腹腔镜食管肌层切开加胃底折叠术治疗贲门失弛症的护理

目的总结贲门失弛症在腹腔镜下行食管肌层切开加胃底折叠术的护理经验。方法对7例贲门失弛症患者采用单腔气管插管静吸复合麻醉,人工CO2气腹后腹腔镜下行食管肌层切开加胃底折叠术;术前加强患者的心理护理,改善营养状况,完善各项术前检查和术前准备;术后加强各种引流管的护理,鼓励患者早期活动,进行饮食指导,注重并发症的观察及处理。结果患者手术过程顺利,平均手术时间175.7min;术中平均出血45.7mL;无手术及护理相关的并发症,平均住院时间5.4d。术后随访1～10个月,体质量增长平均5.4kg;手术效果优5例,良2例。结论腹腔镜应用于贲门失弛症的治疗可行及有效,加强围术期护理,是保证手术顺利进行和减少术后并发症的重要环节。     

腹腔镜食管下段贲门肌层切开联合Dor胃底折叠术治疗贲门失弛缓症

目的:探讨腹腔镜食管下段贲门肌层切开联合Dor胃底折叠术治疗贲门失弛缓症的临床应用价值。方法:回顾性分析31例行腹腔镜食管下段贲门肌层切开联合Dor胃底折叠术治疗的贲门失弛缓症患者术前与术后3个月的临床数据。结果:31例均成功行腹腔镜手术,27例术前与术后3个月吞咽困难评分(1.10±0.18与0.91±0.12,P<0.01)、术前与术后胸骨后疼痛评分(0.38±0.04与0.36±0.03,P<0.05)症状得到有效缓解,体质量指数(21.32±1.26与20.47±1.34,P<0.05)及生活质量指数(85.69±7.78与80.43±9.19,P<0.05)明显优于术前。结论:腹腔镜食管下段贲门肌层切开联合Dor胃底折叠术对于改善贲门失弛缓症患者临床症状及提高生活质量具有重要的意义。     

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。     

经胸小切口食管肌层切开术治疗贲门失弛缓症

目的总结经胸小切口食管肌层切开术治疗贲门失弛缓症的临床经验. 方法 25例贲门失弛缓症患者中中度9例,重度16例 ,均接受了手术治疗.手术经左胸腋后线第7或第8肋间进胸,切口6～8cm,行食管肌层切开.全组均未行抗反流手术. 结果全部患者顺利完成手术,无死亡,平均手术时间50分钟,术后平均住院天数10天.1例患者因损伤食管黏膜,于术中予以修补,其余患者术后无并发症.随访全部患者,吞咽困难消失,无胃食管反流症状.8例术后行24小时食管pH监测无病理性反流. 结论经胸小切口行食管黏膜外肌层切开术,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发生.     

腹腔镜胃底折叠术治疗胃食管反流性疾病临床分析

目的　探讨腹腔镜胃底折叠术治疗胃食管反流性疾病的可行性及安全性。　方法　回顾性分析 2 0 0 1年 6月至 2 0 0 1年 10月对 5例行腹腔镜胃底折叠术的胃食管反流性疾病的临床资料。　结果　 3例行腹腔镜Nissen胃底折叠术 ,2例腹腔镜Toupet胃底折叠术。术后症状完全缓解。食道下段压力由 (7 32± 1 34)mmHg提高到 (18 2 0± 3 4 3)mmHg(t=12 2 3,P <0 0 1) ,2 4 -小时PH值监测评分由183 36± 96 76降低到 8 0 4± 2 12 (t=8 4 7,P <0 0 1) ,较手术前有明显改善 ,并达到正常范围。无手术并发症 ,无中转开腹及死亡病例。　结论　对于严重的胃食管反流性疾病 ,腹腔镜胃底折叠术是一种安全、有效的治疗方法。     

腹腔镜180°前胃底折叠术治疗胃食管反流性疾病临床研究

目的 探讨腹腔镜180°前胃底折叠术治疗胃食管反流性疾病(gastroesophageal refulxdisease,GERD)的安全性及有效性.方法 2005年1月至2008年4月采用腹腔镜180°前胃底折叠术治疗胃食管反流性疾病54例,术后随访3～25个月,对酸反流的主观和客观指标进行分析.结果 腹腔镜180°前胃底折叠术治疗术后反酸症状完全消失,食管下段测压由术前(6.7±1.3)mmHg(ImmHg=0.133kPa),提高到术后6个月(19.1±3.4)mmHg(P1<0.01).术后1年(21.6±1.8)mmHg(R2<0.01),24h pH监测DeMeester评分由术前97.2±2.7降低到术后6个月6.4±2.2(P1<0.01),术后1年6.7±2.3(P2<0.01)较术前明显改善,并达到正常范围,无术后严重并发症,无中转开腹及死亡病例.结论 与以往较为公认的Nissen术和Toupet术相同,腹腔镜180°前胃底折叠术治疗GERD是一种安全、有效的术式.并且副反应少.     

腹腔镜Nissen与Toupet胃底折叠术治疗胃食管反流性疾病的临床分析

目的 比较腹腔镜Nissen与Toupet胃底折叠术治疗胃食管反流性疾病（GERD）的优缺点及其适应证。方法 回顾分析2001年6月至2005年12月腹腔镜胃底折叠术后GERD的83例临床资料。其中65例行腹腔镜Nissen胃底折叠术，18例行腹腔镜Toupet胃底折叠术。结果 两组均无中转开腹及死亡病例。术后两组症状均完全消失。平均随访2．6年，Nissen组未出现症状复发，Toupet组2例病人症状复发，需服抑酸药物控制。术后4个月复查食道测压和酸反流的指标两组均在正常范围内。Nissen组食道炎症的治愈率为84．6％，Toupet组为66．7％。术后4d，Nissen组吞咽困难、腹胀的发生率明显高于Toupet组（分别为27．7％和16.7％）；术后1年，两组之间的差别明显减小（分别为1．5％和0）。结论 Toupet胃底折叠术后短期内吞咽困难的发生率明显低于Nissen胃底折叠术，但随着术后恢复时间的延长，两者间差异明显减小。对中重度GERD应首选腹腔镜Nissen胃底折叠术，对高龄，术前检查提示食管蠕动功能明显减弱的病人，可考虑行腹腔镜Toupet胃底折叠术。     

经胸小切口食管肌层切开治疗贲门失弛缓症

目的 总结经胸小切口食管肌层切开治疗贲门失弛缓症经验。方法 分析42例贲门失弛缓症患者接受经胸腔小切口食管肌层切开手术治疗结果，手术切口6—8cm，行食管下段肌层切开，上方超过狭窄1cm，下方切口至胃壁肌层0．5～1cm。全组均未行抗反流手术。结果平均手术时间60min，术后平均住院时间11d。1例围手术期死亡，死因为食管黏膜破裂合并多重细菌感染；2例损伤食管黏膜予以修补；其余无任何并发症，术后第1天开始进食，行黏膜修补者术后3d进食。术后随访，全部患者吞咽困难症状消失。28例行食管pH监测无病理性反流，与术前DeMeesrer评分比较，差异有统计学意义。结论经胸小切口食管肌层切开术，创伤小、恢复快、并发症少。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。     

Laparoscopic esophagomyotomy with posterior partial fundoplication for primary esophageal motility disorders

Background: The outcomes of a laparoscopic esophagomyotomy with posterior partial fundoplication were compared between groups of patients with primary motility disorders. Methods: In this study, 47 patients (26 women and 21 men, ages 24 to 77 years; mean, 47 years) with significant dysphagia or chest pain who failed conservative treatment underwent a laparoscopic esophagomyotomy and posterior partial fundoplication. Preoperative evaluation revealed four groups of primary motility disorders: achalasia (n= 12), nutcracker esophagus (n= 12), hypertensive lower esophageal sphincter (LES) (n= 16), and diffuse esophageal spasm (n= 7). Statistical analysis was performed by Cramer's V test. Results: Average follow-up period was 30.3 months. There was no mortality or early morbidity. Late morbidity included dysphagia or chest pain over 6 weeks in 10 patients (21%), recurrent gastroesophageal reflux disease (GERD) in 3 patients (6%), and recurrent motility disorder in 2 patients (4%). Overall, 94% of the patients ultimately had complete resolution of dysphagia or chest pain. There was no significant difference in outcomes between groups. Conclusion: Early results suggest that laparoscopic esophagomyotomy with posterior partial fundoplication provides safe and effective relief from dysphagia and chest pain in patients with each of the primary motility disorders. Received: 18 February 1999/Accepted: 16 December 1999/Online publication: 13 June 2000     

Treatment of esophageal achalasia with laparoscopic Heller myotomy and Dor partial anterior fundoplication: Prospective evaluation of 100 consecutive patients

In this article we report our experience in 100 consecutive achalasia patients who were treated with laparoscopic Heller myotomy and Dor antireflux fundoplication, with particular regard to the technical problems encountered, the learning curve, and the long-term follow-up. The operation was completed laparoscopically in 94 patients, with a median operative duration of 150 minutes, and a continuous steady reduction in the operating time from the first patients to the last. In six patients the operation was completed through “open” access. Postoperative complications were recorded in six cases. Follow-up was completed in all 100 patients, with a median follow-up of 24 months. Overall, actuarial life-table analysis showed a probability of 90% that patients would be symptom free over a S-year period. Radiologic assessment showed a significant reduction in the esophageal diameter, and manometry showed a significant reduction in the lower esophageal sphincter resting pressure and residual pressure. Twenty-four-hour pH monitoring showed postoperative reflux in 6.9% of the patients. Persistent dysphagia or chest pain was reported by eight patients, which constituted treatment failures. Seven of these eight patients were eventually treated with multiple pneumatic dilatations, which were successful in six cases. It was concluded that laparoscopic Heller myotomy with Dor fundoplication is a feasible and effective treatment for achalasia, with an actuarial success rate of 90% at 5 years.     

Long-term results of laparoscopic Heller myotomy with partial fundoplication for the treatment of achalasia

BACKGROUND: Treatment options for achalasia include medications, endoscopic balloon dilation, injection of botulinum toxin, or surgery. METHODS: The clinical course of 75 consecutive patients who underwent minimally invasive Heller myotomy and partial fundoplication for achalasia between 1991 and 2001 was reviewed by means of a questionnaire. RESULTS: Mean follow-up was 5.3 (range .8 to 10.9) years. Sixty-four percent of questionnaires were returned. Thirty-seven patients (84%) felt much better and 6 (14%) slightly better; 1 (2%) rated the result as unchanged. Twenty-six patients (59%) experienced weight gain. Seven patients (16%) had persistent swallowing problems and 5 (11%) reported frequent reflux. Twenty-five percent underwent additional therapy, including dilation (n = 8, 18%), repeat surgery (n = 2, 5%), and botulinum toxin injection (n = 2, 5%). Eighteen patients (41%) were using a proton pump inhibitor or H2 blocker, three were on a calcium channel blocker (7%), and 1 was using nitroglycerine (2%). CONCLUSION: Laparoscopic Heller myotomy can achieve short- and long-term results comparable to open surgery and should be considered the treatment of choice for patients suffering from achalasia. Despite the frequent need for further therapy, patient satisfaction is good.     

Complete vs partial fundoplication in children with esophageal atresia

Purpose

The purpose of the study was to compare outcomes after partial vs complete fundoplication in patients with prior esophageal atresia repair.

Methods

All patients undergoing fundoplication following esophageal atresia repair at a tertiary care pediatric hospital from 1987 to 2006 were retrospectively reviewed. All children had at least 1 year of follow-up postfundoplication.

Results

Of 47 children, 31 (66%) had a partial fundoplication and 16 (34%) had complete fundoplication. Demographics, presence of tracheoesophageal fistula, early complications of esophageal atresia repair, gastroesophageal reflux symptoms before fundoplication, and operative details of fundoplication were statistically similar between groups, except for the frequency of hiatus repair during fundoplication (23% vs 69%, P = .004). Patients were followed for a median of 4.98 years (range, 1-17.8 years). Postfundoplication symptoms of vomiting (39% vs 31%), dysphagia (45% vs 38%), retching (10% vs 25%), abnormal findings on barium study, and need for reoperation (19% vs 13%) were not statistically different between groups. However, a greater proportion of children undergoing partial fundoplication achieved long-term symptom- and medication-free recovery (52% vs 13%, P = .012).

Conclusions

Our data suggest that partial fundoplication is associated with a greater likelihood of symptom- and medication-free recovery than complete fundoplication in children with previously repaired esophageal atresia.     

Robotic-assisted heller myotomy versus laparoscopic heller myotomy for the treatment of esophageal achalasia: multicenter study

Laparoscopic Heller myotomy (LHM) has become the standard treatment option for achalasia. The incidence of esophageal perforation reported is about 5%–10%. Robotically assisted Heller myotomy (RAHM) is emerging as a safe alternative to LHM. Data comparing the two approaches are scant. The aim of this study was to compare RAHM with LHM in terms of efficacy and safety for treatment of achalasia. A total of 121 patients underwent surgical treatment of achalasia at three institutions. A retrospective review of prospectively collected perioperative data was performed. Patients were divided into two groups: group A (RAHM), 59 patients, and group B (LHM), 62 patients. All the operations were completed using minimally invasive techniques. There were 63 women and 58 men, with a mean age of 45 ±19 years (14–82 years). Fifty-one percent of patients in group A and 95% of patients in group B reported weight loss. Duration of symptoms was equal for both groups. Dysphagia was the main complaint in both groups (P = NS). There was no difference in preoperative endoscopic treatment in both groups (44% versus 27%, P = NS). Operative time was significantly shorter for LHM in the first half of the experience (141 ± 49 versus 122 ± 44 minutes, P < .05). However, in the last 30 cases there was no difference in operative time between the groups (P = NS). Intraoperative complications (esophageal perforation) were more frequent in group B (16% versus 0%). The incidence of postoperative heartburn did not differ by group. There were no deaths. At 18 and 22 months, 92% and 90% of patients had relief of their dysphagia. This study suggests that RAHM is safer than LHM, because it decreases the incidence of esophageal perforation to 0%, even in patients who had previous treatment. At short-term follow-up, relief of dysphagia was equally achieved in both groups. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (oral presentation). This study was supported in part by a grant provided by Intuitive Surgical, Inc. and Ethicon Endo-Surgery, Inc.     

经口内镜下肌切开术对贲门失弛缓症患者的食管动力学影响

目的评价经口内镜下肌切开术（POEM）对贲门失弛缓症患者的食管动力学影响。方法2011年9．11月间复旦大学附属中山医院内镜中心对20例贲门失弛缓症患者行POEM手术．所有患者于术前和术后第3天利用固态高分辨率胃肠动力学检查系统行食管动力学检查．分析手术前后食管下括约肌静息压（LESP）、食管下括约肌4s完全松弛压（4sIRP）、食管下括约肌松弛率（LESRR）、食管下括约肌长度（LESL）和食管体部收缩性和传导性的变化。结果POEM术后,LESP由术前的（29．1±17．0）mmHg下降为（14．6±4．9）mmHg,下降幅度为49．8％（P〈0．01）;4slRP由术前的（24．2±15．1）mmHg下降为（10．4±3．4）mmHg（P〈0．01）;但手术前后LESRR和LESL的差异无统计学意义（P〉0．05）。20例患者术前食管运动均缺少蠕动性收缩,术后有7例患者食管收缩运动发生了变化,甚至出现了蠕动,但仍达不到正常水平;其余13例患者的蠕动情况无明显变化。结论POEM术可显著降低贲门失弛缓症患者食管下括约肌压力和松弛压．但对食管的收缩运动却无明显影响。     

Esophageal manometric characteristics and outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication for epiphrenic diverticula

Purpose  The purpose of this study is to characterize the esophageal motor and lower esophageal sphincter (LES) abnormalities associated with epiphrenic esophageal diverticula and analyze outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication. Methods  The endoscopic, radiographic, manometric, and perioperative records for patients undergoing laparoscopic esophageal diverticulectomy, anterior esophageal myotomy, and partial fundoplication from 8/99 until 9/06 were reviewed from an Institutional Review Board (IRB)-approved outcomes database. Data are given as mean ± standard deviation (SD). Results  An esophageal body motor disorder and/or LES abnormalities were present in 11 patients with epiphrenic diverticula; three patients were characterized as achalasia, one had vigorous achalasia, two had diffuse esophageal spasm, and five had a nonspecific motor disorder. Presenting symptoms included dysphagia (13/13), regurgitation (7/13), and chest pain (4/13). Three patients had previous Botox injections and three patients had esophageal dilatations. Laparoscopic epiphrenic diverticulectomy with an anterior esophageal myotomy was completed in 13 patients (M:F; 3:10) with a mean age of 67.6 ± 4.2 years, body mass index (BMI) of 28.1 ± 1.9 kg/m² and American Society of Anesthesiologists (ASA) 2.2 ± 0.1. Partial fundoplication was performed in 12/13 patients (Dor, n = 2; Toupet, n = 10). Four patients had a type I and one patient had a type III hiatal hernia requiring repair. Mean operative time was 210 ± 15.1 min and mean length of stay (LOS) was 2.8 ± 0.4 days. Two grade II or higher complications occurred, including one patient who was readmitted on postoperative day 4 with a leak requiring a thoracotomy. After a mean follow-up of 13.6 ± 3.0 months (range 3–36 months), two patients complained of mild solid food dysphagia and one patient required proton pump inhibitor (PPI) for gastroesophageal reflux disease (GERD) symptoms. Conclusion  The majority of patients with epiphrenic esophageal diverticula have esophageal body motor disorders and/or LES abnormalities. Laparoscopic esophageal diverticulectomy and anterior esophageal myotomy with partial fundoplication is an appropriate alternative with acceptable short-term outcomes in symptomatic patients.