腹腔镜下胃底Nissen折叠术式治疗的食管裂孔疝临床应用

目的探讨使用腹腔镜行食管裂孔疝修补术的安全性和疗效评价。方法对38例食管裂孔疝患者使用腹腔镜行食管裂孔疝修补术,做胃底360°折叠术(Nissen术),9例应用补片修补疝缺口,29例采用7号丝线缝合。结果38例腹腔镜食管裂孔疝修补术全部获得成功。手术时间30～190min,平均手术时间110min,失血10～50ml;术后24～48h进流质饮食,无术后并发症;术后平均住院5.7d。结论腹腔镜下胃底Nissen折叠术式具有疗效好、安全和创伤小的优点。值得进一步推广应用。     

腹腔镜Nissen胃底折叠术治疗胃食管反流病

目的 探讨腹腔镜Nissen胃底折叠术治疗胃食管反流病的效果.方法 对近2年来收治的109例胃食管反流病实施腹腔镜Nissen胃底折叠术患者的临床资料进行回顾性分析.结果 108例成功完成手术.1例因难以控制的脾上极胃短血管出血而中转开腹.手术用时30-245(平均68.1)min,术中出血5～450(平均30.0)mL;术后住院天数2～8(平均4.2)天.术后102例获3～27个月的随访,7例失访.随访患者中99例(97.1%)反酸、烧心等消化道症状基本消失,2例(2.0%)明显缓解,1例(0.9%)无效.术后2例出现较严重的吞咽困难,1例严重上腹胀气,2例腹泻,1例出现术后食管裂孔疝.结论 腹腔镜Nissen胃底折叠术是治疗胃食管反流病的一种微创、安全、有效的治疗方法.     

腹腔镜疝修补术结合Nissen胃底折叠术治疗胃食管反流合并食管裂孔疝的疗效

目的分析腹腔镜疝修补术结合Nissen胃底折叠术治疗胃食管反流合并食管裂孔疝患者的临床疗效观察。 方法选择内蒙古包钢医院2019年7月至2020年5月就诊的80例胃食管反流合并食管裂孔疝患者,按不同手术方式分为A组和B组,每组患者40例。A组采用腹腔镜疝修补术+Nissen胃底折叠术,B组采用腹腔镜疝修补术+Dor胃底折叠术。比较2组患者手术情况、食管反流情况、食管压力、消化病生存质量指数（GLQI）评分、胃食管反流病疗效评分（GERD-Q）、复发率以及不良反应情况。 结果2组患者手术情况差异均无统计学意义（P>0.05）;术后3个月,反流时间、次数,长反流次数、酸反流时间百分比明显改善,且A组改善幅度更明显（P<0.05）;食管残余压平均值、下段括约肌压力、松弛率和无效吞咽率均明显改善,且A组改善情况优于B组（P<0.05）;2组患者GLQI与GERD-Q评分均有所改善,且A组GLQI评分高于B组,GERD-Q评分低于B组（P<0.05）;2组不良反应和复发率比较差异无统计学意义（P>0.05）。 结论腹腔镜疝修补术联合Nissen胃底折叠术对抗反流,减轻术后吞咽困难具有明显效果,有效改善患者生活质量和食管下括约肌压力安全有效。     

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。     

腹腔镜Nissen胃底折叠术治疗老年胃食管反流病

目的:对比腹腔镜Nissen 胃底折叠术在老年组和非老年组胃食管反流病(GERD)的疗效,评价其在老年人应用的可行性.方法:回顾分析因GERD行腹腔镜Nissen胃底折叠术治疗的老年病人28例,随机选取同时期非老年GERD病人40例作为对照组,分析不同年龄组患者的治疗效果.结果:术后两组症状完全消失.食管下段压力由(8.8±2.6)mmHg(1mmHg =0.133 kPa)提高到(18.23±3.6)mmHg(P＜ 0.01),24 h pH值检测评分由105.4±3.7降低到8.12±2.1(P＜ 0.01),较术前明显改善,并达到正常范围.平均随访4.5年,非老年组症状复发2例,老年组1例.远期吞咽困难老年组发生8例,非老年组为1例,差异有统计学意义(P＜ 0.05).结论:在老年GERD病人中实施腹腔镜Nissen 胃底折叠术与在非老年病人中实施一样安全、有效,但远期吞咽困难发生率较非老年人为高.     

腹腔镜Nissen胃底折叠术治疗胃食管返流病的长期效果

目的:评价腹腔镜Nissen胃底折叠术(laparoscopic Nissen fundoplication,LNF)治疗胃食管返流病的长期效果。方法:从MEDLINE、EMBASE、中国生物医学数据库(CBM)及Cochrane试验注册中心检索纳入了1991年到2007年10月发表的LNF治疗返流性食管炎的随机对照实验,并对纳入研究的方法学质量(随机方法、分配隐藏、盲法)进行评价,最后用Rev-Man4.2.9软件进行分析。结果:纳入4个随机对照实验(RCT),包括440例患者,纳入随访研究共387例。术后主观结果如满意度[OR0.5095%CI(0.25,1.00)]、术后抑酸药物的使用[OR0.4595%CI(0.08,2.53)]、返酸和烧心症状差异无统计学意义,吞咽困难LNF发生率高于传统胃底折叠术(conventional Nissen fundoplicationm,CNF)[OR4.1695%CI(1.51,11.50)]。客观结果如再手术率[OR1.7795%CI0.78,4.72)]、食管测压和24h pH检测两组间差异无统计学意义。结论:本研究中LNF治疗胃食管返流病的长期效果和传统胃底折叠术差异无统计学意义,但LNF术后吞咽困难发生率可能较高。     

腹腔镜Nissen胃底折叠术联合胃大弯袖状切除术

手术要点：距幽门3—5cm处起,以超声刀贴胃壁分离大网膜,向上至贲门左侧His角。打开胃小弯上部小网膜,剔除贲门前肥厚脂肪垫,游离两侧膈肌脚根部,游离腹段食管,修补扩大的食管裂孔2—3针。胃镜引导下,用腔镜专用直线切割闭合器沿胃大弯侧距幽门4～6cm处开始向胃底方向连续切割闭合,鱼鳍状保留胃底,切除胃大弯侧3／5。残胃腔内胃镜注气,胃切缘外喷水检查有无漏气,以除外胃切缘漏。两个相邻钉仓切缘间以及有出血处以3-0可吸收线缝合加固。牵拉保留的胃底从食管后方绕过行改良Nissen法折叠,即将绕过食管后方的左侧胃底与右侧胃底前壁缝合2～3针,完成食管周围的360°折叠,并将胃底缝合固定于右侧膈肌脚2～3针。     

腹腔镜Toupet胃底折叠术治疗食管裂孔疝合并胃食管反流病的临床疗效

目的探讨腹腔镜Toupet胃底折叠术治疗食管裂孔疝合并胃食管反流病的临床疗效。 方法选取2012年1月至2018年6月,吉林大学第二医院就诊的80例食管裂孔疝合并胃食管反流病患者为研究对象。依据患者具体状况行不同类型的疝修补术,所有患者均行腹腔镜Toupet胃底折叠术。于术后统计患者手术效果及反流情况,观察手术前后食管压变化。 结果与术前相比,术后6个月患者反流时间显著缩短、反流次数与长反流次数显著减少、酸反流时间百分比显著下降,差异均有统计学意义（P<0.05）。与术前相比,术后6个月患者DeMeester及GERDQ评分均显著下降,差异均有统计学意义（P<0.05）。与术前比较,术后6个月患者LES压力、残余压均显著升高,松弛率显著下降,差异均有统计学意义（P<0.05）。 结论腹腔镜Toupet胃底折叠术治疗食管裂孔疝合并胃食管反流病可有效增加食管压力,抑制患者反流症状,疗效良好,值得推广应用。     

Day-case laparoscopic Nissen fundoplication

Introduction:

For day-case laparoscopic surgery to be successful, patient selection is of the utmost importance. This study aimed to assess the feasibility of day-case laparoscopic Nissen fundoplication and to identify factors that may lead to readmission and overstay.

Methods:

A retrospective review of all patients who underwent day-case laparoscopic Nissen fundoplication over a 4-year period (2006 through 2010) was undertaken. Patient age, social circumstances, and other demographics were recorded as well as any comorbidities and ASA score. The primary endpoint measured was rate of readmission and overstay.

Results:

A total of 72 patients fulfilled the inclusion criteria for day-case surgery. Five patients (6.94%) required admission immediately following the procedure, ie, overstayed or were readmitted. The rates were 1.38% (P=.05, CI 95%) for readmission and 5.55% (P=.05, CI 95%) for overstay. Six (8.33%) patients were classified as ASA III, and 3 (50%) were readmitted or overstayed.

Conclusion:

Day-case laparoscopic Nissen fundoplication is a feasible, safe option. The authors conclude that ASA score of III and increasing age correlate with an increasing incidence of overstay and readmission. Therefore, we would recommend the use of integrated pathways and advanced planning to reduce these rates.     

Causes of long-term dysphagia after laparoscopic Nissen fundoplication.

BACKGROUND: Laparoscopic fundoplication has revolutionized the surgical treatment of gastroesophageal reflux disease. Despite improvements in the technique of fundoplication, persistent dysphagia remains a significant cause of postoperative morbidity. METHOD: Causes of persistent postoperative dysphagia were analyzed in a consecutive series of 167 patients after laparoscopic Nissen fundoplication. Short gastric vessel division and its effect on postoperative dysphagia were analyzed. RESULTS: Follow-up was possible in 139 patients (83%). The mean follow-up period was 27 +/- 21 months. Nine patients (6%) had persistent (moderate to severe) dysphagia, and 33 patients (24%) had mild dysphagia. The satisfaction score among patients with persistent dysphagia was significantly lower than that in patients with mild dysphagia (P < 0.0002). On the other hand, the satisfaction rate among patients with mild dysphagia and those who are asymptomatic was similar. Manometry, performed in 7 of 9 persistent dysphagia patients revealed no difference in postoperative lower esophagus sphincter (LES) pressure and relaxation as compared with that in the control group (n = 52). Six of 9 patients with persistent dysphagia underwent a re-do antireflux procedure. Dysphagia as related to fundic mobilization (complete vs. partial) or bougie size (< 58 Fr. vs. > or = 58 Fr.) revealed no difference in the dysphagia ratings. CONCLUSIONS: Laparoscopic short Nissen fundoplication with or without fundic mobilization achieved an acceptable long-term dysphagia rate. Careful patient selection, identification of the short esophagus, and accurate construction of the fundoplication can lead to a decrease in the incidence of persistent postoperative dysphagia.     

Effects of laparoscopic Nissen fundoplication on esophageal motility

Background This study aimed to evaluate the long-term impact of laparoscopic Nissen fundoplication on esophageal motility in patients with preoperative esophageal dysmotility. Methods This study prospectively followed 580 patients who underwent laparoscopic Nissen fundoplication between 1992 and 1999. Esophageal manometry, 24-h pH monitoring, and symptom score assessment were performed before surgery, then 6 months, 2 years, and 5 years after surgery. Preoperatively, 533 of the patients (93.5%) had normal esophageal contractile pressure (group 1), whereas 38 of the patients (6.5%) had reduced contractile pressure (<30 mmHg) (group 2). Results Esophageal contractile pressures increased significantly in the patients with low preoperative values, whereas it remained unchanged in the patients with normal preoperative contractile pressures. Both groups reported a significant reduction in the dysphagia symptom score after surgery. Conclusion Nissen fundoplication produces a significant long-lasting increase in esophageal contractile pressures in patients with preoperative esophageal dysmotility (i.e., contractile pressure lower than 30 mmHg). Preoperative esophageal dysmotility is therefore not a contraindication to laparoscopic Nissen fundoplication. Presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) meeting, Fort Lauderdale, FL, 13–16 April 2005     

Dumping syndrome as a complication of laparoscopic Nissen fundoplication in an adult.

BACKGROUND: Dumping syndrome is a recognized complication of various gastric surgical procedures, such as vagotomy, pyloroplasty, and gastrojejunostomy. However, it has not to date been reported following laparoscopic Nissen fundoplication in adults. CASE REPORT: We describe the case of a 34-year-old woman who developed late dumping syndrome following an uneventful laparoscopic Nissen fundoplication for gastroesophageal reflux disease. CONCLUSION: This condition should be considered in patients who develop hypoglycemic symptoms following laparoscopic fundoplication.     

Day-case laparoscopic Nissen fundoplication

Introduction   Nissen fundoplication has been performed laparoscopically for over 15 years, being associated with shorter hospital stay and fewer complications than conventional open surgery with good long-term outcomes. Day-case laparoscopic Nissen fundoplication (LNF) is rarely performed in the UK and most series in the literature report length of stay >2 days. Methods   The objective of this study was to examine the safety and efficacy of day-case LNF. The clinical records of all patients undergoing LNF under the care of three surgeons in a district general hospital (DGH) during a 5-year period (January 2003 to December 2007) were reviewed to examine length of stay, complications, length of procedure, grade of operating surgeon and symptoms on follow-up. Results   One hundred thirteen day-case LNFs were recorded in this series. Day-case LNF patients had median age of 45 years (range 20–68 years, 65% (64.6%) male) and 98% were American Society of Anesthesiologists (ASA) grade I or II. Twenty-one cases (19%) were performed by higher surgical trainees. Median operative time was 54 minnutes (range 25–120 min). Only one perioperative complication (port-site bleed) occurred, treated without prolonging length of stay. The proportion of all LNF performed as day cases increased from 8% to 52% during the study period. Median operative time has significantly reduced from the first 20 consecutive LNF cases to the latest 20 cases [65 min (range 40–120 min) versus 48 min (range 25–72 min); p = 0.037]. At follow-up (median 7 weeks, range 2–31 weeks) 82% of patients had improvement in all presenting symptoms. Eight patients had postoperative complications [wound infection (n = 2), persistent regurgitation requiring laparoscopic division of a gastric band adhesion (n = 1), dysphagia (n = 5 with two patients requiring redo partial fundoplication and one patient requiring dilatation) and there were no conversions to open surgery. Conclusion   Day-case LNF is safe and effective for treating selected patients with gastroesophageal reflux disease (GERD) in a DGH. The proportion of day-case LNFs is increasing in our unit. Half of the LNFs in a DGH can be done as day cases. Experience is associated with a significant reduction in operative time.     

腹腔镜Nissen胃底折叠术对胃食管反流病患者食管动力学的影响

目的通过食管高分辨率测压（high resolution manometry,HRM）对比胃食管反流病（gastroesophageal reflux disease,GERD）患者腹腔镜下Nissen胃底折叠术（laparoscopic Nissen fundoplication,LNF）前后食管动力学的改变情况,探讨手术的抗反流原理。 方法选取2014年6月至2016年7月,火箭军总医院73例连续住院的GERD患者,LNF术前1周内行包括HRM在内一系列术前评估,术后GERD症状明显缓解且吞咽困难等并发症已经消失时复查HRM。对手术前后2次HRM的9个食管动力学参数进行对比分析,并按术前是否存在食管裂孔疝进一步分组分析。 结果术后患者食管长度平均延长了（0.43±1.72）cm,腹腔内下食管括约肌长度平均延长了（1.20± 0.94）cm,术后患者下食管括约肌静息压平均增加了（5.99±7.79）mmHg（1 mmHg=0.133 kPa）,综合松弛压平均增加了（3.41±5.43）mmHg;远端收缩分数平均增加了（157.26±596.01）mmHg·s·cm,远端收缩延迟时间平均增加了（0.93±2.30）s;上述6个动力学参数与术前比较差异均有统计学意义（P=0.04,<0.01,<0.01,<0.01,0.03,<0.01）。而术后下食管括约肌长度、食管上括约肌压力和收缩前沿速度与术前相比差异无统计学意义（P=0.83,0.43,0.73）。食管长度、下食管括约肌长度和远端收缩分数在食管裂孔疝患者中较无食管裂孔疝患者改善更为显著（P<0.01,<0.01,<0.01）。 结论LNF主要通过延长腹腔内食管长度,增强下食管括约压力,增强食管的廓清功能,从而到达有效的抗反流作用。其中合并食管裂孔疝的患者较无食管裂孔疝患者术后上述食管动力学改善更为显著。     

The respiratory advantage of laparoscopic Nissen fundoplication

Background/purpose

Laparoscopic Nissen fundoplication is replacing the open approach in the treatment of children with gastroesophageal reflux. The postoperative respiratory advantages seem obvious but remain unproven. The authors hypothesized that laparoscopic Nissen fundoplication provides postoperative respiratory advantages in neurologically normal children as well as those with mental retardation or profound neurologic impairment.

Methods

The charts of all laparoscopic Nissen fundoplications over a 4-year period were reviewed. Sixty-one laparoscopic procedures were compared with the most recent 61 consecutive open Nissen fundoplications. The following variables were reviewed: age, weight, gender, preexisting comorbidities, operating time, postoperative pulmonary complications, and length of stay. Categorical data were compared for significance utilizing χ² cross tabulation. Variables representing numerical data were compared by t test.

Results

Although there appeared to be a trend toward sicker patients in the open group, the laparoscopic group showed significantly improved rates of extubation, shorter recovery room stays, shorter durations of chest physiotherapy, fewer intensive care unit admissions, more rapid resumption of baseline feedings, and overall decreased length of stay (P < 0.05). Pulmonary benefits also were noted in the neurologically impaired population when analyzed separately.

Conclusions

Laparoscopic Nissen fundoplication confers a definable benefit with a significant pulmonary advantage in both neurologically normal children and those with neurologic impairment.     

Postoperative chylous ascites: a rare complication of laparoscopic Nissen fundoplication.

The accumulation of chylous fluid in the abdominal cavity is an infrequent, yet alarming, complication in abdominal surgery. Laparoscopic fundoplication has assumed a central role in the surgical treatment of gastroesophageal reflux disease and is significantly altering the balance of therapy toward more common and earlier surgical intervention. We report the case of a 67-year-old woman with gastroesophageal reflux disease and intense esophagitis who underwent a laparoscopic Nissen fundoplication in February 2000. The procedure was performed without apparent complications. Twenty days later, the patient complained of abdominal pain and distension. Ultrasonography showed ascites, whereas endoscopic and radiological exploration of the fundoplication demonstrated no abnormalities. A paracentesis was performed, which showed a milky fluid with high concentrations of triglycerides (1024 ng/dL) and cholesterol (241 ng/dL). The patient was treated successfully with total parenteral nutrition for 3 weeks, followed by a low-fat diet. To our knowledge, this is the third reported case of chylous ascites after a Nissen fundoplication and the second case after laparoscopic fundoplication. The development of chylous ascites seems to be related to the injury of lymphatic vessels, including the thoracic duct, during the retroesophageal window dissection. The careful dissection and judicious use of diathermy is proposed to prevent this rare complication.     

The accuracy of gastric insufflation in testing for gastroesophageal perforations during laparoscopic Nissen fundoplication.

BACKGROUND: Laparoscopic Nissen fundoplication is an effective technique for the symptomatic relief of the manifestations of gastroesophageal reflux disorder but is associated with a 0.8-1% rate of gastroesophageal perforation. Early detection and repair of these injuries is critical to patient outcome, but occult injuries occur and may be missed. Gastric insufflation technique evaluates the integrity of the gastroesophageal wall after laparoscopic Nissen fundoplication. Gastric insufflation technique involves occlusion of the proximal stomach with a noncrushing bowel clamp while insufflating the submerged gastroesophageal junction. We conducted an animal study to assess the utility of gastric insufflation technique. METHODS: Five pigs (mean weight, 40.4 kg) underwent testing of laparoscopic gastric insufflation technique. In four animals, laparoscopic Nissen fundoplication was performed and then gastroesophageal junction injuries were created (3-5 mm distraction-type wall injuries). Non-crushing bowel clamps provided occlusion of the pylorus and then the proximal stomach during gastroesophageal insufflation. The gastroesophageal junction was then submerged. In the fifth animal, gastric insufflation technique was repeated while calibrated injuries were created to determine the smallest detectable injury. An injury was considered detectable if rising air bubbles were noted from the submerged gastroesophageal structures. Maximal luminal pressures needed to detect injuries were recorded with an in-line manometer. RESULTS: In all animals, 5-7 mm injuries of the gastroesophageal junction were easily detected using gastric insufflation technique when the proximal stomach was occluded. When the pylorus alone was occluded, detection of gastroesophageal injuries was inconsistent. Small injuries (<3 mm) of the esophagus were difficult to visualize with pyloric occlusion alone but were consistently detectable with proximal stomach occlusion at pressures less than 20 mm Hg. When the pylorus alone was occluded, the smallest detectable stomach perforation was a 16-gauge needle puncture while applying maximal gastric pressure (40-60 mm Hg) and a 2.5 mm linear injury when generating lower pressures (20 mm Hg). CONCLUSION: Proximal stomach occlusion and insufflation appears to effectively detect esophageal injuries of likely clinical importance (>2.5 mm). Pyloric occlusion and insufflation reliably evaluates the anterior stomach for injury. Gastric insufflation technique is a useful method for detecting gastroesophageal injury after laparoscopic Nissen fundoplication.     

Effects of prior endoluminal gastroplication on subsequent laparoscopic Nissen fundoplication

Background The long-term results of endoluminal gastroplication (ELGP) for gastroesophageal reflux disease (GERD) are still under investigation. Laparoscopic Nissen fundoplication (LNF) has unquestionable results in the treatment of GERD and, therefore, it would be unfortunate to compromise this treatment option by performing alternative therapies such as ELGP. Methods Six patients underwent ELGP for the treatment of GERD symptoms. After symptoms returned, these patients elected to have a LNF. Results There was no sign of periesophagitis or intraperitoneal adhesion formation found at hiatal dissection that hindered or complicated the LNF procedure. Recent follow-up has shown that the patient’s GERD symptom scores have decreased, as expected after a de novo LNF. Conclusion ELGP does not alter the surgical dissection or results of a subsequent LNF.