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1.
Laparoscopic gastrostomy as an adjunctive procedure to laparoscopic fundoplication in children 总被引:2,自引:0,他引:2
Infants and children requiring fundoplication for gastroesophageal reflux frequently have significant associated medical
problems necessitating placement of a gastrostomy at the time of fundoplication. This article reviews the techniques, complications,
and results of 141 laparoscopic Stamm gastrostomies performed in conjunction with laparoscopic fundoplication in infants and
children. The three techniques employed were the T-fastener technique (63/141) which is best utilized in patients with thick abdominal walls; the trocar-site technique (53/141) which is technically easy to perform but prone to infection and fistula formation; and the U-stitch technique (26/141). General complications of laparoscopic gastrostomy include development of gastrocutaneous fistulae (2/141), perigastrostomy
cellulitis (8/141), and the formation of granulation tissue at the gastrostomy site (45/141). The only perioperative death
was due to a technical error during gastrostomy tube placement. Our preferred method for laparoscopic gastrostomy in most
children is the U-stitch technique.
Received: 19 March 1996/Accepted: 8 May 1996 相似文献
2.
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
3.
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
4.
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
5.
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
6.
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
7.
D. D. Coster W. H. Bower V. T. Wilson R. T. Brebrick G. L. Richardson 《Surgical endoscopy》1997,11(6):625-631
Background: Since 1992, all patients at our institution who have met standard accepted criteria for surgical intervention for complicated
gastroesophageal reflux disease have been entered into a prospective sequential clinical study to evaluate outcomes of the
laparoscopic approach to the Nissen-Rosetti procedure and a modified Toupet procedure.
Methods: A standardized workup with upper GI series, esophagography, and endoscopy was used in all patients. Manometry, pH testing,
and other special tests were used selectively. A measuring technique was used to determine wrap size without the use of dilators.
The short gastric vessels were left intact in all patients. A cosurgeon approach was used, with technical factors described
herein.
Results: Some 226 of 231 cases were completed laparoscopically (98%)—125 patients in the Nissen-Rosetti group and 101 in the partial
fundoplication group. There were no clinical failures in either group. The partial fundoplication group performed better than
the Nissen-Rosetti group in all categories of comparison. Return to normal eating habits was much earlier in the partial wrap
group (p < 0.0001). Postop distal esophageal sphincter pressures in the two groups were equal at 15 mmHg. Eight patients suffered
significant dysphagia requiring endoscopy and dilatation, all in the Nissen-Rosetti group (p < 0.01). Minor complications occurred in 12% of the total group. There was a total surgical revision rate of 3%. There were
no gastric or esophageal perforations. Average operative time was 30 min. Average hospital stay was 1.4 days. Hospital charges
for the laparoscopic approach averaged $6,000 dollars compared to $12,000 for the open approach.
Conclusion: Laparoscopic partial fundoplication is as effective as laparoscopic Nissen-Rosetti fundoplication, with a higher satisfaction
rate and fewer side effects. Measuring for wrap and hiatus size eliminates the need for and risk of using stiff dilators.
By utilizing cosurgeons and currently available technology, cost, operative time, hospital time, and complications can be
reduced to a finite minimum.
Received: 12 December 1995/Accepted: 12 August 1996 相似文献
8.
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
9.
Prosthetic reinforcement of posterior cruroplasty during laparoscopic hiatal herniorrhaphy 总被引:1,自引:2,他引:1
Symptomatic gastroesophageal reflux after Nissen fundoplication may occur if the wrap herniates into the thorax. In an attempt
to prevent recurrent hiatal hernia we employed polytetrafluoroethylene (PTFE) mesh reinforcement of posterior cruroplasty
during laparoscopic Nissen fundoplication and hiatal herniorrhaphy. Three patients with symptomatic gastroesophageal reflux
and a large (≥8 cm) hiatal defect underwent laparoscopic posterior cruroplasty and Nissen fundoplication. The cruroplasty
was reinforced with a PTFE onlay. No perioperative complications occurred, and in follow-up (≤11 months) the patients are
doing well. When repairing a large defect of the esophageal hiatus during fundoplication, the surgeon may consider reinforcement
of the repair with PTFE mesh.
Received: 5 March 1996/Accepted: 3 June 1996 相似文献
10.
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
11.
Awad ZT Filipi CJ Mittal SK Roth TA Marsh RE Shiino Y Tomonaga T 《Surgical endoscopy》2000,14(5):508-512
Laparoscopic antireflux surgery is the procedure of choice for gastroesophageal reflux disease (GERD). However, many clinicians
have reservations about its application in patients with complicated GERD, notably those with esophageal shortening. In this
report, we present our experience with the laparoscopic management of the shortened esophagus. A total of 235 patients with
primary GERD underwent laparoscopic antireflux procedures, 38 of whom were suspected preoperatively to have a shortened esophagus.
Of the 235 patients, 8 (3.4%) needed a left thoracoscopically assisted gastroplasty in addition to laparoscopic Toupet repair
(n= 4) or Nissen fundoplication (n= 4). Complications included pleural effusion (n= 1), pneumothorax (n= 2), and minor atelectasis (n= 1). The average hospital stay was 3 days. Results were satisfactory in 7 of 8 patients, with a mean follow-up of 20.2 months
(range, 9–34 months). The surgical management of the shortened esophagus is difficult. However, the role of minimally invasive
techniques is justified. Early results are appealing, with less morbidity, satisfactory control of GERD related symptoms,
and a shortened hospital stay.
Received: 3 August 1999/Accepted: 10 November 1999/Online publication: 17 April 2000 相似文献
12.
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
13.
E. Eypasch E. Neugebauer F. Fischer H. Troidl A. L. Blum D. Collet A. Cuschieri B. Dallemagne H. Feussner K.-H. Fuchs H. Glise C. K. Kum T. Lerut L. Lundell H. E. Myrvold A. Peracchia H. Petersen J. J. B. van Lanschot 《Surgical endoscopy》1997,11(5):413-426
Background: Laparoscopic antireflux surgery is currently a growing field in endoscopic surgery. The purpose of the Consensus Development
Conference was to summarize the state of the art of laparoscopic antireflux operations in June 1996.
Methods: Thirteen internationally known experts in gastroesophageal reflux disease were contacted by the conference organization team
and asked to participate in a Consensus Development Conference. Selection of the experts was based on clinical expertise,
academic activity, community influence, and geographical location. According to the criteria for technology assessment, the
experts had to weigh the current evidence on the basis of published results in the literature. A preconsensus document was
prepared and distributed by the conference organization team. During the E.A.E.S. conference, a consensus document was prepared
in three phases: closed discussion in the expert group, public discussion during the conference, and final closed discussion
by the experts.
Results: Consensus statements were achieved on various aspects of gastroesophageal reflux disease and current laparoscopic treatment
with respect to indication for operation, technical details of laparoscopic procedures, failure of operative treatment, and
complete postoperative follow-up evaluation. The strength of evidence in favor of laparoscopic antireflux procedures was based
mainly on type II studies. A majority of the experts (6/10) concluded in an overall assessment that laparoscopic antireflux
procedures were better than open procedures.
Conclusions: Further detailed studies in the future with careful outcome assessment are necessary to underline the consensus that laparoscopic
antireflux operations can be recommended.
Received: 29 November 1996/Accepted: 14 December 1996 相似文献
14.
The value of 24-h pH study in evaluating the results of laparoscopic antireflux surgery in children 总被引:4,自引:0,他引:4
Background: The performance of laparoscopic antireflux surgery is steadily increasing among pediatric surgeons. Different techniques
are being used. However, due to a lack of standardized follow-up methods, postoperative results are difficult to compare.
In this study, we describe the results of postoperative 24-h pH study as an objective criterion for evaluating the results
of laparoscopic Thal antireflux surgery.
Methods: In a prospective study, 53 patients underwent a laparoscopic Thal procedure. Preoperatively, all patients were subjected
to 24-h pH monitoring, an upper GI series, and esophagogastroscopy. pH monitoring was performed 3 months postoperatively to
evaluate the effect of the fundoplication. Esophagogastroscopy was repeated in case of preoperative esophagitis.
Results: In one patient, the laparoscopy was converted to an open procedure. Feeding was commenced on day 1 in 49 of the 53 children.
Mean hospitalization time was 4.4 days. One patient was reoperated for a too-tight fundoplication, and two patients died of
unrelated causes. Ultimately, 44 of 50 children (88%) were free of symptoms; however, 11 of 41 children (25%) still displayed
pathological reflux on pH monitoring.
Conclusions: The Thal fundoplication can be performed laparoscopically in children. Children have a quick recovery, and hospitalization
is short (4.4 days). At follow-up, nearly 90% of the children are free of symptoms. However, 25% still have pathological reflux
as measured with pH monitoring. Therefore, questionnaires alone are not a sufficient means of measuring outcome postoperative.
pH monitoring is a valuable additional tool for the objective postoperative evaluation of the results of (laparoscopic) antireflux
procedures.
Received: 9 July 1998/Accepted: 6 October 1998 相似文献
15.
First results of laparoscopic gastrostomy 总被引:2,自引:1,他引:1
Background: Laparoscopic gastrostomy as an alternative to open gastrostomy was introduced with various technical variants 5 years ago.
However, long-term results of these new methods are still lacking.
Methods: From 4/1993 to 2/1996, laparoscopic gastrostomies were performed on 42 patients (50.9 ± 15.6 [24–71] years) with esophageal
stenosis in locally advanced hypopharyngeal (17 patients) or oropharyngeal (nine patients) carcinoma, incurable esophageal
carcinoma (13 patients) and cerebral dyspagia (three patients). Operating time was 38 ± 11 min [15–65 min]. Procedure-related
mortality was 0%. Major complications occurred in 2/42 (4.7%) patients; minor complications were found in 4/42 (9.4%) patients.
During a total usage time of 427 months, 14 stoma infections occurred (0.11 infections/100 days).
Conclusion: Laparoscopic gastrostomy allows a safe, fast, and cheap reestablishment of enteral nutrition. The procedure is minimally
invasive and can also be performed under local anesthesia. It has become our method of choice in patients with malignant,
nonresectable subtotal stenosis of the hypopharynx or esophagus.
Received: 5 March 1996/Accepted: 31 July 1996 相似文献
16.
Evaluation of laparoscopic Toupet fundoplication as a primary repair for all patients with medically resistant gastroesophageal reflux 总被引:5,自引:2,他引:3
Background: This prospective study assesses the outcome results in 100 consecutive patients with gastroesophageal reflux disease (GERD)
treated with a laparoscopic Toupet fundoplication.
Methods: GERD was confirmed by 24-h pH study and/or esophagogastroduodenoscopy (EGD). Pre- and postoperative symptoms, operative times,
and perioperative complications were recorded on standardized data forms. Early follow-up was at 3 months and late follow-up,
including 24-h pH, manometry, and EGD was at 22 months.
Results: Preoperative symptoms included heartburn (92%), regurgitation (58%), water brash (39%), and dysphagia (39%). Mean operative
time was 3.2 hours. There were no conversions to celiotomy and there were no mortalities. The perioperative complication rate
was 14%; 6% (5/83) of patients reported heartburn at 3 months and 20% (15/74) at 22 months. Early and late dysphagia was 20%
(17/83) and 9% (7/74), respectively; 24-h pH testing was abnormal in 90% of symptomatic patients (9/10), 39% of asymptomatic
patients (12/31), and 51% overall.
Conclusions: Despite early improvement in reflux symptoms following laparoscopic Toupet fundoplications, there is a high incidence of
recurrent GERD. Symptomatic follow-up underestimates the true incidence of 24-h pH-documented reflux. Based on these results
we cannot recommend the laparoscopic Toupet repair for GERD patients with normal esophageal motility.
Received: 24 March 1997/Accepted: 28 May 1997 相似文献
17.
W. O. Richards R. H. Clements P. C. Wang C. D. Lind H. Mertz J. K. Ladipo M. D. Holzman K. W. Sharp 《Surgical endoscopy》1999,13(10):1010-1014
Background: There is still some controversy over the need for antireflux procedures with Heller myotomy in the treatment of achalasia.
This study was undertaken in an effort to clarify this question.
Methods: To determine whether Heller myotomy alone would cause significant gastroesophageal reflux (GER), we studied 16 patients who
had undergone laparoscopic Heller myotomy without concomitant antireflux procedures. Patients were asked to return for esophageal
manometry and 24-h pH studies after giving informed consent for the Institutional Review Board (IRB)-approved study at a median
follow-up time of 8.3 months (range, 3–51). Results are expressed as the mean ± SEM.
Results: Fourteen of the 16 patients reported good to excellent relief of dysphagia after myotomy. They were subsequently studied
with a 24-h pH probe and esophageal manometry. These 14 patients had a significant fall in lower esophageal sphincter (LES)
pressure from 41.4 ± 4.2 mmHg to 14.2 ± 1.3 mmHg, after the myotomy (p < 0.01, Student's t-test). The two patients who reported more dysphagia postoperatively had LES pressures of 20 and 25 mmHg, respectively. Two
of 14 patients had DeMeester scores of >22 (scores = 61.8, 29.4), while only one patient had a pathologic total time of reflux
(percent time of reflux, 8%). The mean percent time of reflux in the other 13 patients was 1.9 ± 0.6% (range, 0.1–4%), and
the mean DeMeester score was 11.7 ± 4.6 (range, 0.48–19.7).
Conclusions: Laparoscopic Heller myotomy is effective for the relief of dysphagia in achalasia if the myotomy lowers the LES pressure
to <17 mmHg. If performed without dissection of the entire esophagus, the laparoscopic Heller myotomy does not create significant
GER in the postoperative period. Clearance of acid refluxate from the aperistaltic esophagus is an important component of
the pathologic gastroesophageal reflux disease (GERD) seen after Heller myotomy for achalasia. Furthermore, GERD symptoms
do not correlate with objective measurement of GE reflux in patients with achalasia. Objective measurement of GERD with 24
h pH probes may be indicated to identify those patients with pathologic acid reflux who need additional medical treatment.
Received: 12 May 1998/Accepted: 15 December 1998 相似文献
18.
Immediate and delayed effects of laparoscopic Nissen fundoplication on pulmonary function 总被引:1,自引:1,他引:0
Background: An effort was made to assess the respiratory outcomes of laparoscopic Nissen fundoplication (LNF).
Methods: Prospective follow-up of 69 patients undergoing LNF for gastroesophageal reflux disease. Outcomes included pulmonary function
testing, 24-h pH recording, esophageal manometry, and symptom assessment.
Results: There was an improvement (p < 0.0001) in heartburn and cough scores. There was a significant fall in spirometry (p < 0001), diffusing capacity (p < 0.0001), and respiratory muscle strength (p < 0.0001) 36 h after surgery, which had returned to baseline by 1 month. At 6 months, the patients (n= 16) with impaired preoperative diffusing capacity showed improvement (17.8 ± 3.7 to 19.8 ± 4.6 ml/min/mmHg, p= 0.0245).
Conclusion: Patients undergoing LNF have impaired gas exchange before surgery which tends to improve 6 months after surgery. There is
an early reversible impairment in respiratory function due to diaphragm dysfunction. Patients with a preoperative 1-s forced
expired volume > 1.5, or 50% predicted, are unlikely to develop signficant early respiratory complication.
Received: 22 April 1996/Accepted: 9 July 1996 相似文献
19.
R. Rosati U. Fumagalli S. Bona L. Bonavina M. Pagani A. Peracchia 《Surgical endoscopy》1998,12(3):270-273
Background: Extramucosal myotomy of the lower esophagus and cardia, combined with anterior fundoplication, is, in our opinion, the procedure
of choice to treat stage I–III esophageal achalasia.
Methods: After a successful experience with open surgery in over 280 patients, from January 1992 through February 1997, 61 patients
underwent laparoscopic Heller-Dor for stage I–III achalasia. Conversion to laparotomy was done in three cases. All procedures
were performed under intraoperative endoscopic control. Intraoperative complications were seven mucosal tears, which were
sutured laparoscopically in five cases. The sole postoperative complication was bleeding from an acute gastric ulcer (conservative
treatment).
Results: Follow-up consisted of clinical and radiographic study 1 month after surgery, and endoscopy and manometry within 1 year.
After a mean follow-up (F.U.) of 21 months (1–62), clinical results range from excellent to good in 98.2%. One patient (1.7%)
complaining of recurrent dysphagia improved after endoscopic dilation. Esophageal diameter reduced from 52 to 27 mm. LES pressure
reduced from 30.3 ± 12.4 to 10.7 ± 3.5 mmHg (basal) and from 14.8 ± 9.3 to 2.9 ± 2.1 mmHg (residual).
Conclusions: Laparoscopic Heller-Dor operation is feasible, safe, and effective. Special care should be taken in patients with previous
endoscopic dilations.
Received: 3 April 1997/Accepted: 28 July 1997 相似文献
20.
Laparoscopic esophagomyotomy with posterior partial fundoplication for primary esophageal motility disorders 总被引:2,自引:0,他引:2
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 相似文献