小儿胃食管反流症

小儿胃食管反流症（ＧＥＲＤ）是一种儿科常见的疾病，它可以导致小儿营养不良、生长发育迟 缓、食管炎、肺炎等多种并发症。目前认为ＧＥＲＤ的发生是由食管下端括约肌张力减低、食管蠕动 和廓清能力降低、解剖因素、食管黏膜屏障的损坏及胃排空功能障碍等因素有关。治疗目的在于 加强食管的抗反流防御机制，减少胃食管反流；减缓症状，预防和治疗并发症以及防止复发，一般 根据症状的轻重不同可分为非系统性治疗、系统性内科治疗和外科手术治疗。     

小儿胃食管反流病的治疗

胃食管反流（gastroesophageal reflux,GER）是指胃内容物包括从十二指肠流入胃的胆盐和胰酶反流入食管,可分为病理性和生理性,生理性反流可发生在正常的儿童,空腹或睡眠的情况下不发生反流;病理性反流是发作频繁或持续,导致了食管炎、食管不适的症状或呼吸道疾病等。胃食管反流的治疗是一个较长的过程,包括改变生活方式、内科药物治疗和外科手术治疗。要根据对患儿生活质量（尤其与健康相关的生活质量）的影响和治疗的经济性来选择治疗方式和药物。儿童大多数病理性反流经保守治疗,能获得满意的效果。     

健康儿童及病理性胃食管反流患儿食管动力功能研究

目的了解小儿食管运动的生理学,探讨小儿病理性胃食管反流(GER)发生的食管动力学基础。方法对60例健康儿童和62例经食管pH监测诊断为病理性GER的患儿用低顺应性毛细管灌注系统进行食管测压研究,并对健康儿童组不同年龄段之间,两组同一年龄段之间进行食管动力功能比较。结果健康儿童组下食管括约肌长度(LESL)随着年龄的增加而增长,胸内段和腹内段也相应增加(P＜0.01),下食管括约肌压力(LESP)以～1岁组为高(P＜0.05);上食管括约肌长度(UESL)随年龄的增加而增长(P＜0.01),上食管括约肌压力(UESP)以～1岁组和～3岁组为低(P＜0.01)。病理性反流患儿的食管动力功能,除～7岁组食管蠕动传导速度低于同一年龄段健康儿童外(P＜0.05),其余指标两组同一年龄段间的差异均无显著性。结论LESP的抗反流功能与年龄关系不大,LESL、UESL和UESP的功能3岁以后逐渐成熟,小儿病理性GER的发生与LESP、LESL关系不大。     

碱性胃食管反流的研究进展

胃食管反流病 (ｇａｓｔｒｏｅｓｏｐｈａｇｅａｌｒｅ ｆｌｕｘｄｉｓｅａｓｅ ,ＧＥＲＤ)是指胃及 /或十二指肠内容物反流入食管所引起的组织损伤和临床症状 ,为一类常见的上消化道动力障碍性疾病 ,占食管疾病的 75 .0 %。Ｐｅｌｌｅｇｒｉｎｉ等[1] 利用 2 4ｈｐＨ监测将胃食管反流分为三种类型 ,即酸性、碱性和混和性 ,首次提出碱性胃食管反流 (ａｌｋａｌｉｎｅｇａｓｔｒｏｅｓｏｐｈａｇｅａｌｒｅｆｌｕｘ ,ＡＧＥＲ)的概念 ,并将食管下段ｐＨ >7作为碱性反流的判定标准。Ｖａｅｚｉ等[2 ] 认为碱性反流实际上是指十二指肠内容物反…     

先天性膈疝的研究进展

先天性膈疝的研究进展徐哲综述李桂生赖炳耀审校小儿先天性膈疝（ＣＤＨ）发病率约为１∶２２００～１∶５０００，为较常见的小儿先天性疾病之一。近年来越来越受到世界各国的关注，特别是治疗观念上比以前有了明显改进，现对其研究进展概述如下。一、ＣＤＨ患儿的产前诊...     

婴儿期胃食管反流病及其诊治

胃食管反流(gastroesophageal reflux,GER)是指胃内容物无意识地反流到食管,甚至口咽部,如十二指肠内容物反流到食管称十二指肠胃食管反流(DGER).胃食管反流病(gastroesophageal reflux disease,GERD)是指反流引起的具有一系列食管内、外症状和(或)并发症的临床症候群,需作评估和治疗.小儿GERD严重影响儿童生长发育和生活质量,但临床上部分儿科医师对此病尚缺乏足够认识.文献[1]<中华儿科杂志>编委会和中华医学会儿科学分会消化学组于2006年共同制定的"小儿GERD诊治方案(试行)",对规范诊治我国小儿GERD有指导作用.     

小儿胃食管反流

近年来胃食管反流(GaStro-esophagealreflux GER)被证实是儿科的一个常见而重要的临床问题,受到欧美儿科医生的普遍重视,并开展了很多有关这方面的研究工作。MartinAbram 副教授前几年访华时也对GER 作了专题报告,但国内对GER 的重视非常不够,实用儿科学最新版尚无GER 的记载。由于本症很常见,容易漏诊,早期体检治疗对其疗效甚佳,但诊断过晚常导致食管狭窄、贫血、反复呼吸道感染、生长发育不良,甚至婴儿猝死。故有必要将GER 作一简要介绍。     

先天性膈疝的临床特点及外科治疗经验

为提高新生儿先天性膈疝（CDH）的早期诊断、治疗及预后水平，对28例先天性膈疝病例进行临床特征、手术过程回顾性分析。全部进行正位及胸部X-线检查，5例做上消化道造影，13例做血气分析。X-线证实胸腔内有含水的肠管，腹析显示部分婴儿严重的缺氧、呼吸性酸中毒；消化道造影显示结肠或小肠在胸腔内。结果：2例新生儿放弃治疗，26例患儿手术治疗，3例死亡，23例病人恢复良好。结果：对患有先天性膈疝的新生儿必须早期诊断和手术治疗。     

小儿胃食管反流症

小儿胃食管反流症（GERD）是一种儿科常见的疾病，它可以导致小儿营养不良、生和发育迟缓、食管炎、肺炎等多种并发症。目前认为GERD的发生是由食管下端括约肌张力减低、食管蠕动和廓清能力降低、解剖因素、食管黏膜屏障的损坏及胃排空功能障碍等因素有关。治疗目的在于加强食管的抗反流防御机制，减少胃食管反流；减缓症状，预防和治疗并发症以及防止复发，一般根据症状的轻重不同可分为非系统性治疗、系统性内科治疗和外科手术治疗。     

Abnormality of lower esophagus associated with congenital diaphragmatic hernia

We observed two cases of anatomic and functional abnormalities of the lower esophagus associated with congenital diaphragmatic hernia (Bochdalek's hernia). In the first case, severe dilation and gastroesophageal reflux were noted during postoperative treatment. In the second, atresia at the anal end of the dilated lower esophagus was found and esophagogastrostomy was later performed. These cases suggest that kinking of the esophagocardial (EC) junction that occurred during intestinal herniation into the fetal thorax might have caused lower esophageal ectasia and/or atresia of the EC junction. Correspondence to: K. Sue     

Gastroesophageal reflux and diaphragmatic motility after repair of congenital diaphragmatic hernia.

At the Department of Pediatric Surgery in Graz, 31 boys and 23 girls were operated on for congenital diaphragmatic hernia (CDH) from 1978 to 1994. In 49 patients the defect was on the left, in five on the right side. In 46 cases, the hernia was diagnosed within the first week of life; in eight children at a later date. 19 children (35%) died. 25 of the 35 survivors (71%) came to a follow-up examination on average 9.4 (1-17) years after the operation. 24 h pH-monitoring or manometry and Upper G.I. series revealed pathological gastroesophageal reflux (GER) in 16 patients. Nine children were treated conservatively; in seven patients an antireflux procedure was performed. A thoracic position of the stomach or left liver lobe, presence of a hernial sac, gestational age, prenatal diagnosis, use of a patch or severity of lung hypoplasia did not significantly influence the incidence of GER. In three patients, a hiatal hernia was found. The motility of the diaphragm was documented with M-mode sonography (n = 18); a restricted motility could be demonstrated in five patients. GER is very common in patients after repair of CDH. We recommend long-term follow-up with special interest in respect of GER.     

The vagus and recurrent laryngeal nerves in experimental congenital diaphragmatic hernia

Background The etiology of the anatomic and functional abnormalities of the esophagus in infants surviving congenital diaphragmatic hernia (CDH) remains unclear. We showed previously that fetal rats with CDH have malformations of neural crest-derived structures. The aim of this study was to examine the anatomy of the vagus and the recurrent laryngeal nerves, both of neural crest origin, in rats with CDH.Methods We used the nitrofen-induced CDH fetal rat model. Nine control fetuses from four dams and nine fetuses with CDH from seven dams were included in this study. Embryos were fixed in formalin and a thoracic block from the larynx to tracheal bifurcation was serially sectioned in the horizontal plane. One in every ten sections was stained with hematoxylin and eosin. The image was digitalized using biological software (TDR-3dbase). Vagus and recurrent laryngeal nerves, trachea, esophagus and the great vessels were examined. In order to obtain the three-dimensional reconstructions, 90–120 consecutive images were used.Results In comparison with controls there were striking abnormalities of the vagus and the recurrent laryngeal nerves in fetuses with CDH: (1) absence of the left (2/9) or right (2/9) vagus nerves; (2) absence of the left (3/9) or right (3/9) recurrent laryngeal nerves; (3) marked hypoplasia of the trunk of the vagus (2/9); (4) deviations of their normal course and change of normal anatomical relationships into the mediastinum (2/9); and (5) abnormal branching of the lower portion of the vagus (1/9).Conclusions Rat fetuses with CDH have anomalies of the vagus and recurrent laryngeal nerves that support the concept of a neural crest involvement in the origin of this malformation. 3-D reconstructions allow a detailed analysis and provide a precise insight into the real anatomy. These observations may explain esophageal motility disorders in CDH.     

Esophageal motility and gastroesophageal reflux in children with chronic respiratory diseases

Children with chronic respiratory diseases may be a high-risk population for gastroesophageal reflux (GER). In order to describe GER in this population, we systematically studied 7-h pH-metry and prolonged esophageal manometry (over 45 min) in 124 children admitted for respiratory disorders without digestive symptoms. The results showed that: (1) GER varied in significance before and after meals; (2) postprandial reflux was correlated with esophageal motor activity, but preprandial reflux was not; (3) moderate refluxers had reduced lower esophageal sphincter (LES) pressure, but severe refluxers had no significative decrease in LES pressure. The use of multivariate analysis permitted us to conclude that long-term esophageal manometry and pH-metry were complementary in defining severe GER. Offprint requests to: M. Bouchoucha     

Esophageal hiatal hernia after omphalocele repair

Esophageal hiatal hernias (EHH) are probably caused by congenital, traumatic, or iatrogenic factors, although the etiology remains unknown. EHHs may develop after abdominal wall closure for omphalocele or gastroschisis due to the increased intra-abdominal pressure, however, there have been few reports in the literature. We present a case of EHH developing after abdominal wall closure. Accepted: 5 March 1997     

新生儿胃食管反流发病机理的研究

为探讨新生儿胃食管反流（ＧＥＲ）的发病机理，对３８例经钡餐造影诊为ＧＥＲ的患儿进行食管ｐＨ值动态监测和食管动力功能检查，１５例无症状儿作对照组。结果：ＧＥＲ组各项反流指标均显著大于对照组。３８例中１８例为生理性ＧＥＲ，２０例为病理性ＧＥＲ。病理性反流组下食管括约肌压力（ＬＥＳＰ）和屏障压（ＢＰ）均显著低于对照组，而食管功能的其他指标则差异无显著意义。以总ｐＨ值＜４百分时间２．７７％和综合评分８．９２为９５％参考值上限，则ＧＥＲ组病理性反流的检出率为５５．３％（２１／３８），高于对照组的６．７％（１／１５）（Ｐ＜０．０１）。ＬＥＳＰ和ＢＰ的９５％参考值下限分别为８．３９ｋＰａ、８．１５ｋＰａ，对照组无一例ＬＥＳＰ低下，ＧＥＲ组ＬＥＳＰ降低占１５．７％（６／３８），二组差异无显著意义（Ｐ＞０．０５）。提示：新生儿期食管功能已成熟，新生儿ＧＥＲ的发生不单是ＬＥＳＰ降低这一因素，还可能与短暂下食管括约肌松驰有关。     

胸腔镜手术治疗新生儿先天性膈疝

目的探讨胸腔镜手术治疗新生儿膈疝的手术经验及技术难点分析。方法对27例新生儿CDH患儿采用胸腔镜手术治疗。顺序还纳疝入脏器,脾脏还纳时切忌使用尖锐器械直接压迫还纳,应间接推挤或以胃结肠等空腔脏器辅助推挤还纳,避免脾脏及血管撕裂导致出血。后外侧膈肌缺损严重者可行膈肌缘-肋间肌-膈肌缘缝合,适度打紧线结完成膈肌闭合修复。膈肌缺损严重可先连续缝合尽可能对合关闭缺损,测量缺损薄弱处大小,将体外裁剪好的补片置入胸腔,贴紧固定补片至膈肌薄弱处并以4-0 prolene线间断缝合。结果27例膈疝中左侧25例,右侧2例。产前诊断23例,产前诊断胎龄为(28.2±5.1)周;出生孕周为(37.5±2.7)周,孕周最小为28.0周;出生体重为(2.90±0.70)kg,最小为1.36 kg。所有患儿均采用胸腔镜手术,23例顺利完成,4例中转。存活23例(85%),死亡4例(15%)。手术年龄为出生后(41.0±40.0)h,手术时间为(159.0±14.0)min,行补片修补3例,术后有创呼吸机使用时间为(5.1±1.2)d,术后住院时间为(18.0±4.0)d。术后1例复发,第二次经胸腔镜完成手术,预后良好,3例并发胸腔积液均经保守治疗痊愈。结论胸腔镜手术治疗新生儿CDH安全可行,术者有丰富的胸腔镜操作经验下,可优先考虑,补片修补可以在腔镜下顺利完成,术中心肺功能不稳定,二氧化碳分压(PaCO2)持续高于65~75 mmHg(1 mmHg=0.133 kPa)应及时中转开放手术。低体重早产儿对胸腔镜手术的耐受性并不低于足月儿。     

先天性膈疝术后肺功能转归的临床研究

目的探索先天性膈疝患儿术后肺功能的转归情况。方法收集2016年11月至2019年3月在上海交通大学医学院附属新华医院小儿外科门诊随访并行肺功能检查的膈疝患儿肺功能数据,同时收集患儿治疗时的临床资料,包括患儿性别、膈疝类型、Apgar评分、出生体重、肝脏位置、血气分析、呼吸机维持时间和住院周期等进行统计分析。结果45例患儿纳入分析,其中男19例,女26例;左侧膈疝39例,右侧6例。共行89次肺功能检查,随访时间为(9.3±7.3)个月,20例患儿行1次检查,25例行2次及以上检查。以最近一次肺功能检查数据为准,45例患儿中呼吸功能正常者有7例(15.6%),呼吸功能存在异常组有38例(84.4%)。肺功能检查表现为潮气呼吸功能正常、阻塞性通气功能障碍、混合性通气功能障碍、限制性通气功能障碍的分别为10次、62次、11次和6次。肺功能检查时间、膈疝类型和肝脏疝入情况与肺功能检查结果存在相关性(P<0.05)。与限制性通气功能障碍组患儿的月龄相比,阻塞性通气功能障碍组患儿的月龄较大[(8.9±6.9)个月比(1.3±0.5)个月,P=0.001]。25例接受多次肺功能检查结果显示,随着患儿年龄的增长,其"达峰时间比"和"达容时间比"显著增加(P<0.05)。结论部分先天性膈疝患儿术后早期存在不同程度的肺功能异常,需给予高度重视;年龄、膈疝类型和肝脏疝入情况可能是影响肺功能异常的危险因素。     

Esophageal electromyography in the diagnosis of gastroesophageal reflux in infants and children

Electromyography (EMG) was performed by drawing a probe out through the esophagus in 38 patients with gastroesophageal reflux (GER) aged 3 weeks to 9 years; 22 asymptomatic infants served as controls. While drawing the probe through the esophagus, the EMG esophageal profile picture was obtained: zones with EMG (L _EMG ) and with EKG only (L _EKG ) were revealed. It was found that the EMG zone in patients with GER was significantly shorter in comparison with controls, i. e., less than one-half the esophageal length. The index L _EMG /L _EKG was always less than 1 in patients with GER and more than 1 in the control group. As a result of the EMG findings, GER was excluded in 7 patients with vomiting, 4 of whom had other causes while 3 proved to be physiological and resolved spontaneously. The method also appeared to be useful for evaluating the effectiveness of GER treatment.