贲门失弛缓症术后远期食管功能改变对进食情况的影响及护理

改良Heller手术是治疗贲门失弛缓症有效的方法之一,但改良Heller手术为减轻症状的手术,并不能从根本上治愈贲门失弛缓症[1]。此手术是通过食管下段贲门部肌层切开,使食管下括约肌张力减低,解除梗阻,食物靠重力作用通过食道进入胃内。术后不同程度吞咽不适是较常见的Heller术后并发症[2]。本文通过对66例贲门失迟缓症患者术后10年以上食管功能变化的随访追踪,阐明其     

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。     

腹腔镜改良Heller手术治疗贲门失弛缓症

目的:探讨腹腔镜改良Heller术治疗贲门失弛缓症的临床应用价值。方法:2004年2月至2008年4月我们为6例贲门失弛缓症患者行腹腔镜改良Heller术并随访。结果:手术时间45~122min,平均(74.0±29.0)min;术中出血5~65ml,平均(23.7±22.7)ml;无一例中转开腹及并发症发生;住院3~8d,平均(5.5±1.8)d。术后随访3~46个月,平均(26.8±16.2)月,5例症状缓解,1例轻度吞咽困难。结论:腹腔镜改良Heller手术具有术野清晰、并发症少、患者创伤小、康复快、住院时间短等优点,是治疗贲门失弛缓症首选方法之一。     

腹腔镜手术治疗贲门失弛缓症5例报道

目的探讨腹腔镜微创手术治疗贲门失弛缓症的应用价值。方法 2007年11月至2009年12月期间,中国医科大学附属盛京医院微创外科对5例贲门失弛缓症患者实施腹腔镜改良Heller手术并胃底折叠术。结果手术过程顺利,手术时间120~165 min,平均139 min;术中失血50~200 ml,平均88 ml;术后第1天进食,吞咽困难症状消失,无手术相关并发症。5例患者均痊愈出院。术后随访8~31个月,平均19个月,无症状复发或出现返流症状。结论腹腔镜手术治疗贲门失弛缓症安全、效果良好,值得进一步推广。     

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。     

腹腔镜Heller手术治疗贲门失弛缓症

目的 探讨腹腔镜Heller手术治疗贲门失弛缓症的疗效及安全性。方法 回顾性分析2008年5月至2011年3月期间行腹腔镜Heller手术的12例贲门失弛缓症病人资料及随访结果。结果 12例病人均完成腹腔镜手术,中位手术时间93（81~109）min,中位术中出血量30（23~48）ml,中位住院天数9（7~10）d。其中2例出现术中食管黏膜破损,经术中修补后均顺利愈合,全部病例围手术期均无出现严重并发症。中位随访时间13（8~21）个月,术后症状缓解成功率91.7%（11/12）。结论 腹腔镜Heller手术治疗贲门失弛缓症疗效可靠并具有较好的安全性。     

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。     

改良Heller手术附加膈肌瓣成形术治疗贲门失弛缓症

贲门失弛缓症是常见的食管良性疾病,改良Heller手术是治疗贲门失弛缓症的标准术式.我科1965年12月至2009年12月采用改良Heller手术附加膈肌瓣成形术治疗130例贲门失弛缓症患者,疗效满意.     

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??Laparoscopy combined with esophagogastroscopy in the minimally invasive treatment of achalasia of cardia: an analysis of 26 cases ZHAO Hong-zhi, QIN Ming-fang, WANG Qing, et al. Center of Tianjin Minimally Invasive Surgery, Nankai Hospital, Tianjin 300100??China
Corresponding author: ZHAO Hong-zhi, E-mail: tjzhhzh@sina.com
Abstract Objective To investigate the feasibility and clinical value of laparoscopy combined with esophagogastroscopy in the minimally invasive treatment of achalasia of cardia. Methods From December 2005 to March 2009, 26 patients with achalasia of cardia were performed combined laparoscopic and esophagogastroscopic surgery at Nankai Hospital of Tianjin. The combined surgery comprised of laparoscopic Heller myotomy with Dor fundoplication and intraoperative gastroscopic guidance and examination. Perioperative clinical outcome data of all patients were collected and analyzed prospectively. Results All laparoscopic surgeries were accomplished successfully. No conversion to open surgery or severe complications were noted in the study. Perforation of esophageal mucosa occurred in 1 patient??which discovered by esophagogastroscopy during laparoscopic operation. The patient was received laparoscopic neoplasty immediately. With postoperative follow-up of 4 to 42 months, none of the patients appeared dysphagia or vomiting. There was one patient who appeared mild regurgitation and chest pain in the first year after operation. After 3 months of operation??postoperative assessment consisted of endoscopic, radiologic, manometric and pH metric studies showed a satisfactory result. Conclusion Laparoscopy operation should be the feasible procedure to treat the typical esophagic achalasia with the advantages of little trauma, quick recovery and reliable effect. Combined with intraoperative gastroscopic guidance and examination, it can improve the security and decrease the complication during laparoscopy operation.     

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。     

Computer-enhanced robotic telesurgery minimizes esophageal perforation during Heller myotomy.

BACKGROUND: Laparoscopic Heller myotomy has emerged as the treatment of choice for achalasia. However, intraoperative esophageal perforation remains a significant complication. Computer-enhanced operative techniques have the potential to improve outcomes for certain operative procedures. Robotic, computer-enhanced laparoscopic telemanipulators using 3-dimensional magnified imaging and motion scaling are designed uniquely to facilitate certain operations requiring fine-tissue manipulation. We hypothesized that computer-enhanced robotic Heller myotomy would reduce intraoperative complications compared with laparoscopic techniques. METHODS: All patients undergoing an operation for achalasia at 3 institutions with a robotic surgery system (DaVinci; Intuitive Surgical Corporation, Sunnyvale, Calif) were followed-up prospectively. Demographics, perioperative course, complications, and hospital stay were recorded. Follow-up evaluation was obtained via a standardized symptom survey, office visits, and medical records. Data were compared with preoperative symptoms using a Mann-Whitney U test, and operating times were compared using the ANOVA test. RESULTS: Between August 2000 and August 2004 there were 104 patients who underwent a robotic Heller myotomy with partial fundoplicaton. There were 53 women and 51 men. All patients were symptomatic. The operative time was 140.55 minutes overall, but improved from 162.63 minutes to 113.50 minutes from 2000-2002 to 2003-2004 (P = .0001). There were no esophageal perforations. There were 8 minor complications and 1 patient required conversion to an open operation. Sixty-six (62.3%) patients were discharged on the first postoperative day and the average hospital stay was 1.5 days. A symptom survey was completed in 79 of 104 patients (76%) at follow-up evaluation. Symptoms improved in all patients with an average follow-up symptom score of 0.48 compared with 5.0 before the operation (P = .0001). Forty-three of the 79 patients from whom follow-up data were collected had a minimum follow-up period of 1 year. The follow-up period averaged 16 months. No patients required reoperation. CONCLUSIONS: Computer-enhanced robotic laparoscopic techniques provide a clear advantage over standard laparoscopy for the operative treatment of achalasia. We have shown in this large series that Heller myotomy can be completed using this technology without esophageal perforation. The application of computer-enhanced operative techniques appears to provide superior outcomes in selected procedures.     

Laparoscopic surgery for esophageal achalasia

Laparoscopic surgery for esophageal achalasia was first reported by Shimi et al. in 1991. Subsequently the procedure has been performed all over the world and laparoscopic Heller myotomy and Dor fundoplication (Heller and Dor operation) is now thought to be the operation of first choice. It is indicated for patients who are resistant to medical therapy (calcium blocker etc.) or have pneumatic dilatation and those with frequent aspiration at night. As Csendes et al. reported that surgical treatment was better than pneumatic dilatation and as laparoscopic surgery is less invasive, the indications for the laparoscopic Heller and Dor operation can include all achalasia patients except those who respond to medical therapy, do not accept surgery, or cannot tolerate surgery. We successfully performed the laparoscopic Heller and Dor operation on 22 patients, all of whom had an uneventful postoperative course. Manometric evaluation, endoscopic examination, and 24-hour pH monitoring showed good results. There are six important technical points: 1) flexible laparoscopy; 2) pneumoperitoneum; 3) gauze in the abdominal cavity to absorb blood; 4) laparosonic coagulating shears; 5) extracorporeal knot-tying technique; and 6) intracorporeal knot-tying technique. If an experienced surgeon is in charge, the laparoscopic Heller and Dor operation is an ideal, minimally invasive treatment for esophageal achalasia.     

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.     

The laparoscopic Heller-Dor operation remains an effective treatment for esophageal achalasia at a minimum 6-year follow-up

Background The aim of this study was to investigate the long-term clinical outcome of the laparoscopic Heller Dor procedure for esophageal achalasia.Methods A total of 71 consecutive patients with a minimum 6 year follow-up were evaluated. These patients were seen at 1 and 6 months after the operation (at which time barium swallow, endoscopy, manometry, and pH monitoring were performed), and annually thereafter. A dedicated symptom score, that combined severity and frequency of symptoms was used.Results The median symptom score decreased from 22 (range, 9-29) preoperatively to 4 (range, 0-16) at last follow-up, (p < 0.01). During the follow-up period, 13 patients suffered symptom recurrence; seven of them (54%) had already been diagnosed at the 1-year follow-up. All of these patients were treated with complementary pneumatic dilations. Overall, at a minimum of 6- years after the operation, 81.7% of the patients were satisfied with the treatment and were able to eat normally.Conclusions The long-term outcome of laparoscopic surgical treatment of esophageal achalasia is only slightly affected by the length of the follow-up and most of the symptomatic failures occur in the early period after the operation.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Denver, CO, USA, 31 March-3 April 2004     

Laparoscopic Heller Myotomy for Achalasia Cardia—Initial Experience in a Teaching Institute

Laparoscopic Heller cardiomyotomy and Dor fundoplication is the surgical procedure of choice for esophageal achalasia. The aim of our study was to investigate the clinical outcome and safety of laparoscopic Heller–Dor procedure performed by using Hook electrocautery and as a teaching module for advanced laparoscopic surgery. Between January 2005 and December 2010, 25 consecutive patients with achalasia underwent laparoscopic Heller–Dor operation by a single surgeon. All the patients received upper gastrointestinal series (barium swallow), esophagogastroscopy, and esophageal manometry to exclude esophageal carcinoma and to confirm the diagnosis. All the patients were operated by laparoscopic modified Heller myotomy with Dor fundoplication by using hook electrocautery. Among 25 operated patients, 14 were male and 11 were female with a median age of 43 years (range 18–72 years). The mean operative time was 93.3 min (range 50–50 min), the mean operative blood loss was 90 ml (range 40–200 ml), the median time to oral feeding was 2 days (2–4 days), and the median hospital stay was 4 days (4–7 days). There was no conversion to open surgery. Intraoperative mucosal perforation was encountered in three patients and was repaired in all of them by laparoscopic suture. All the patients had an uneventful recovery without postoperative complication and had excellent clinical response (96 %) during follow-up. Laparoscopic Heller–Dor operation using hook electrocautery is safe, inexpensive, and effective treatment for achalasia which is useful for teaching and training surgical residents in advanced laparoscopic surgery.     

胃食管结合部常见良性疾病的腹腔镜治疗

目的探讨腹腔镜手术治疗胃食管结合部常见良性疾病（胃食管反流病和贲门失弛缓症）的可行性和临床应用价值。方法2001年6月～2009年6月,对283例胃食管反流病（GERD组）实施腹腔镜胃底折叠术,其中Nissen胃底折叠术127例,Toupet胃底折叠术55例,Dor胃底折叠术101例;对33例贲门失弛缓症（贲门失弛缓症组）实施腹腔镜Heller肌切开联合Dor胃底折叠术。结果全组无中转开腹,手术时间60～125min,平均78min;术中出血量40～120ml,平均66ml;术后住院时间3～21d,平均4.2d。术后临床症状均得到缓解,无严重并发症及死亡病例。术后3个月复查胃镜、上消化道造影、食管测压和24hpH检测均恢复正常。GERD组272例随访3个月～8年,平均3.5年,对手术结果满意率95.6%（260/272）,21例有进固体食物时轻度哽噎感,6例反酸症状复发,使用抑酸药物可控制。贲门失弛缓症组33例随访3个月～4年,平均2.1年,均可正常进食,无吞咽困难或反酸表现。结论腹腔镜手术治疗胃食管结合部良性病变具有独特优势,充分体现微创手术创伤小、恢复快、安全可行、疗效可靠的优点。     

Importance of preoperative and postoperative pH monitoring in patients with esophageal achalasia

Gastroesophageal reflux (GER) can develop in patients with esophageal achalasia either before treatment or following pneumatic dilatation or Heller myotomy. In this study we assessed the value of pre- and postoperative pH monitoring in identifying GER in patients with esophageal achalasia. Ambulatory pH monitoring was performed preoperatively in 40 patients with achalasia (18 untreated patients and 22 patients after pneumatic dilatation), 27 (68%) of whom complained of heartburn in addition to dysphagia (group A), and postoperatively in 18 of 51 patients who underwent a thoracoscopic (n=30) or laparoscopic (n=21) Heller myotomy (group B). The DeMeester reflux score was abnormal in 14 patients in group A, 13 of whom had been treated previously by pneumatic dilatation. Two types of pH tracings were seen: (1) GER in eight patients (7 of whom had undergone dilatation) and (2) pseudo-GER in six patients (all 6 of whom had undergone dilatation). Therefore 7 (32%) of 22 patients had abnormal GER after pneumatic dilatation. Postoperatively (group B) seven patients had abnormal GER (6 after thoracoscopic and 1 after laparoscopic myotomy). Six of the seven patients were asymptomatic. These findings show that (1) approximately one third of patients treated by pneumatic dilatation had GER; (2) symptoms were an unreliable index of the presence of abnormal GER, so pH monitoring must be performed in order to make this diagnosis; and (3) the preoperative detection of GER in patients with achalasia is important because it influences the choice of operation. Presented at the Thirty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, Calif., May 19–22, 1996.