食管裂孔疝合并胃食管反流病的外科治疗

胃食管反流病（gastroesophageal reflux disease, GERD）的外科治疗近年来日益受到重视,但是由于目前国内尚无胃食管反流病外科治疗的指南或专家共识意见,因此胃食管反流病的外科治疗仍然主要基于临床经验或参考国外指南。食管裂孔疝（hiatal hernia, HH）合并胃食管反流病临床多见,外科手术效果确切,但在临床实践中仍然存在一些问题,现综述如下。     

袖状胃切除同期食管裂孔疝修补防止胃食管反流的疗效

目的:探讨袖状胃切除同期行食管裂孔疝修补手术在减重和抗反流中的应用价值。方法:本研究纳入2019年12月至2020年12月在浙江省人民医院减重代谢中心接受腹腔镜袖状胃切除术的合并胃食管反流病的21例肥胖患者,根据患者是否同期行食管裂孔疝修补分为单纯减重手术组（9例）和同期联合手术组（12例）。结果:两组患者术后体重、腰...     

腹腔镜Toupet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Toupet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。 方法选取2012年1月至2018年6月,吉林大学第二医院就诊的80例食管裂孔疝合并胃食管反流病患者为研究对象。依据患者具体状况行不同类型的疝修补术,所有患者均行腹腔镜Toupet胃底折叠术。于术后统计患者手术效果及反流情况,观察手术前后食管压变化。 结果与术前相比,术后6个月患者反流时间显著缩短、反流次数与长反流次数显著减少、酸反流时间百分比显著下降,差异均有统计学意义（P<0.05）。与术前相比,术后6个月患者DeMeester及GERDQ评分均显著下降,差异均有统计学意义（P<0.05）。与术前比较,术后6个月患者LES压力、残余压均显著升高,松弛率显著下降,差异均有统计学意义（P<0.05）。 结论腹腔镜Toupet胃底折叠术治疗食管裂孔疝合并胃食管反流病可有效增加食管压力,抑制患者反流症状,疗效良好,值得推广应用。     

抗反流手术治疗滑动型食管裂孔疝

目的 探讨抗反流手术治疗滑动型食管裂孔疝的机制,并利用贲门入口点位测定法评价抗反流手术疗效.方法 1992年至2008年,经腹手术治疗滑动型食管裂孔疝136例.根据手术方式分成典型Nissen手术组27例,短松式Nissen手术组109例.结果 全组无术中死亡.术后1个月内典型Nissen手术组出现吞咽困难2例,反酸1例;短松式Nissen手术组反酸9例,轻度吞咽困难3例.术后随访2年以上,典型Nissen手术组27例,其中2例有明显吞咽困难,1例恶心、呕吐,2例24 h食管pH监测有明显酸反流;短松式Nissen手术组105例,其中2例有吞咽困难,3例复发,7例24 h食管pH监测有明显酸反流.典型Nissen手术组和短松式Nissen手术组术后2年有效率分别为81.5%和88.1%,两组间手术后各项指标差异无统计学意义(P＞0.05).贲门入口点位测定:抗反流手术术前贲门入口位于10点～11点间占80.1%;术后贲门人口位于9点以下占91.7%.结论 经腹的典型Nissen手术、短松式Nissen手术治疗食管裂孔疝均可取得较为理想的效果.其机制为通过简单的胃底折叠,加固多种抗胃、食管反流机制,如升高LES压力、延长LES长度、加深和加固His角和增加腹内食管长度等,其中最主要抗反流机制在于延长腹段食管,使贲门入口下移至9点或9点以下位置.贲门入口点位测定法对抗反流手术的成功具有实际临床意义.

Abstract：

Objective To investigate the mechanism of anireflux procedures in treating sliding hiatal hernia and the effectiveness of the method of cardia position by clock to evaluate the outcome of antireflux procedures. Methods From 1992 to 2008, 136 patients with sliding hiatal hernia underwent transabdominal antireflux surgery: 27 patients received Nissen procedure and 109 recieved floppy Nissen operation. Results There is no postoperative death. Within one month after operation, in the Nissen group, 2 patients developed severe dysphagia and 1 had regurgitation; in the floppy Nissen group, 9 patients had regurgitation, and 3 had dysphagia. During the over-2-year follow-up period, 2 patients developed severe dysphagia,1 had nausea and 2 had significant reflux in the Nissen group. While 3 patients recturred, 2 had dysphagia and 7 had significant reflux in the floppy Nissen group. The effective rates of the Nissen group and the floppy Nissen group were 81.5% and 88.1%, respectively. There was no significant difference in postoperative tests between two groups ( P ＞ 0.05 ). Tests of cardia position by o'clock showed that cardia positions of 80. 1% patients before surgery were located at sites between 10 and 11 o'clock and those of 91.7% after surgery being at 9 o' clock or less. Conclusions The Niseen and the floppy Nissen fundoplication can reach good long-term results in treatment of sliding hiatus hernia. Mechanism of these antireflux procedures include, by fundoplication, increasing esophageal sphincter pressure, prolonging the sphincter length, deepening His angle and prolonging abdominal esophagus, etc. Among them, the last one, descending the cardia position to 9 o'clock or less is vital to antireflux.The test of cardia position by o'clock is practically important to reach the successful result.     

腹腔镜手术治疗食管裂孔疝及胃食管反流性疾病的临床体会

目的:探讨腹腔镜手术治疗食管裂孔疝及胃食管反流性疾病的临床疗效及安全性。方法:回顾分析2009年1月至2012年11月36例食管裂孔疝及胃食管反流性疾病患者的临床资料,20例行腹腔镜手术(腹腔镜组),16例行开腹手术(开腹组)。观察两组患者手术时间、术中出血量、术后住院时间、术后抗生素使用时间、术后胃肠道功能恢复时间及术后并发症。结果:腹腔镜组手术时间、术中出血量、术后住院时间、术后抗生素使用时间、术后胃肠道功能恢复时间及术后并发症发生率均显著优于开腹组(P<0.05)。结论:腹腔镜手术治疗食管裂孔疝及胃食管反流性疾病安全、可靠,具有广阔的临床应用前景。     

抗胃食管反流外科治疗的远期疗效观察

目的探讨胃食管反流外科治疗的远期疗效。方法1988年11月至2004年1月手术治疗129例胃食管反流病(GERD),分别采用N issen手术(65例)、贲门斜行套叠术(39例)、Belsey4号手术(17例)、Toupet手术(3例)、Thal手术(1例)、Dor手术(4例)等6种方法治疗。116例得到随访,计算临床症状评分,并与术前比较。手术前后分别有95例及51例行食管压力测定检查,56例及35例行24 h食管pH值监测及DeM eester评分;术前常规行内镜检查,术后48例行内镜检查,对结果进行比较。结果在随访的116例患者中,临床症状评分由术前的(4.1±0.4)分降为术后的(1.1±1.0)分,较术前显著降低(t=27.21,P<0.01)。手术疗效优42例(36.2%),良60例(51.7%),可7例(6.0%),差7例(6.0%),手术远期优良率87.9%(102/116)。N issen、Belsey 4号和贲门斜行套叠术三者间疗效无差异。结论外科手术是治疗GERD的有效方法,N issen手术、贲门斜行套叠术和Belsey 4号手术疗效相近。     

影响胃食管反流病外科治疗疗效的临床因素分析

目的:从反流症状缓解情况、吞咽困难及手术满意度三个方面分析影响抗胃食管反流术后疗效的相关因素。方法:分析192例抗胃食管反流术患者术后不良主诉的发生率,通过多因素回归分析明确相关独立危险因素。结果:本组患者反流症状不缓解率约为21.8%（42例）,危险因素包括术前抑郁状态和质子泵抑制剂用药时间过长;持续吞咽梗阻感发生率...     

腹腔镜疝修补术结合Nissen胃底折叠术治疗胃食管反流合并食管裂孔疝的疗效

目的分析腹腔镜疝修补术结合Nissen胃底折叠术治疗胃食管反流合并食管裂孔疝患者的临床疗效观察。 方法选择内蒙古包钢医院2019年7月至2020年5月就诊的80例胃食管反流合并食管裂孔疝患者,按不同手术方式分为A组和B组,每组患者40例。A组采用腹腔镜疝修补术+Nissen胃底折叠术,B组采用腹腔镜疝修补术+Dor胃底折叠术。比较2组患者手术情况、食管反流情况、食管压力、消化病生存质量指数（GLQI）评分、胃食管反流病疗效评分（GERD-Q）、复发率以及不良反应情况。 结果2组患者手术情况差异均无统计学意义（P>0.05）;术后3个月,反流时间、次数,长反流次数、酸反流时间百分比明显改善,且A组改善幅度更明显（P<0.05）;食管残余压平均值、下段括约肌压力、松弛率和无效吞咽率均明显改善,且A组改善情况优于B组（P<0.05）;2组患者GLQI与GERD-Q评分均有所改善,且A组GLQI评分高于B组,GERD-Q评分低于B组（P<0.05）;2组不良反应和复发率比较差异无统计学意义（P>0.05）。 结论腹腔镜疝修补术联合Nissen胃底折叠术对抗反流,减轻术后吞咽困难具有明显效果,有效改善患者生活质量和食管下括约肌压力安全有效。     

抗胃食管反流外科进展

过去１０年，胃食管反流病的治疗在三方面取得了重大进展。其一是强有力抗泌酸药物的研制成功，提高了食管炎的治愈率，使许多病人免于手术；其二是近年抗反流手术并发症有所减少；其三是开展了腹腔镜抗反流手术。现就抗胃食管反流外科的进展综述如下。抗反流手术的选择目...     

Sliding hiatal hernia in patients with gastroesophageal reflux: physiopathology and surgical treatment

BACKGROUND: The aims of the study were to evaluate how the sliding hiatal hernia, in patients with gastroesophageal reflux disease (GERD), acts on the lower esophageal sphincter (LES) and esophageal clearance, and how surgical therapy corrects the physiopathological parameters. METHODS: Records of 25 patients with only GERD and of 15 with GERD associated to hiatal hernia (> 3.5 cm) were reviewed. Ten subjects without symptoms and/or endoscopic and functional signs of GERD were considered as control group. The selection of the patients was done by reviewing radiographic examination, endoscopy and functional tests (esophageal manometry, pH-monitoring). RESULTS: Manometry showed a greater LES incompetence (pressure and length) and a worse peristalsis (distal amplitude) in the group with reflux and hiatal hernia against patients with reflux only. Also, patients with hiatal hernia had more acid exposure (total time pH < 4 in the distal esophagus) and a longer time of esophageal clearance, at pH-monitoring. The functional tests in 8 patients, before and after laparoscopic Toupet fundoplication with posterior closing of the crura, showed a normalised LES, esophageal clearance and acid exposure. Esophageal peristalsis did not show any statistically significance. CONCLUSIONS: The presence of hiatal hernia, in patients with GERD, causes worse LES, peristalsis and clearance with a greater acid exposure of the esophagus. Fundoplication, by reconstructing the sphincter-diaphragm unit, normalises the preoperative physiopathology situation but without an effective peristalsis improvement.     

Diagnosis and treatment of hiatal hernia and gastroesophageal reflux

From 1962 to 1988, 17 patients with esophageal hiatal hernia with or without gastroesophageal reflux were treated. Among these, 14 patients received various types of gastroesophageal junction reconstructive procedures. Experience demonstrated that the clinical studies including gastroesophagography, endoscopy and intraluminal pressure patterns of esophagus are important diagnostic measures. It also seems, to us that intraluminal esophageal pressure monitoring during surgical operation is particularly useful in determining the adequacy of gastroesophageal reconstruction and may provide a dynamic evaluation of function of the gastroesophageal junction area. Some aspects of diagnosis and surgical treatment are discussed in detail.     

An improved surgical technique for the complicated hiatal hernia with gastroesophageal reflux

Although so-called valve reconstruction procedures at the gastroesophageal junction provide marked relief for most patients with gastroesophageal reflux and hiatal hernia, there is a recurrence rate of 10 to 15%. Many of the recurrences are in patients with obesity, severe pulmonary disease, or stricture, or in patients who have developed a recurrence from other previous types of surgical therapy. Since the primary cause of failure in hiatal hernia repair is tension on the distal esophagus, which is created as a result of securing an adequate length of intraabdominal esophagus, the Collis gastroplasty, which lengthens the esophagus by construction of a tube of the lesser curvature of the stomach, combined with a Belsey reconstruction of the gastroesophageal angle and dilation in cases of stricture, has been successfully employed over the past three years in patients with factors that predispose to recurrence. This technique provides adequate length without tension, and in more than 39 such patients there has been no evidence of reflux or recurrence of hernia by clinical symptoms or cine esophagogram. No mortality or significant morbidity has been observed.     

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。     

Surgical treatment of gastroesophageal reflux disease in the presence of coexistent hiatal hernia

Experience of treatment of coexistent hiatal hernia (HH) and gastroesophageal reflux disease (GERD) in 491 patients using simultant hernioplastic and antireflux operation was summarized. Complete fundoplication was performed in 478 (97.4%) patients, noncomplete one--in 13 (2.6%), cruroraphy--in 321 (65.4%), including complex method of hernioplasty--in 80 (16.3%). Postoperative mortality was 0.8% (4 patients). The tactical and methodical principles applied have permitted to guarantee the physiologicity and safety of the coexistent HH and GERD surgical treatment.     

Fundoplication for the treatment of gastroesophageal reflux in hiatal hernia

Fundoplication, using an abdominal approach, is advocated to create an adequate substitute for the insufficient sphincter in gastroesophageal reflux associated with hiatus hernia. To achieve success, correct indications for surgical treatment are important. Based on experience with approximately 1,400 patients over the past 20 years, these include: (a) a retrosternal burning sensation (in 90% of our cases); (b) objective confirmation of reflux by means of x-ray and endoscopic examination, together with biopsy examination of the esophageal mucosa and gastric acid evaluation; and (c) evidence of organic complications such as endobrachyesophagus with ulcerostenotic changes at the junction between the esophageal and gastric mucosa. Long-term follow-up of 590 patients with simple reflux esophagitis who underwent fundoplication showed that 87.5% were symptom free. In 44 patients with complicated gastroesophageal reflux disease, fundoplication produced clinical healing in 84.1%.

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Résumé La fundoplicature par voie abdominale est conseillée en cas de reflux gastro-oesophagien associé à une hernie hiatale, car cette opération pallie la fonction du sphincter déficient. Le succès dépend des indications opératoires. En nous basant sur près de 1,400 cas vus au cours de 20 dernières années, nous pouvons préciser les éléments importants de ces indications: (a) sensation de brûlure rétrosternale (80% des cas); (b) confirmation objective du reflux par examen radiologique et endoscopique, biopsie de la muqueuse oesophagienne et étude de la sécrétion gastrique; (c) complications organiques telles que endobrachyoesophage avec sténose et ulcérations à la jonction gastro-oesophagienne. Un follow-up de longue durée de 590 malades avec simple oesophagite de reflux, traités par fundoplicature, a montré que 87.5% sont sans symptomes. Sur 44 malades avec reflux gastro-oesophagien compliqué, la fundoplicature a guéri cliniquement 84.1% d'entre eux.