatively. Esophageal motility was analyzed for contraction amplitudes in the distal two thirds of the esophagus, frequency of peristaltic, simultaneous, and interrupted waves, and the total number of defective propagations. In addition, parameters defining the function of the lower esophageal sphincter were evaluated. RESULTS: After antireflux surgery, 76 patients (97%) were free of heartburn and regurgitation and had no esophagitis on endoscopy. The rate of dysphagia decreased from 49% preoperatively to 10% postoperatively (P < .001). Features defining impaired esophageal body motility improved significantly after antireflux surgery. The median DeMeester score on 24-hour esophageal pH monitoring decreased from 33.3 to 1.1 (P < .001). CONCLUSIONS: Partial posterior fundoplication provides an effective antireflux barrier in patients with impaired esophageal body motility. Postoperative dysphagia is diminished, probably because of improved esophageal body function.     

Laparoscopic fundoplication: Nissen versus Toupet two-year outcome of a prospective randomized study of 200 patients regarding preoperative esophageal motility

Objective To determine the influence of preoperative esophageal motility on clinical and objective outcome of the Toupet or Nissen fundoplication and to evaluate the success rate of these procedures. Summary background data Nissen fundoplication (360°) is the standard operation in the surgical management of gastroesophageal reflux disease (GERD). In order to avoid postoperative dysphagia it has been proposed to tailor antireflux surgery according to pre-existing esophageal motility. Postoperative dysphagia is thought to occur more commonly in patients with esophageal dysmotility and it has been recommended to use the Toupet procedure (270°) in these patients. We performed a randomized trial to evaluate this tailored concept and to compare the two operative techniques concerning reflux control and complication rate (dysphagia). Methods 200 patients with GERD were included in a prospective, randomized study. After preoperative examinations (clinical interview, endoscopy, 24-hour pH-metry and esophageal manometry) 100 patients underwent either a laparoscopic Nissen procedure (50 with and 50 without motility disorders), or Toupet (50 with and 50 without motility disorders). Postoperative follow-up after two years included clinical interview, endoscopy, 24-hour pH-metry, and esophageal manometry. Results After two years 85% (Nissen) and 85% (Toupet) of patients were satisfied with the operative result. Dysphagia was more frequent following a Nissen fundoplication compared to Toupet (19 vs. 8, p < 0.05) and did not correlate with preoperative motility. Concerning reflux control the Toupet proved to be as good as the Nissen procedure. Conclusion Tailoring antireflux surgery according to the esophageal motility is not indicated, as motility disorders are not correlated with postoperative dysphagia. The Toupet procedure is the better operation as it has a lower rate of dysphagia and is as good as the Nissen fundoplication in controlling reflux.     

Five-year comprehensive outcomes evaluation in 181 patients after laparoscopic Nissen fundoplication

BACKGROUND: We conducted an objective followup of 181 patients after laparoscopic Nissen fundoplication during a 5-year period after surgery. STUDY DESIGN: Patients underwent 24-hour pH recording, esophageal manometry, and symptom score assessment for six gastroesophageal reflux disease symptoms preoperatively and at 6 months, 2 years, and 5 years after surgery. RESULTS: Laparoscopic fundoplication was associated with a significant (p < 0.0001) increase in lower esophageal sphincter pressure and a significant (p < 0.0001) drop in duration of acid reflux in 24 hours, and symptom score, 6, 24, and 60 months after surgery when compared with preoperative values. Twenty-one patients (12%) have experienced recurrence of reflux-type symptoms, but only six have required repeat surgery. Lower esophageal sphincter tone dropped between 6 months and 5 years after surgery, but was still an effective antireflux barrier. Patient satisfaction with surgery dropped over the 5-year followup but remained high, at 86%, after 5 years. CONCLUSIONS: Laparoscopic Nissen fundoplication remains an effective antireflux procedure at 5 years.     

Comparison of Nissen fundoplication and Belsey Mark IV in the management of gastroesophageal reflux

Our experience for the past four years with antireflux surgery has been reviewed. The Nissen fundoplication resulted in symptomatic improvement in 87.5 per cent of cases as compared with 64 per cent who were improved after the Belsey Mark IV procedure. Objective evaluation as measured by the standard acid reflux test (SART) revealed recurrent reflux in 9 per cent of those who underwent fundoplication and in 47 per cent of those treated with the Belsey repair. Mortality rates were similar. These results indicate that Nissen fundoplication is superior to the Belsey Mark IV procedure in the management of gastroesophageal reflux.     

Postprandial bloating after laparoscopic Nissen fundoplication.

OBJECTIVE: To evaluate the prevalence and possible contributing factors to postprandial bloating in patients having chronic gastroesophageal reflux disease (GERD) before and after laparoscopic Nissen fundoplication. DESIGN: A prospective cohort study. SETTING: A tertiary care teaching hospital. PATIENTS: Five hundred and seventy-eight patients with proven GERD. INTERVENTION: Laparoscopic Nissen fundoplication. OUTCOME MEASURES: Symptom severity scores for postprandial bloating and dysphagia, esophageal motility and 24-hour pH measurement before and at 6 months, 2 years and 5 years after laparoscopic Nissen fundoplication. RESULTS: Of the 598 patients, 436 (73%) reported some postprandial bloating before the procedure. The symptom score for bloating significantly improved after surgery (p < 0.0001). There were no significant differences in the lower esophageal sphincter basal pressures or 24-hour pH scores between those who reported improvement or worsening of their postprandial bloating. At 6 months after surgery, 54% of patients experienced postprandial bloating; of these, 49% reported improvement, 21% reported worsening and 30% reported no change in bloating symptoms compared with the preoperative state. Of the patients who reported worsening of postprandial bloating 6 months after surgery, 86 were reassessed 2 years after surgery and 71% reported improvement of this symptom over this time interval. CONCLUSIONS: Bloating is a common symptom in patients who suffer from chronic GERD. Laparoscopic Nissen fundoplication lessens the severity of this symptom in most patients. In a small subgroup of patients, antireflux surgery may exacerbate the bloating, but this improves over time.     

An experimental study of the effectiveness of various antireflux operations.

After a hypotensive lower esophageal sphincter was created in cats by circular myectomy of the distal esophagus, a comparative study was performed of the sphincter-enhancing operations currently in use: the Nissen fundoplication, the Belsey Mark IV, and the Hill posterior gastropexy. Subdiaphragmatic transposition of the myectomized segment was included to assess the effectiveness of intraabdominal positioning on lower esophageal sphincter competence.The mean lower esophageal sphincter pressure after Nissen fundoplication (21.7 ± 1.5 cm H₂O) did not differ significantly from control values (24.3 $pL 1.8 cm H₂O), whereas significantly lower pressures were recorded after the Belsey Mark IV (11.7 ± 1.5 cm H₂O), Hill posterior gastropexy (9.0 ± 1.5 cm H₂O), and subdiaphragmatic transposition (4.0 ± 1.5 cm H₂O) procedures. The adaptive response of the lower esophageal sphincter to increased intragastric pressure was restored to near normal levels by both the Nissen and Belsey procedures, whereas the Hill posterior gastropexy and subdiaphragmatic transposition were less effective. In addition, pH reflux testing clearly indicated that the Nissen fundoplication afforded maximum protection against acid reflux.The experimental evidence suggests that optimum results in the surgical treatment of gastroesophageal reflux are achieved when the resting lower esophageal sphincter pressure and the adaptive response are restored to normal levels. The Nissen fundoplication accomplishes these objectives more effectively than the alternative antireflux procedures.     

Nissen vs toupet laparoscopic fundoplication

BACKGROUND: Nissen fundoplication (360 degrees ) is the standard operation for the surgical management of gastroesophageal reflux disease (GERD). To avoid postoperative dysphagia, it has been proposed that antireflux surgery be tailored according to the degree of preexisting esophageal motility. Postoperative dysphagia is thought to occur more commonly in patients with esophageal dysmotility and the Toupet procedure (270 degrees ) has been recommended for these patients. We performed a randomized trial to evaluate this tailored concept and to compare the two operative techniques in terms of reflux control and complication rate (dysphagia). Our objective was to determine the impact of preoperative esophageal motility on the clinical and objective outcome, following Toupet vs Nissen fundoplication and to evaluate the success rate of these procedures. METHODS: From May 1999 until May 2000, 200 patients with GERD were included in a prospective randomized study. After preoperative examinations (clinical interview, endoscopy, 24-h pH study and esophageal manometry), 100 patients underwent either a laparoscopic Nissen (50 with and 50 without motility disorders), or a Toupet procedure (50 with and 50 without motility disorders). Postoperative follow-up after 4 months included clinical interview, endoscopy, 24-h pH study and esophageal manometry. RESULTS: Interviews showed that 88% (Nissen) and 90% (Toupet) of the patients, respectively, were satisfied with the operative result. Dysphagia was more frequent following a Nissen fundoplication than after a Toupet (30 vs 11, p <0.001) and did not correlate with preoperative motility. In terms of reflux control, the Toupet proved to be as effective as the Nissen procedure. CONCLUSION: Tailoring antireflux surgery to esophageal motility is not indicated, since motility disorders are not correlated with postoperative dysphagia. The Toupet procedure is the better operation because it has a lower rate of dysphagia and is as effective as the Nissen fundoplication in controlling reflux.     

Long-term Result of Total versus Partial Fundoplication after Esophagomyotomy for Primary Esophageal Motor Disorders

Background The selection of the type of fundoplication or the necessity for an added fundoplication after esophagomyotomy (Heller’s operation) for the treatment of achalasia remains controversial. The present retrospective study was designed to compare the long-term results of total and partial fundoplication on the myotomized esophagus. Methods Between 1978 and 1998, a total of 64 consecutive patients with achalasia or diffuse esophageal spasm underwent esophagomyotomy and an antireflux operation via a left thoracotomy approach. Twenty-one had a total fundoplication (Nissen Group) during the period 1978–1983. After 1984 and until 1998, the remaining 43 patients were treated with addition of a Belsey Mark IV partial fundoplication (Belsey Group) to protect the myotomized esophagus. Clinical, radiologic, radionuclide transit, manometric, 24–h pH monitoring, and endoscopic assessments were obtained before and after the operation. Results There were no operative deaths or major complications in either group. After 6 years of follow-up the Belsey group was compared to the Nissen group. A higher frequency of dysphagia (7/18 versus 3/31; p = 0.025), more barium stasis (9/13 versus 10/27; p = 0.056), and increased radionuclide material retention (52.4% versus 29.2%; p = 0.044) were observed in the Nissen group. These findings were confirmed by endoscopy, which showed increased esophageal lumen dilation (10/15 versus 8/26; p = 0.026) and more frequent food retention (11/15 versus 6/26; p = 0.002). Functionally, both operations successfully reduced the lower esophageal sphincter pressure gradient (from 23.8 to 7.7 mmHg for the Nissen group, and from 27.4 to 8.2 mmHg for the Belsey group; p = 0.656). In the Nissen group, the esophageal diameter observed on radiology increased from 3.9 cm preoperatively to 5.5 cm postoperatively (p = 0.012), whereas it remained identical for the Belsey group (ranging from 5.4 cm to 5.3 cm; p = 0.695). Reoperation to relieve recurrent dysphagia and esophageal retention was necessary in 8 patients from the Nissen group and in 1 patient from the Belsey group (p < 0.001). Conclusions When treating achalasia or diffuse esophageal spasm by esophageal myotomy and an antireflux operation, a total fundoplication adds too much resistance to allow esophageal emptying and is considered as inappropriate. A partial fundoplication provides proper antireflux effects without causing significant esophageal emptying difficulties. The abstract of this work was accepted as free paper and oral presentation at International Surgical Week 2007 (Abstract 215), Montreal, Canada, August 26–30, 2007.