胸腔镜辅助食管下段肌层纵行切开术治疗贲门失弛缓症18例

目的探讨胸腔镜辅助食管下段肌层纵行切开术治疗贲门失弛缓症的可行性。方法2000年3月~2O04年9月,18例贲门失弛缓症在胸腔镜辅助下行食管下段肌层纵行切开术。游离下段食管及胃贲门部,自下肺静脉至胃贲门部1 cm胃壁纵行切开食管下段肌层。结果18例均在胸腔镜下完成手术,无中转开胸,无严重并发症,无死亡。手术时间(108.5±6.5)m in,胸腔引流(2.5±0.5)d,术后住院(6.5±0.5)d。术后12、18个月,症状评分由术前(3.1±0.6)分别降为(1.6±0.3)分和(1.9±0.8)分(q=10.558,P<0.05;q=8.446,P<0.05);食管末端直径由术前(7.1±1.3)cm分别降为(3.8±1.2)cm和(3.6±1.3)cm(q=11.046,P<0.05;q=11.715,P<0.05);食管下段括约肌压力(lower esophageal sph incterpressure,LESP)由术前(29.6±3.8)mm Hg分别降低到(21.2±2.3)mm Hg和(19.2±3.9)mm Hg(q=10.443,P<0.05;q=12.929,P<0.05);食管末端pH由术前3.2±0.4分别升至术后5.5±0.3和5.1±0.5(q=23.902,P<0.05;q=19.745,P<0.05);术后12、18个月比较,症状评分、食管末端直径、食管下段括约肌压力均无统计学意义(P>0.05),但食管末端pH值有统计学差异(q=4.157,P<0.05)。结论胸腔镜辅助食管下段肌层纵行切开术可行。     

内镜下食管肌层切开术治疗贲门失弛缓症

Achalasia is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal sphincter. It is characterized by difficulty swallowing, regurgitation, and sometimes chest pain. Peroral endoscopic myotomy (POEM) was developed by Inoue to provide a less invasive permanent treatment for esophageal achalasia. We applied this method to cure successfully a 47-year-old female with achalasia. The procedure was as follows: after creating submucosal tunnel, endoscopic myotomy of circular muscle bundles was carried out at approximately 16 cm in total length ( 15 cm in distal esophagus and 1 cm in cardia). Smooth passing of endoscope through gastroesophageal junction was confirmed at the end of the procedure. The third day after POEM, the barium meal examination revealed the barium smoothly passed though the cardia. The short-term outcome of POEM for achalasia was excellent, and further studies on long-term efficacy and on comparison of POEM with other interventional therapies are awaited.     

胸腔镜手术治疗贲门失弛缓症

胸腔镜手术治疗贲门失弛缓症张晓林李含志刘永春谢周良程兆云钱如林１９９５年１０月至１９９６年６月，我们利用电视胸腔镜与气囊食管扩张器结合，为６例贲门失弛缓症病人进行了食管下段肌层和贲门括约肌切开术，效果满意，现报道如下：临床资料本组男女各３例，年龄２６...     

电视胸腔镜辅助小切口Heller术治疗贲门失弛缓症

目的：探讨电视胸腔镜辅助小切口Heller术治疗贲门失弛缓症的临床效果。方法：回顾分析我院2000年6月～2006年5月16例贲门失弛缓症接受电视胸腔镜辅助小切口Heller术治疗的临床资料。手术经左第8肋间置胸腔镜,第7肋间后外侧切口6～8cm进胸,行食管肌层切开术。结果：16例均顺利完成手术,手术时间56～105min,平均64min,术后住院8～15d,平均11d。1例损伤食管黏膜术中修补,术后无严重并发症。16例随访2～24个月,平均14个月,15例吞咽困难消失,1例症状解除不完全,经食管扩张后症状消失,无胃食管反流症状。结论：电视胸腔镜辅助小切口Heller术,创伤小,恢复快,并发症少,住院时间短,合理掌握胃食管连接部的肌层切开范围,可有效防止术后胃食管反流。     

电视胸腔镜下行食管肌层切开治疗贲门失弛缓症18例

贲门失弛缓症的外科治疗开始于19世纪末，食管贲门黏膜外肌层切开术目前仍是贲门失弛缓症最有效的治疗方法。我院自1997年6月至2004年6月应用电视胸腔镜食管肌层切开术治疗贲门失弛缓症18例，疗效满意。     

贲门失弛缓症胸腔镜手术治疗

1995年 3月以来 ,我们对 31例病人行胸腔镜下贲门失弛缓症肌层切开术 ,取得较好治疗效果。现总结如下。临床资料　全组中男 13例 ,女 18例 ;年龄 10～ 6 9岁。病人有不同程度吞咽困难 6个月～ 30年。术前吞钡Ｘ线食管摄片显示 ,食管扩张直径 <4 0ｃｍ 1例 ,4 0～ 6 0ｃｍ 16例 ,>6 0ｃｍ 14例。 3例伴有不同程度胃下垂。术前曾口服药物治疗 2 8例 ,其中 10例曾施行贲门扩张术 ,1例扩张 3次。手术方法和结果　全组均经胸腔镜行食管贲门肌层切开术。病人右侧卧位 ,经左胸手术。腋中线第 4肋间切口为胸腔镜套管插入口 ,分别在腋前线第 6肋…     

改良Heller手术治疗贲门失弛缓症64例

我科从1986年至2006年经腹行改良Heller手术及附加抗返流装置治疗贲门失弛缓症64例。现将治疗体会报告如下。临床资料1.一般资料:全组64例,男41例,女23例。年龄12~56岁,平均年龄34岁,病程0.5~20年。临床表现:全组均有不同程度的吞咽困难和体重下降。其中23例伴有进食后呕吐、溢     

电视胸腔镜辅助Heller手术治疗贲门失弛缓症

目的探讨电视胸腔镜辅助下Heller手术治疗贲门失弛缓症的可行性、手术方法及疗效。方法2001年3月至2005年12月,19例贲门失弛缓症病人行胸腔镜辅助下Heller手术。结果无中转开胸者,无严重并发症,无死亡病例。手术时间(109·5±7·5)min,胸腔引流(2·5±0·5)d,术后住院(6·5±0·5)d。术后1年以内和1年后病人症状评分由术前2·7±1·1降为1·6±0·7和1·7±0·8,食管末端直径由术前(6·1±1·7)cm降为(4·0±1·1)cm和(3·8±1·1)cm,食管下段括约肌压力(LESP)由术前(28·9±4·1)mmHg降低到(20·1±3·6)mmHg和(19·9±3·3)mmHg,食管末端pH由术前3·4±0·9上升至4·9±1·3和5·0±1·3,同术前相比,4项差异均有统计学意义(P<0·05),而术后远期(>1年)与近期(≤1年)相比差异均无统计学意义(P>0·05)。结论胸腔镜辅助Heller手术技术可行、疗效肯定,值得在有条件的医疗单位推广,但其长期疗效和抗反流作用仍需要大规模的病例和长期随访观察。     

胸腔镜加小切口行Heller手术治疗贲门失弛缓症

目的　探讨胸腔镜加小切口行 Heller手术治疗贲门失弛缓症的手术方法和效果 ,以提高手术疗效。方法　 1996年 1月～ 2 0 0 0年 12月 ,对 3 7例经病史、食管镜和食管 X线钡餐造影确诊为贲门失弛缓症患者 ,在胸腔镜加小切口下行 Heller手术治疗 ,并进行随访观察。　结果　 1例患者改行常规开胸手术。手术时间 1～ 3 .5小时 ,平均手术时间 1.8± 0 .4小时。所有患者术后均未发生食管漏和手术死亡 ,住院期间于胃肠道功能恢复后可正常进食 ,吞咽困难症状消失。至最后 1次随访 ,手术效果优 2 9例 ( 78% ) ,良 5例 ( 14 % ) ,差 3例 ( 8% ) ,后者术后 3个月因吞咽困难复发行食管扩张 ,发生食管反流 4例 ( 11% ) ,但不需手术或药物治疗。　结论　胸腔镜加小切口 Heller手术治疗贲门失弛缓症具有良好的效果。     

腹腔镜Heller括约肌切开术治疗贲门失弛缓症

目的：探讨采用腹腔镜微创手术治疗贲门失弛缓症的可行性及临床效果。方法：对5例患者在术中行胃镜定位、监视下行腹腔镜Heller括约肌切开术治疗。结果：4例手术顺利,1例患者由于粘连严重,术中分破远端食管,经胃镜证实后即行腹腔镜下修补术,术后1d,4例症状明显改善,1例术后1周吞咽困难症状逐渐改善。随访5～17个月,均未再发生吞咽困难、返流、胸骨后疼痛等症状。结论：腹腔镜Heller括约肌切开术治疗贲门失弛缓症创伤小、恢复快,并可作为内科治疗失败后的补救治疗。     

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目的 探讨电视辅助胸腔镜手术（VATS）在治疗食管癌中的应用、手术方法及临床效果。方法 利用胸腔镜技术对38例食管癌病人进行手术，并对手术操作、并发症及术后恢复等情况进行总结性分析。结果 38例病人全部采用VATS方法完成手术，1例发生支气管胸膜瘘，5例术后发生吻合口瘘，经简单对症治疗全部治愈，无死亡病例。术后1年、3年、5年生存者，分别为10、8、4例，术后因肿瘤转移死亡3例，其它原因死亡2例，失访7例，余4例为术后不足1年的病人，尚未见肿瘤复发、转移情况。结论 只要掌握好胸腔镜的操作技巧及食管癌切除的手术指征，VATS治疗食管癌不但是可行的，而且具有广阔的前景。     

Preoperative lower esophageal sphincter pressure affects outcome of laparoscopic esophageal myotomy for achalasia

The primary aim of this study was to identify factors that influence outcome of the surgical treatment of achalasia. A secondary aim was to compare outcomes after laparoscopic Heller myotomy and partial fundoplication using either a Dor or Toupet hemifundoplication. Between 1994 and 2002, a total of 78 patients underwent laparoscopic Heller myotomy and partial fundoplication. Preoperative investigations included esophageal manometry, a videoesophogram, and upper gastrointestinal endoscopy with biopsy. In 64 patients (35 males and 29 females), telephone contact was possible at a median 24 months (IQR 14–34). A Dor fundoplication was performed in 41 patients and a Toupet fundoplication in 23. Symptoms were assessed prior to surgery and at follow-up by an independent physician using standardized definitions to grade the severity of dysphagia, regurgitation, and chest pain. To assess outcome, dysphagia was categorized as persistent or resolved. Persistent was defined as dysphagia that occurred on a weekly or daily basis. Resolved was defined as dysphagia that occurred occasionally or not at all. At follow-up, patients were asked to make a personal evaluation of their outcome as to whether (1) their swallowing was improved by the procedure, (2) they were satisfied with the outcome, and (3) they would undergo surgery again under the same circumstances. There was a significant improvement in dysphagia and regurgitation scores after surgery (P<0.05). The scores for chest pain/heartburn remained unchanged. By physician assessment, dysphagia was resolved in 49 patients (77%) and persisted in 15 (33%). By patient assessment, 62 patients (97%) reported an improvement in the symptom of dysphagia, and 60 (94%) stated that they were satisfied with their improvement and would undergo surgery if they had to make the choice again. On univariate analysis, patients who had resolution of their dysphagia had a significantly higher resting lower esophageal sphincter (LES) pressure prior to myotomy (P=0.01) and on multivariate analysis only a high resting LES pressure prior to surgery was a predictor of resolution of dysphagia (P=0.015). Outcome comparison of patients with Dor and Toupet fundoplications showed no significant differences in physician assessment of postoperative symptom scores and resolution of dysphagia, patient assessment of outcome, or postoperative use of proton pump inhibitors. Ninety-four percent of patients are satisfied with their surgical myotomy for achalasia. By physician assessment dysphagia was resolved in 77% of patients. Ahigh LES resting pressure before surgery predicted resolution of dysphagia.     

电视胸腔镜食管癌切除术16例报告

目的探讨电视胸腔镜手术(video-assisted thoracoscopic surgery, VATS)治疗食管癌的可行性和手术技巧. 方法 2002年10月～2003年10月,应用电视胸腔镜行食管癌切除术16例.其中中段癌13例,中下段癌3例;TNM分期T1 2例,T2 5例,T3 9例;Ⅰ期2例,Ⅱ期8例,Ⅲ期6例. 结果无一例中转开胸手术,VATS手术时间90～150 min,平均110 min.清除纵隔淋巴结6～14枚,平均7.3枚.术后2～3 d拔除胸引流管,引流量300～600 ml .近期无并发症发生. 结论 VATS治疗食管癌技术可行,手术适应证应掌握在Ⅰ～Ⅲ期,且无明显外侵(≤T3 )的食管癌.     

Long-term clinical results of thoracoscopic Heller''s myotomy in the treatment of achalasia

OBJECTIVE: The aim of this study is to review the immediate and long-term results of video-imaged thoracoscopic Heller's myotomy (THM). METHODS: All patients undergoing THM by a single surgeon at one institution were analysed. Follow-up was conducted using a structured questionnaire and oesophageal manometry and/or 24h pH monitoring were undertaken when clinically indicated. RESULTS: Fifty-six consecutive patients (32 males, 24 females, mean age 45+/-18.7 years) suffering from grade 4 dysphagia underwent THM between January 1992 and March 2006. Preoperative mean lower oesophageal sphincter (LOS) pressure was 38.4+/-10.6 mmHg. Eighteen patients (32.1%) had undergone previous pneumatic dilatations. There were no hospital deaths. Oesophageal perforation occurred in two patients; one repaired thoracoscopically and one at thoracotomy. Mean hospital stay was 4+/-1.37 days. At mean follow-up of 5.9+/-4.66 years, freedom from any reintervention was 87% (49/56). Twenty-nine patients (52%) were asymptomatic. In patients with residual or recurrent symptoms (n=27), their severity was significantly reduced from the preoperative period (dysphagia score 1.37+/-0.77 vs 4.00+/-0; p<0.001). Seven patients (12.5%) with troublesome residual or recurrent grade 3-4 dysphagia underwent repeat oesophageal manometric study, showing a mean reduction in LOS pressure from their baseline values of 46.8+/-6.1-30.0+/-5.4 mmHg (p<0.001). Of these patients, three patients with grade 4 dysphagia were reoperated: one open Heller's myotomy and two by cardia resection. Eleven patients complained of troublesome postoperative heartburn; distal oesophageal acid exposure was shown to be abnormal in nine patients (16.9%) and all were successfully managed with medical therapy. CONCLUSION: The results of thoracoscopic treatment for achalasia are at least equivalent to historical outcomes obtained with open surgery but the patient is spared major thoracotomy or the acid reflux associated with a laparoscopic approach.     

Minimally invasive surgical treatment of esophageal achalasia.

BACKGROUND AND OBJECTIVES: A minimally invasive approach is considered the treatment of choice for esophageal achalasia. We report the evolution of our experience from thoracoscopic Heller myotomy (THM) to laparoscopic Heller myotomy (LHM). Our objective is to define the efficacy and safety of these 2 approaches. METHODS: Between March 1993 and December 2001, 36 patients underwent minimally invasive surgery for achalasia. Sixteen patients underwent THM without an antireflux procedure, and 20 patients underwent LHM with partial anterior fundoplication (n = 13) or closure of the angle of His (n = 7). RESULTS: Mean operative time and mean hospital stay were significantly shorter for LHM compared with that of THM (148.3 +/- 38.7 vs 222 +/- 46.1 min, respectively; P = 0.0001) and (2.06 +/- 0.65 days vs 5.06 +/- 0.85 days, respectively; P = 0.0001). Six of 16 patients (37.5%) in the THM group experienced persistent or recurrent dysphagia compared with 1 of 20 patients (5%) in the LHM group (P = 0.01). Heartburn developed in 5 patients (31.2%) after THM and in 1 patient (5%) after LHM (P = 0.06). Regurgitation developed in 4 patients (25%) after THM and in 2 patients (10%) after LHM (P = 0.2). Lower esophageal sphincter (LES) basal pressure decreased significantly from 30.1 +/- 5.07 to 15.3 +/- 2.1 after THM and from 31.8 +/- 6.2 to 10.4 +/- 1.7 after LHM (P = 0.0001). Mean esophageal diameter was significantly reduced after LHM compared with that after THM (from 53.9 +/- 5.9 mm to 27.2 +/- 3.3 mm vs 50.8 +/- 7.6 mm to 37.2 +/- 6.9 mm respectively: P = 0.0001). CONCLUSION: In our experience, LHM is associated with better short-term results and is superior to THM in relieving dysphagia. LHM with partial anterior fundoplication should be considered the treatment of choice for achalasia.     

Results of the laparoscopic Heller-Dor procedure for pediatric esophageal achalasia

Background: Esophageal achalasia is not a frequent disorder in children and different treatments have been proposed during past decades. This study reviews the results of the laparoscopic Heller-Dor procedure performed in pediatric patients in two different surgical units. Methods: We included the patients aged <14 years with a minimum follow-up of 6 months operated on in the period 1994–2001. A single longitudinal anterior esophageal myotomy (Heller) and a 180° anterior gastropexy (Dor) were laparoscopically performed. The patients were checked to detect intra- or postoperative complications and recurrence. Results: Twenty children were operated on. Mean follow-up was 45 months (range 6–102). Postoperative clinical score was Visick 1 in 15 cases and Visick 2 in five. Conclusions: As complication and recurrence rates are very low we consider modified Heller myotomy and Dor gastropexy through a laparoscopic approach our first choice to treat esophageal achalasia in the pediatric population.     

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).