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1.
This paper addresses gastric herniation following laparoscopic fundoplication for reflux esophagitis. Case history: A 46-year-old
woman underwent Nissen fundoplication. Two days postoperatively she developed gastric herniation and perforation with subsequent
pleural effusion and necrotizing fasciitis of the chest wall. A patent crural repair might reduce the occurrence of paraoesophageal
herniation.
Received: 12 April 1996/Accepted: 26 November 1996 相似文献
2.
Background: Persistent postoperative dysphagia occurs in up to 24% of patients who undergo a laparoscopic Nissen fundoplication for reflux
disease [7]. We hypothesized that patient history, pH testing, and esophageal manometry could be used to preoperatively identify
patients at risk for this complication.
Methods: Of 156 laparoscopic Nissen fundoplications performed over a 27-month period, we identified 19 patients (12%) who suffered
from postoperative dysphagia longer than 3 months. The presenting complaint of preoperative swallowing difficulty was noted
as was the presence of a known esophageal stricture. Preoperative pH testing and esophageal manometry were performed for all
subjects. We compared the following parameters to an age and gender-matched control group: history of esophageal stricture,
presence of preoperative dysphagia, DeMeester reflux score, upper esophageal sphincter pressure and relaxation, esophageal
body motility, location of respiratory inversion point, and lower esophageal sphincter length, resting pressure, and relaxation.
Data were compared via t-test and Fisher's exact test.
Results: Patients who presented before surgery with complaints of difficulty swallowing were more likely to suffer from postoperative
dysphagia (p= 0.029). Incidence of stricture, DeMeester score, and manometric measurements did not differ between the dysphagia and control
groups (p > 0.05 for all parameters).
Conclusions: Although preoperative studies are not helpful in identifying patients at risk for persistent dysphagia after laparoscopic
Nissen fundoplication, patients presenting with the preoperative complaint of difficulty swallowing are at increased risk
for this complication.
Received: 1 April 1999/Accepted: 22 July 1999 相似文献
3.
Laparoscopic fundoplication in infants and children 总被引:2,自引:0,他引:2
Background: Laparoscopic fundoplication is a new method for treating gastroesophageal reflux in children. We present 160 children with
gastroesophageal reflux treated by laparoscopic fundoplication.
Methods: Patients underwent either a laparoscopic Nissen or Toupet fundoplication. Many patients also required gastrostomies and gastric
outlet procedures.
Results: Twelve patients (7.5%) were converted to open fundoplication. Laparoscopic gastrostomies were placed in 112 patients (75.7%)
and laparoscopic gastric outlet procedures in 62 patients (41.9%). Feedings were initiated by postoperative day 2 in 126 children
(85.7%). Sixty-four percent were discharged by postoperative day 3. Complications occurred in 11 of 148 fundoplications (7.4%),
in nine of 112 gastrostomies (8.0%), and in three of 62 gastric outlet procedures (4.8%). One patient died as a result of
a surgical error in placing a gastrostomy (0.7%).
Conclusion: Laparoscopic fundoplication appears to foster a more rapid recovery and decreased hospital stay while maintaining complication
rates similar to or better than open fundoplication.
Received: 22 March 1996/Accepted: 12 June 1996 相似文献
4.
Background: The purpose of this study was to evaluate the results of 138 cases of gastroesophageal reflux disease resolved laparoscopically
with the Rossetti modification of the Nissen fundoplication and to compare them with findings from other studies in an effort
to evaluate the procedure's ability to transfer from an academic setting to a community hospital setting.
Methods: We performed laparoscopic Nissen fundoplication on 138 patients and followed them for up to 45 months. Measures included
postoperative reflux persistence, complications, operating time, length of hospital stay, and others. These findings were
compared, using the Fisher's exact test, chi-square test, and the two-sample t-test, with results from other studies using open and laparoscopic procedures.
Results: No patient undergoing laparoscopic fundoplication experienced gastroesophageal reflux after surgery. Complications, not statistically
significantly different from those in other studies, occurred in 15 (10.9%), and conversion to an open procedure was required
in two (1.5%). The most common postoperative complaint has been dysphagia (21.7%). Operative time averaged 70.6 min, decreasing
from an average of 236 min for the first 10 cases to 40.8 min for the last 10. This measure was statistically significantly
lower than all other operative times to which it was compared, except one to which it was almost identical (69.9 min). Length
of stay (LOS) averaged 2.3 days, ranging from a low of 7 h to a high of 9 days, which made it fall well within limits set
by other studies. Overall, LOS fell from a 3.0-day average for the first 20 cases to a 1.9-day average for the last 20 cases.
Conclusions: Laparoscopic Nissen fundoplication resolved gastroesophageal reflux in all 138 patients, and measures for complications,
operating time, and LOS were well within values reported by other studies, indicating the ability of this procedure to be
successfully transferred from academic medical centers to the community hospital setting.
Received: 7 October 1996/Accepted: 14 May 1997 相似文献
5.
360° laparoscopic fundoplication with tension-free hiatoplasty in the treatment of symptomatic gastroesophageal reflux disease 总被引:1,自引:0,他引:1
Basso N De Leo A Genco A Rosato P Rea S Spaziani E Primavera A 《Surgical endoscopy》2000,14(2):164-169
Background: Since laparoscopic Nissen fundoplication was first described by Cuschieri in 1989 and later by Dallemagne in 1991, this procedure
has been widely employed for the treatment of symptomatic gastroesophageal reflux disease (GERD) and/or hiatal hernia. However,
a relatively high incidence (7–11%) of intrathoracic Nissen valve migration/paraesophageal hernia following laparoscopic fundoplication
has recently been reported.
Methods: Between November 1992 and August 1995, 65 consecutive patients with severe GERD and/or hiatal hernia underwent laparoscopic
360° fundoplication. In nine of these 65 (13.8%) patients, an intrathoracic Nissen valve migration had occurred within 4 months.
Six of these patients were symptomatic and were again submitted to the laparoscopic intervention. Videotapes of both the first
and second operation were reviewed. In all cases, it was apparent that, at the first operation, closure by stitches of the
hiatus was under tension, and at the second operation, the muscle fibers of the right crus were disrupted, probably due to
the tension between the suture margins during the inspiratory movements of the diaphragm. These findings prompted us to perform
an effective tension-free closure of the hiatus. A polypropylene mesh (3 × 4 cm) was placed on the hiatus behind the esophagus
and fixed with eight metallic agraphes (2 + 2 on the superior edge and 2 + 2 on the lateral sides of the right and left cruses).
Results: Between August 1995 and February 1998, the technique, complete with 360° fundoplication, was used for 67 patients with GERD.
At mean follow-up of 22.5 months (range, 1–30), there was no evidence of postoperative paraesophageal hernia or complications
related to the use of the mesh.
Conclusions: This tension-free hiatoplasty seems to be an effective solution to prevent postoperative paraesophageal hernia in patients
undergoing antireflux laparoscopic surgery. However, longer follow-up is still needed.
Received: 9 July 1998/Accepted: 19 April 1999 相似文献
6.
Complications of laparoscopic antireflux surgery in childhood 总被引:6,自引:2,他引:4
Background: The aim of this study was to assess the complications associated with the laparoscopic treatment of gastroesophageal reflux
disease (GERD) in children.
Methods: From March 1992 to March 1998, we used the laparoscopic approach to treat 289 children affected by gastroesophageal reflux
disease. The patients' ages ranged between 4 months and 17 years (median, 4.3 years), and their body weight ranged between
5 and 52 kg. In 148 children (51.3%), we adopted a Nissen-Rossetti procedure and in 141 (48.7%) a Toupet technique.
Results: The duration of surgery ranged between 40 and 180 min (median, 70). There were no deaths and no anesthesiological complications
in our series. We recorded 15 (5.1%) intraoperative complications: six pleural perforations, four lesions of the posterior
vagus nerve, two esophageal perforations, two gastric perforations, and one pericardiac perforation. Conversion to open surgery
was necessary in only four cases (1.3%). We recorded 10 (3.4%) postoperative complications: one peritonitis due to an esophageal
perforation not detected during the intervention that required a reoperation, five cases of herniation of the epiploon through
a trocar orifice, three cases of dysphagia that disappeared spontaneously after a few months, and one case of delayed gastric
emptying that subsequently required a pyloroplasty. We had six recurrences of GERD (2.1%). In two cases, a new fundoplication
was performed using the laparoscopic approach; in the other four, the GERD was controlled with medical therapy.
Conclusion: Our results show that laparoscopic fundoplication is an adequate treatment for children with GERD that has a low rate of
complications. When severe complications do occur, they can be treated effectively via the laparoscopic approach.
Received: 16 November 1999/Accepted: 16 December 1999/Online publication: 5 June 2000 相似文献
7.
Background: There is a certain amount of controversy regarding the need to divide the short gastric vessels (SGV) in laparoscopic fundoplication
for treatment of gastroesophageal reflux disease (GERD). In addition, there is often difficulty in identifying the crural
fibers when encircling the lower esophagus.
Methods: We determine whether it is necessary to divide the SGV by trying to appose the gastric fundus to the anterior abdominal wall
intraoperatively. If this could be done easily, the SGV are preserved. When their division is required, a posterior gastric
approach is employed. We have also found that the injection of methylene blue into the left crural fibers anterior to the
esophagus is helpful in identifying the left side when dissection posterior to the gastroesophageal junction is difficult.
Results: Between 1992 and 1995 we performed 20 laparoscopic fundoplications for GERD. All patients had at least grade 3 esophagitis
(Savary-Miller scale), increased esophageal exposure to acid (median DeMeester score of 195), and decreased lower esophageal
sphincter (LES) pressure. The median operative time was 175 min. There were no conversions to open surgery, and there was
no mortality. Three patients developed transient postoperative dysphagia and one patient had pneumonia. The median hospital
stay was 3 days; all patients were free of reflux symptoms at follow-up ranging from 7 to 42 months.
Conclusion: We conclude that the techniques described by us aid in intraoperative decision making and allow laparoscopic fundoplication
to be both simple and effective.
Received: 29 March 1996/Accepted: 28 May 1996 相似文献
8.
Background: Advocates of the Toupet partial fundoplication claim that the procedure has a lower rate of the side effects of dysphagia
and gas bloat than a complete Nissen fundoplication. However, there is increasing recognition that reflux control is not always
as good with the Toupet procedure as with the Nissen. Therefore, we set out to evaluate the factors contributing to success
and failure in patients who underwent laparoscopic modified Toupet fundoplication (LTF).
Methods: A total of 143 patients undergoing LTF for documented gastroesophageal reflux disease (GERD) were evaluated prospectively
in regard to their outcomes over a 4-year period. All patients had preoperative esophagogastroduodenoscopy (EGD) and manometry;
24-h pH testing was used selectively. Esophageal manometry was requested of all patients 6 weeks postoperatively. Clinical
follow-up was by office visit or questionnaire every 6 months after surgery; patients with significant problems were investigated
further. Failure was defined as the development of recurrent reflux documented by endoscopy, 24-h pH test, or wrap disruption
on barium swallow, or severe dysphagia persisting >3 months and requiring surgical revision.
Results: At a mean follow-up of 30 months (range, 3–51), 21 of 143 patients failed LTF; two had dysphagia and 19 had recurrent reflux.
Failure was associated with preoperative findings of a defective lower esophageal sphincter (LES) (14/21), complicated esophagitis
(13/21), and failure to divide short gastric vessels (12/19) (chi-square p < 0.05). Defective esophageal body peristalsis, present in 14 patients, resulted in failure in six cases. Presence of either
complicated esophagitis or a defective LES was associated with a 3-year 50% success rate, whereas presence of mild esophagitis
and a normal LES was reflected in a 96% 3-year success rate.
Conclusion: Laparoscopic Toupet fundoplication should be reserved for milder cases of GERD, as assessed by manometry and endoscopy.
Received: 29 June 1998/Accepted: 2 July 1999 相似文献
9.
A. S. Lowham C. J. Filipi R. A. Hinder L. L. Swanstrom K. Stalter A. dePaula J. G. Hunter T. G. Buglewicz K. Haake 《Surgical endoscopy》1996,10(10):979-982
Background: This study retrospectively assesses the mechanisms of 13 esophageal or gastric injuries resulting from dilator or nasogastric
tube placement during laparoscopic foregut surgery and is intended to assist in determining methods of prevention.
Methods: Information regarding esophageal or gastric injury during laparoscopic foregut surgery was obtained from six experienced
laparoscopic surgeons. The specific mechanisms of injury were determined by discussion with the operating surgeon and review
of the operative reports.
Results: Eleven cases of esophageal or gastric perforation occurred during bougie insertion and two perforations occurred secondary
to nasogastric tube placement during Nissen fundoplication or Heller myotomy. Five perforations required conversion to open
operation for repair including two delayed thoracotomies. The 13 injuries occurred during the performance of 1,620 laparoscopic
foregut operations for an overall incidence of 0.8%.
Conclusion: Foregut injury resulting from esophagogastric intubation during laparoscopic surgery is more common than expected. Risk factors
include esophageal anatomy, intrinsic pathologic changes of the esophagus, and inexperience. Prevention must focus on close
communication between the surgeon and anethesiologist and safe techniques of dilator insertion. 相似文献
10.
Background: It has been suggested that antireflux surgery may cause an improvement in esophageal motor function (EMF) and lead to reduced
postoperative dysphagia.
Methods: We evaluated the changes in dysphagia symptom scores and esophageal and lower esophageal sphincter (LES) pressures in patients
before (n= 381), at 6 months (n= 260), and at 24 months (n= 97) after laparoscopic fundoplication.
Results: There was a significant increase in LES basal and nadir pressure following surgery in all patients and an improvement in
EMF only in patients with poor preoperative esophageal motor function. A total of 76% of the patients reported no dysphagia
or an improved dysphagia score 6 and 24 months after surgery. This improvement was more marked in patients with poor EMF.
An improvement in EMF did not correlate with the improvement in dysphagia score reported by other patients. Patients with
increased dysphagia scores 2 years after surgery had significantly higher LES basal and nadir pressures as compared to other
patients.
Conclusions: Laparoscopic Nissen fundoplication is associated with an overall reduction in dysphagia scores and leads to an improvement
in esophageal motor function in patients with poor preoperative esophageal motility. Tightness and inadequate relaxation of
the wrap during swallowing may be a determinant of long-term dysphagia.
Received: 5 May 1997/Accepted: 19 August 1997 相似文献
11.
A comparison of laparoscopic Nissen fundoplication and Rossetti's modification in 239 patients 总被引:4,自引:0,他引:4
Background: Laparoscopic Nissen fundoplication and the Rossetti modification represent two different surgical approaches to resolving
gastroesophageal reflux disease (GERD). Concerns have arisen that the Rossetti modification results in increased postoperative
dysphagia. In this study, we compared a group of patients who underwent a laparoscopic Nissen fundoplication with a group
who had undergone the Rossetti modification to determine if there was a significant difference in postoperative dysphagia.
Additionally, we wanted to confirm that the Nissen procedure performed laparoscopically could resolve GERD as successfully
as the Rossetti modification, with no difference in operative complications.
Methods: We prospectively collected data on 101 patients who underwent laparoscopic Nissen fundoplication and compared outcomes with
those of 138 patients who had undergone the laparoscopic Rossetti modification in a previous series.
Results: All patients experienced resolution of reflux symptoms. No statistically significant differences were found between the groups
in terms of intraoperative or postoperative complications, conversions to open procedure, or length of hospitalization. Paradoxically,
there was a significant difference in operating time between the Rossetti and the Nissen groups (70.6 min vs 45.6 min, p= 0.006). Postoperative dysphagia requiring dilation was significantly higher in the Rossetti group (21.7% vs 8.9%, p= 0.008). However, there was a significantly higher percentage of patients in the Rossetti group who had had esophagitis preoperatively
(95.7% vs 86.1%, p= 0.009), although the proportion of patients having Barrett's esophagus was higher in the Nissen group (9.4% vs 24.8%, p= 0.001).
Conclusions: Both approaches resolved reflux symptoms without significant differences in complications, conversions, or length of stay.
Preoperative differences between groups, as well as the method of sequentially comparing the two different procedures, prevent
us from attributing greater postoperative dysphagia in the Rossetti group solely to the choice of surgical approach. Prospective
randomized studies are needed to control for variables, such as surgical team experience and patient differences.
Online publication: 17 April 2000 相似文献
12.
The influence of laparoscopic surgery on postoperative polymorphonuclear leukocyte function 总被引:10,自引:4,他引:6
Sietses C Wiezer MJ Eijsbouts QA van Leeuwen PA Beelen RH Meijer S Cuesta MA 《Surgical endoscopy》2000,14(9):812-816
Background: Laparoscopic surgery is thought to result in a better preservation of patients' immunological defenses. Polymorphonuclear
leukocytes (PMN) are the most important effector cells in the elimination of pathogenic microorganisms. Because little is
known about their function after laparoscopic surgery, we studied PMN phagocytosis, antigen expression, and oxygen radical
production.
Methods: In this study, 17 patients scheduled for Nissen fundoplication were randomly assigned to undergo either a laparoscopic or
conventional procedure. To study phagocytic capacity, PMN were incubated with fluorescein isothiocyanate (FITC)-labeled Staphylococcus aureus. Plasma opsonic capacity was measured by comparing PMN phagocytosis in the presence of patients' own plasma with phagocytosis
in the presence of control plasma. Cellular activation was measured by the expression of various cell surface markers and
by assessment of PMA-stimulated oxidative burst.
Results: Phagocytosis by PMN in the presence of patients' plasma was significantly lower 2 h after the conventional operation. No
decrease in phagocytosis was observed when control plasma was used, indicating a decreased opsonic capacity of plasma after
conventional surgery. No changes were observed after laparoscopic surgery. Furthermore, CD11b expression was significantly
lower after the laparoscopic approach, indicating a blunted cellular activation. A significantly lower PMA-stimulated oxidative
burst further confirmed the tempered stimulation after laparoscopic surgery.
Conclusions: Laparoscopic surgery results in a preservation of the plasma opsonic capacity, and thereby the ability of PMN to phagocytose
bacteria. Moreover, the postoperative cellular activation is reduced. The preserved phagocytosis and the blunted activation
may prevent the development of postoperative infectious complications.
Received: 12 February 1999/Accepted: 30 September 1999/Online publication: 9 August 2000 相似文献
13.
Laparoscopic surgery preserves monocyte-mediated tumor cell killing in contrast to the conventional approach 总被引:10,自引:2,他引:8
Sietses C Havenith CE Eijsbouts QA van Leeuwen PA Meijer S Beelen RH Cuesta MA 《Surgical endoscopy》2000,14(5):456-460
Background: Experimental animal research shows that immunologic defenses against tumor cells are disturbed by surgical trauma, resulting
in an increased rate of tumor implantation and the growth of subsequent metastases. Minimally invasive surgery is associated
with a preservation of postoperative immunologic functions and, in animal models, with decreased tumor growth. The objective
was to study the influence of several surgical procedures, approached conventionally and laparoscopically, on interleukin-6
(IL-6) and monocyte-mediated cytotoxicity (MMC).
Methods: Five groups of five patients each were included in this prospective study: laparoscopic cholecystectomy (minor trauma) group,
Nissen fundoplication (laparoscopic and conventional as moderate trauma) groups, and sigmoid colectomy (laparoscopic and conventional
as major trauma) groups. Preoperatively, 1 and 4 days after surgery, IL-6 and MMC against SW948 colon cancer cell line were
determined.
Results: The IL-6 levels differed significantly between the three laparoscopic procedures (p= 0.004) and increased according to the degree of trauma. There was no significant difference in MMC between the three laparoscopic
procedures. However, MMC was suppressed after conventional procedures and preserved after laparoscopic procedures (p= 0.001). There was no correlation between IL-6 levels and changes in MMC.
Conclusions: More extensive laparoscopic procedures induce increased levels of IL-6, reflecting higher levels of trauma. Conventional
surgical procedures result in depressed MMC in the postoperative period. After laparoscopic procedures, MMC is preserved.
These findings may be of importance in preventing implantation and growth of cancer cells spread by surgical manipulation.
Received: 10 December 1998/Accepted: 25 March 1999 相似文献
14.
Background Late complications are rarely encountered after laparoscopic Nissen fundoplication. These complications include acute gastric
herniation through the esophageal hiatus, port-site herniation, recurrent reflux, and anatomic failure of the fundoplication.
Only three cases of late gastric perforation after laparoscopic Nissen fundoplication have been reported, all associated with
intrathoracic wrap herniation.
Methods We retrospectively reviewed all cases of gastric perforation after laparoscopic antireflux procedures performed between July
1991 and March 2002 by a single surgeon.
Results In this series of 1,600 laparoscopic antireflux procedures, we found six delayed gastric fundal perforations occurring in
three patients at 1, 41, 48, 51, 68, and 72 months after surgery. All the perforations were on the anterior wall of the fundus
of the stomach and were distant from the stitches of the fundoplication. None of the perforations was associated with severe
peritoneal contamination.
Conclusions This series of late gastric fundal perforations in 0.2% of our patients after laparoscopic fundoplication may have been caused
by medications, gastric stasis, ischemia, or a foreign body such as a stitch or Teflon pledget. 相似文献
15.
Laparoscopic vs conventional Nissen fundoplication 总被引:18,自引:6,他引:12
Background: Laparoscopic Nissen fundoplication has gained wide acceptance among surgeons, but the results of the laparoscopic procedure
have not been compared to the results of an open fundoplication in a randomized study.
Methods: Some 110 consecutive patients with prolonged symptoms of grade II–IV esophagitis were randomized, 55 to laparoscopic (LAP)
and 55 to an open (OPEN) Nissen fundoplication. Postoperative recovery, complications, and outcome at 3- and 12-month follow-up
were compared in the two groups.
Results: Five LAP operations were converted to open laparotomy due to esophageal perforation (two), technical difficulties (two),
and bleeding (one). In the OPEN group (two) patients underwent splenectomy. There was no mortality. The mean hospital stay
was 3.2 days in the LAP group and 6.4 in the OPEN group. Dysphagia and gas bloating were the most common complaints 3 months
after the operation in both groups. These symptoms had disappeared at the 12-month follow-up examination. All patients in
the LAP group and 86% in the OPEN group were satisfied with the result.
Conclusions: Laparoscopic Nissen fundoplication is a safe and feasible procedure. Complications are few and functional results are good
if not better than those of conventional open surgery.
Received: 15 May 1996/Accepted: 10 September 1996 相似文献
16.
Granderath FA Schweiger UM Kamolz T Asche KU Pointner R 《Archives of surgery (Chicago, Ill. : 1960)》2005,140(1):40-48
BACKGROUND: Postoperative intrathoracic wrap migration is the most frequent morphological complication after laparoscopic antireflux surgery. Previous authors have studied the use of prosthetic materials for hiatal closure to prevent recurrence of hiatal hernia and/or postoperative intrathoracic wrap herniation. HYPOTHESIS: Patients with prosthetic hiatal closure have a higher rate of short-term dysphagia but a significantly lower rate of postoperative intrathoracic wrap herniation at follow-up. DESIGN: Prospective randomized trial. We compared patients who underwent laparoscopic Nissen fundoplication with simple sutured hiatoplasty with those who underwent laparoscopic Nissen fundoplication with prosthetic hiatal closure. SETTING: University-affiliated community hospital. PATIENTS: One hundred consecutive patients undergoing laparoscopic Nissen fundoplication for gastroesophageal reflux disease and hiatal hernia repair. INTERVENTION: Laparoscopic Nissen fundoplication with simple sutured crural closure (n = 50 [group 1]) vs laparoscopic Nissen fundoplication with simple sutured cruroplasty and onlay of a polypropylene mesh (n = 50 [group 2]). MAIN OUTCOME MEASURES: Recurrences; complications; results of esophageal manometry, 24-hour pH monitoring, esophagogastroduodenoscopy, and barium swallow test; and symptomatic outcome. RESULTS: Patients in both groups had similar preoperative values in esophageal manometry, 24-hour pH monitoring, and symptom scoring. At the 3-month and 1-year follow-ups, functional outcome variables (lower esophageal sphincter pressure and DeMeester score) improved significantly compared with the preoperative values. A higher postoperative dysphagia rate could be evaluated in group 2. An intrathoracic wrap migration occurred in 13 patients (26%) in group 1 vs 4 (8%) in group 2 (P<.001). CONCLUSION: Laparoscopic Nissen fundoplication with prosthetic cruroplasty is an effective procedure to reduce the incidence of postoperative hiatal hernia recurrence and intrathoracic wrap herniation. 相似文献
17.
Background: Antireflux operations have been recommended for infants and children suffering from complications related to gastroesophageal
reflux (GER). In recent years, the laparoscopic approach has been used increasingly for antireflux surgery in adult patients.
This is our initial experience with Nissen fundoplication in infants and children under 2 years of age.
Patients: We operated on 11 patients weighing between 3.0 and 10.0 kg. The main indications for surgery were GER-induced aspiration
pneumonia and failure to thrive, in spite of intensive conservative treatment. All patients except one had an associated neurological
abnormality, including six patients with familial dysautonomia.
Results: All attempted operations were completed successfully laparoscopically, with only a few postoperative complications and acceptable
short-term results. The clinical considerations and technical aspects unique to this specific group of patients are discussed.
Conclusion: Laparoscopic Nissen fundoplication is feasible, safe, and effective, even in very small babies.
Received: 16 April 1997/Accepted: 30 June 1997 相似文献
18.
Background: The short esophagus increases the difficulty and limits the effectiveness of laparoscopic Nissen fundoplication. In our experience,
∼20–25% of esophagi judged by preoperative criteria to be foreshortened will, after dissection, be insufficiently long to
allow 2 cm of esophagus to reside below the diaphragm without inferior distraction (i.e., tension free). Collis gastroplasty
combined with Nissen fundoplication has become the standard approach for the creation of an intraabdominal neoesophagus and
fundic wrap.
Methods: After developing methods of performing totally laparoscopic stapled gastroplasty in the cadaver lab in 1994, we started applying
the technique clinically in 1996. We performed 220 laparoscopic antireflux procedures between January 1996 and July 1997.
Of these 220 patients, 26% were suspected to have esophageal foreshortening based on preoperative barium studies and/or endoscopy.
Results: After hiatal dissection, nine patients, or 16% of those suspected to have esophageal foreshortening and 4% of the entire
population, required the laparoscopic Collis-Nissen procedure. There was symptomatic improvement in all patients as assessed
by patient-initiated symptom scores.
Conclusions: The management of patients with esophageal foreshortening is a complex problem. We believe that our technique of laparoscopic
Collis-Nissen provides an effective means of achieving intraabdominal placement of the fundic wrap while maintaining the benefits
of a minimally invasive approach.
Received: 8 September 1997/Accepted: 17 December 1997 相似文献
19.
S. S. Rothenberg D. Bratton G. Larsen R. Deterding H. Milgrom S. Brugman M. Boguniewicz S. Copenhaver C. White J. Wagener L. Fan J. Chang T. Stathos 《Surgical endoscopy》1997,11(11):1088-1090
Background: The relationship between severe reactive airway disease (RAD) and gastroesophageal reflux disease (GERD) has been noted but
the relationship is poorly understood. This study reports our experience with laparoscopic fundoplication and it's effect
on the pulmonary status of children with severe steroid-dependent reactive airway disease.
Methods: Fifty-six patients with severe steroid-dependent RAD and medically refractory GERD underwent laparoscopic Nissen fundoplications.
Mean age was 7 years and mean weight was 20 kg. All patients had the procedure completed successfully laparoscopically with
an average operative time of 62 min. Average hospital stay was 1.6 days.
Results: Forty-eight of 56 patients noted significant improvement in their respiratory symptoms in the first week. Fifty of 56 patients
have been weaned off their oral steroids and four others have had a greater than 50% decrease in their dose. Sixteen patients
had a documented increase in their FEV1 in the initial postoperative period (avg. 26%).
Conclusion: Patients with steroid-dependent RAD and GERD refractory to medical management show improvement in their respiratory status
following fundoplication and the majority can be weaned off of their oral steroids. Laparoscopic techniques allow this procedure
to be performed safely even in this high-risk group of patients.
Received: 25 March 1997/Accepted: 5 July 1997 相似文献
20.
The influence of surgical technique on clinical outcome of laparoscopic Nissen fundoplication 总被引:1,自引:0,他引:1
Background: During laparoscopic Nissen fundoplication (LNF), it is unclear whether the short gastric vessels (SGV) should be divided,
the crura reapproximated, or the wrap sutured to the crus.
Methods: Since first performing LNF, we have consistently utilized a <2.5-cm wrap performed over a >50 Fr dilator. Other technical
details have varied, and these are reviewed in terms of early clinical outcome. Of 105 consecutive patients undergoing LNF,
two were converted to open operation (2%). In the remaining 103 patients with ≥3-month follow-up (mean 17 months), the initial
46 (group 1; 45%, mean age ± SEM = 47 ± 2 years) had selective division of the SGV, crural closure, and wrap fixation. In this group, 32 patients (70%) underwent SGV division, 30 patients
(65%) had crural closure (10 anteriorly/20 posteriorly), and 14 patients (30%) had the wrap sutured to the crus. During the
subsequent 57 LNFs (group 2; 55%, 47 ± 2 years), all patients underwent SGV division, posterior crural closure, and suture
of the wrap to the crus.
Results: Clinical outcome at ≥3 months was compared between the two groups. The frequencies of mild reflux symptoms, meteorism, and
persistent dysphagia were similar in the two groups. However, the incidences of slippage of the wrap into the chest and the
need for secondary intervention (esophageal dilatation and/or laparoscopic reoperation) decreased significantly from 15% and
13% of patients in group 1, respectively, to no occurrences in group II. Chi-square analyses revealed that combinations of
these technical variables were significantly related to the improved outcome in group II.
Conclusion: Based on these data demonstrating improved clinical outcome, we recommend routine division of the SGV, posterior closure
of the crura, and fixation of the wrap to the crus during LNF.
Received: 28 March 1996/Accepted: 11 June 1996 相似文献