食管动力学及24小时食管pH监测在胸痛诊断中的意义

目的探讨食管动力学、24小时食管pH及24小时动态心电图监测对反复发作性胸痛的诊断价值. 方法对46例反复发作胸痛的患者进行食管动力学检测、24小时食管pH及24小时动态心电图监测,根据检查结果,给予相应治疗,并观察近期效果.结果 46例患者中发现非特异性食管功能障碍24例,其中伴有胃食管反流14例、心肌缺血4例;贲门失弛缓症5例,其中伴有胃食管反流1例;弥漫性食管痉挛4例,其中伴有胃食管反流4例、心肌缺血2例;胡桃夹食管(nutcracker esophagus)1例.结论对反复发作性胸痛患者联合食管测压、24小时食管pH和24小时动态心电图监测有助于食管源性及心源性胸痛的诊断,而且对其鉴别诊断亦有帮助.     

婴幼儿食管裂孔旁疝混合疝的临床特征和外科治疗

目的以食管动力学和胃食管反流评估食管裂孔旁疝和混合疝的3种抗反流手术疗效。方法24例1.5月龄～3岁,体重(7.39±2.02) kg的病儿中,15例用食管裂孔修补加Dor手术,5例加Toupet手术,3例仅做单纯修补;1例自愈。同时进行了手术前后食管动力及24 h食管pH监测。结果术前除3例不存在胃食管反流外,余均存在不同程度胃食管反流。术后优良率为91.3%;食管狭窄5例,仅1例有吞咽困难症状。术后食管下括约肌压力［(24.72±9.66) mm Hg对(20.45±9.01) mm Hg(1 mm Hg=0.133 kPa)］以Toupet术增高明显;食管下括约肌长度［(2.31±0.65) cm对(1.36±0.53)cm］以Dor手术增长明显。术后24 h食管pH监测参数明显改善,并以Toupet手术改善最显著。结论3种抗反流手术均能有效减轻胃食管反流,以Toupet手术效果最佳。     

食管测压及24小时食管pH监测的临床应用

目的　对 95例食管测压及 2 4小时食管 p H监测患者的结果进行总结分析。　方法　采用 SG- 型消化道压力检测仪进行食管测压及 MK- 型胃肠动态 p H监测仪行 2 4小时食管 p H监测 ,其中 4 4例发作性胸痛同步进行 2 4小时 Holter监测。　结果　 13例贲门失弛缓症患者术前和术后食管末端括约肌压力和 2 4小时 p H监测De Meester评分差别有显著性意义 ( P<0 .0 1) ;4 4例发作性胸痛中明确为弥漫性食管痉挛 10例 ,异常酸反流 19例 ,可疑为心源性胸痛 2例 ,13例未能明确原因 ;食管癌切除食管胃底包套吻合术后 2 3例吻合口均有一高压区 ( 13.5 3±3.17mm Hg) ,15例有异常反流 ( De Meester评分为 97.5 8± 73.2 9) ;4例食管裂孔疝中有 3例存在严重胃食管反流而行手术治疗。　结论　食管测压及 2 4小时 p H监测对食管功能性疾病的诊断及某些食管手术效果的判定有重要意义。     

113例食管破裂与穿孔的外科治疗

目的总结各种原因所致的食管破裂与穿孔的治疗效果。方法统计1996年至2005年收治的113例食管破裂和穿孔者的各种致伤原因，比较保守治疗与手术治疗的疗效和死亡率、24h以内手术治疗与24h以上手术治疗的疗效和死亡率。结果28例食管颈部损伤均获治愈。85例食管胸部损伤，手术治疗的治愈率83．0％，优于保守疗法的68．7％，P〈0．05。在自发性食管破裂病例中，发病后24h内手术者76．7％治愈，24h以上手术者54．5％治愈，P〈0．05。结论食管颈部损伤无论手术修补或保守治疗，均易治愈，预后较好。食管胸部破裂与穿孔手术治疗疗效优于保守治疗，24h以内手术者疗效优于24h以匕者。     

滑动型食管裂孔疝的外科治疗

目的 探讨滑动型食管裂孔疝手术治疗的方法与效果。方法 对经X线钡餐及胃镜检查确诊的52例滑动型食管裂孔疝并食管炎患者行手术治疗,其中Nissen手术47例、Hill手术3例、Boerema手术1例、Rampal手术1例,于术前、术后进行24h食管pH值和食管压力监测。以健康志愿者30例为对照组,行24h食管pH值和食管压力监测。结果 手术组患者术前均存在食管下括约肌的松弛和酸反流,术后则明显改善。52例随访患者中疗效优者33例(63％)、良者14例(27％)、欠佳者3例(2例吞咽困难、1例反流,占6％)、差者2例(2例复发,占4％)。结论 应完善术前检查及正确、严格掌握手术指征,以取得良好的手术疗效;术式以经腹短松式Nissen术为最佳。     

食管动力学及24h食管pH检测在食管外科中的应用——单科室28年经验

目的 总结在食管外科应用食管动力学及24 h食管pH检查的经验.方法 1982年至2009年在不明原因胸痛的诊断及新术式对食管功能的评价等多领域应用食管动力学及24 h食管pH检测.结果 不明原因的胸痛病人中70.4%(74/105例)符合食管源性胸痛诊断.360°胃底折叠可长期保持食管末端括约肌压力(LESP).经腹Heller手术加部分胃底折叠的贲门失弛症病人仅少数术后酸反流.侧侧吻合较传统手工吻合食管上括约肌不松弛及咽部"肩峰波"的比例更低,吻合口收缩压峰值更低,而且颈部吞咽不适感在侧-侧吻合组中较手工吻合组发生率更低.下咽癌切除后采用双侧颈阔肌皮瓣重建全周性颈部食管缺损病例中,食管入口部位仍有一高压区,但显著低于正常人食管上括约肌.食管癌切除、胃食管高位吻合病人幽门括约肌捏断前胃窦收缩压非常显著高于基线收缩压和捏断后收缩压.孤立性幽门收缩波(isolated pyloric pressure wave)的峰压值、频率及持续时间在捏断后较捏断前明显降低.结论 食管动力学及24 h食管pH检查对诊断食管功能性疾病及新术式的评价非常重要.

Abstract：

Objective To retrospectively review the experience of esophageal manometry and 24-hour pH monitoring in esophagus surgery. Methods From 1982 to 2010, patients with unspecific chest pain and undergone esophageal surgery were received esophageal manometry and 24-hour pH monitoring. Results Among the patients with unspecific chest pain, 70.4%(74/105) were diagnosed as esophageal origin. Lower esophageal sphincter pressure (LESP) can be continuously maintained by using 360° fundoplication. Only a minority of patients who underwent transabdominal esophagocardiomyotomy and partial posterior fundoplication had acid reflux postoperatively. Incidence rate of achalasia of upper esophageal sphincter (UES) and pharyngeal "shoulder wave" in side-to-side stapled anastomosis is significantly lower than in traditional hand-sewn anastomosis,as well as contractive pressure in anastomosis region and occurrence of swallow discomfortableness. There is a high pressure region at the esophageal entrance in patients with bilateral platysma muscle flap for cervical esophagus defect following removal of hypopharynx cancer. And the pressure of the region is significantly lower than in healthy controls. Basal pyloric pressure and peak pressure of pylorus in phase Ⅲ of the migrating motor complex increased significantly after gastric conduit was made and anastomosed, but decreased appreciably following pyloric digital fracture. Peak pressure, frequency and duration time of isolated pyloric pressure wave ( IPPW ) decreased after pyloric digital fracture significantly. Conclusion Esophageal manometry and 24-hour pH monitoring are important tools for and diagnosing unspecific chest pain and evaluating the outcome of new surgical procedures.     

经腹行Heller加改良Dor手术治疗贲门失弛症的临床疗效观察

目的 评价经腹行Heller术加改良Dor术治疗贲门失弛症的疗效.方法 经腹行Heller加改良Dor手术治疗贲门失弛症病人33例,其中18例术前及术后均行食管测压检查及24 h食管pH监测,对术前及术后食管下括约肌静息压(LESP)及24 h内食管反流次数、最长反流时间(min)、pH＜4.0时间(min)、pH＜4.0时间百分比(%)等指标进行统计学分析.结果 术后1例仍有吞咽困难,其余32 例症状明显好转.术后1个月复查食管测压检查及24 h食管pH监测,LESP值较术前明显下降(P＜0.001).24 h反流次数、最长反流时间、pH＜4.0时间、pH＜4.0时间百分比等指标较术前均有下降,差异均有统计学意义(P＜0.05).随访30例(90.9%,30/33例),其中症状消失22例(73.3%,22/30例),改善8例(26.7%,8/30例);术前经24 h食管下端pH监测证实其中3例(16.7%,3/18例)存在不同程度的胃食管反流,术后随访均无反流性食管炎发生.结论 经腹行Heller加改良Dor手术除能明显改善贲门失弛症的症状外,还能有效防止术后可能带来的胃食管反流,且手术操作较简单,创伤小,并发症少.

Abstract：

Objective To evaluate the effect of curing achalasia by transabdominally Heller-Dor operation. Methods To summarize 33 cases of achalasia treated by transabdominally Heller-Dor procedure and visit them postoperatvely. 18 patients receive pre- and post-operativemanometry and 24-hour-pH monitoring. The parameters including reflux frequency 、the longest lasting-time of reflux 、the total time(min) of pH ＜4.0 and the percentage( % ) of time of pH ＜4.0 were recorded and compared using statistical mothods. Results Symptom was significantly improved in 32 patients after surgery, while 1 patient remained dysphasia as pre-operative. The LESP, the reflux frequency、the longest lasting-time of reflux 、the total time(min) of pH ＜ 4.0 and the percentage ( % ) of time of pH ＜ 4.0 also declined after operations ( P ＜ 0. 05 ). 30 patients were followed up,22 (73.3% ,22/30) were cured and 8 had mild sypmtom. Reflux did not detected in 3 cases( 16.7% ,3/18 ) with preoperative reflux. Conclusion Transabdominally Heller-Dor operation could dramadically alleviate the symptoms of patients with achalasia, moreover, it could especially prevent the postoperative-reflux, and with the advantages of simple operations, little traumas.     

胃食管反流性咳嗽变异型哮喘24小时食管pH监测的临床研究

目的探讨咳嗽变异型哮喘急性加重期与胃食管反流的关系。方法对23例伴有胃食管反流的咳嗽变异型哮喘急性加重期患者进行24h食管pH监测,分析其反流情况。结果23例患者中,16例JamiesonpH总计分≥12．7分,诊断为胃食管反流性咳嗽变异型哮喘,并给予抗反流治疗,疗程结束后,患者的临床症状消失或缓解,其各项反流指标与治疗前比较差异有统计学意义。结论胃食管反流是咳嗽变异型哮喘的一个主要病因,24h食管pH监测有助于胃食管反流性咳嗽变异型哮喘的诊断,短期抗反流治疗有明显疗效。     

食管穿孔的外科治疗

目的探讨食管穿孔的手术方法及疗效。方法1950年1月～2001年7月我科共收治各种食管穿孔97例，其中65例采用保守治疗，32例采用手术治疗。结果食管穿孔发生在颈段35例均治愈；发生在胸段的62例，治愈54例(87.1％)，死亡8例(12．9％)。结论治疗方法及效果取决于穿孔的原因、部位、时间、大小，食管同时存在的疾病及病人全身情况等。     

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。     

食管闭锁中食管替代术的应用评价

食管闭锁患儿的预后在近十年来有了较大的改善,在低风险因素的患儿中其治愈率近乎达到100%[1],但在长段缺损型食管闭锁的处理上目前依然是个挑战.食管替代术是目前公认的治疗手段.其适应证为:①无法施行一期食管吻合的长段缺失性食管闭锁;吻合断裂需行食管造瘘;早产和呼吸窘迫无法施行一期吻合;扩张无效的严重吻合口狭窄;②以前施行过食管替代手术,替代物严重感染、坏死和溃疡性狭窄等;③化学性烧灼伤反复扩张无效者;④食管恶性疾病如横纹肌肉瘤、畸胎瘤等.     

Distal congenital esophageal stenosis associated with esophageal atresia

A series of six patients with congenital esophageal stenosis associated with esophageal atresia (EA) and distal tracheoesophageal fistula is presented. Three patients required only repeated dilatations, and have had good results. Two patients required limited resections of the distal esophagus, with excellent results. One patient died following a Heller myotomy. Tracheobronchial rests were present in the distal esophagus in the latter three patients. Diagnosis of congenital distal esophageal stenosis following repair of EA requires a high index of suspicion and a careful review of previous esophagrams. It is important to exclude anastomotic stricture and stenosis associated with gastroesophageal reflux. This requires barium esophagram, esophagoscopy with biopsy, and esophageal pH monitoring. Once a congenital basis for distal esophageal stenosis is suspected, management consists of dilatation by bouginage followed by balloon dilatation. Resection is reserved for persistent stenoses from tracheobronchial rests, which usually do not respond to dilatations.     

Isolated cervical esophageal reconstruction for rare esophageal tumors

BACKGROUND: Isolated defects in the cervical esophagus in patients who have not undergone total laryngectomy are uncommon. We report 2 cases of rare esophageal tumors requiring reconstruction of the cervical esophagus after tumor resection. METHODS AND RESULTS: The patients were a 51-year-old woman with an esophageal granular cell tumor and a 54-year-old woman with an esophageal schwannoma. Both defects were reconstructed with a radial forearm flap. A small subclinical leak developed in 1 patient and healed spontaneously within 2 weeks. At 1 year and 2 years of follow-up, both patients were consuming a normal diet and had normal voices. CONCLUSIONS: A thin and well-vascularized flap such as the radial forearm flap is essential for reconstructing an isolated cervical esophageal defect so as to maximize functional outcome.     

Superimposed spontaneous esophageal perforation in congenital esophageal stenosis

Congenital esophageal stenosis (CES) is a very rare embryologic anomaly of tracheoesophageal development that requires lifelong management, usually with frequent esophageal dilations and dietary precautions. We present a patient with spontaneous thoracic esopahgeal perforation in a setting of CES. The patient, a 27-year-old male, recovered uneventfully following open primary esophageal closure. A brief but comprehensive discussion of CES follows the case report.     

EEA esophageal stapling for control of bleeding esophageal varices

Esophageal transection with the EEA stapler was performed in five patients with bleeding esophageal varices. Bleeding from varices has not recurred in surviving patients during follow-up of up to 27 months. One death occurred during the postoperative period. Esophageal transection with the EEA stapler is an effective means of preventing recurrent variceal hemorrhage. This technique is best suited for patients requiring emergency operation to prevent exsanguination and for those in whom a major shunting procedure is contraindicated because of the severity of hepatic disease or other medical illness.     

Fate of the distal esophageal remnant following esophageal replacement

When a colon segment is used for esophageal replacement in patients with esophageal atresia, the distal esophageal remnant is often left in place. We recently treated two patients who developed esophagitis in their esophageal remnants and did not respond to cimetidine and antacids. They were treated by esophagectomy at 22 and 37 years of age with relief of symptoms. One had an ulcer and stricture near the gastroesophageal junction and the second had gastric mucosa (Barrett's esophagus) replacing most of the squamous epithelium. Six additional patients were then reviewed who had resection of their distal esophageal segments between 1978 and 1987. Esophagitis was present in all. Also identified were two specimens with Barrett's esophagus and four with mural bronchial glands as well as surface respiratory and metaplastic squamous epithelium in two, and cartilagenous remnants in two. The findings of chronic inflammation in the esophageal remnant and three cases of Barrett's esophagus raise concern about the possible long-term complication of malignancy. Therefore, we recommend that esophagectomy be performed at the time of esophageal replacement if feasible, or later if symptoms occur or barium studies show esophagitis or ulceration.