Minimally invasive surgery for esophageal cancer]

Minimally invasive surgery is now rapidly developing and becoming a standard surgical option in some fields. In the past, many thoracic surgeons were reluctant to adopt minimally invasive techniques in esophageal cancer surgery due to concern over the oncologic perspectives and technical difficulties. However, over the last few years, thoracic surgeons have progressively embraced the technical advancements and now many experienced centers have adopt minimally invasive surgery as a primary option for non-advanced esophageal cancer operations. In esophageal cancer surgery, the volume of operation performed in some hospital is closely related to the outcome of patients, and the experiences of surgical team play an important role in minimally invasive surgery. Minimally invasive esophageal surgery (MIES) has steep learning curves, also. The merits of MIES are as follows. The conventional esophageal cancer operation has two or triple incisions, resulting in high postoperative morbidity and mortality. However, postoperative complication in MIES became less frequent than conventional surgery. The patient's satisfaction is high. Mid-term outcomes of MIES have been reported that it is safe and feasible in esophageal cancer and survival curves are similar to those of conventional surgery. Therefore, MIES is a valuable therapeutic modality for both esophageal cancer patients and thoracic surgeons.     

Functional results of surgery for bullous emphysema.

Forty-six patients with bullous emphysema were operated on. Respiratory function was investigated before and immediately after surgery, and during the follow-up to five years. The larger the volume of the bullae, the less disturbances of lung function caused by their removal immediately after operation. Respiratory function improved significantly during the long-term follow-up after removal of the bullae that were more than one third of the hemithorax, but it did not change when the bullae were less than one third of the hemithorax and deteriorated after pulmonary resection for the bullae associated with long-term pneumonia. No new bullae were revealed roentgenographically at five years postoperatively.     

Bilious vomiting after gastric surgery: A symptom of sliding esophageal hiatus hernia

Nine patients with bilious vomiting following gastric surgery for peptic ulcer were found to have sliding esophageal hiatus hernias; surgical repair of the hernia in each patient resulted in immediate relief of symptoms. Significant gastroesophageal reflux had been demonstrated in each of the 5 patients in whom preoperative cinefluorography had been performed. As a result of this retrospective analysis, it has been concluded that undiscovered sliding esophageal hiatus hernia is the cause of bilious vomiting in some of the patients heretofore thought to have the afferent-loop syndrome. It is recommended therefore that hiatus hernia be sought, and repaired if feasible, in all patients who are undergoing gastric surgery for peptic ulcer. As injury to the phrenoesophageal ligament at the time of abdominal vagotomy may lessen the competency of the lower esophageal sphincter and predispose to the development of an iatrogenic hiatus hernia, proper steps should be taken at the time of vagotomy to repair any significant operative defects. It is recommended further that cinefluorography be performed in all patients who return for follow-up examinations with symptoms characteristic of the afferent-loop syndrome.     

胃食管反流病合并食管裂孔疝动物实验手术配合体会

目的促使新一代的青年医师、器械护士能够更加熟练掌握胃食管反流病合并食管裂孔疝手术方式及术中能够紧密的配合。 方法新疆维吾尔自治区人民医院微创外科与科研技术部门合作,成功建立了腹腔镜下胃食管反流病合并食管裂孔疝手术小猪动物训练模型,通过动物模型手术训练熟悉手术操作要点及配合要点。 结果共完成腹腔镜食管裂孔疝修补术6次,Nissen胃底折叠术12次,Toupet胃底折叠术12次,Dor胃底折叠术12次,未发生麻醉意外、二氧化碳气栓、失血性休克等严重并发症。预期手术成功完成,没有发生因术中并发症导致实验动物死亡而终止训练等情况。 结论经过腹腔镜抗反流手术动物模型的手术训练可以使医护人员明显缩短学习时间、促进临床术中配合,可以减少手术相关并发症,是一种安全可行的最佳手术训练方法。     

食管裂孔疝的内镜诊断

食管裂孔疝是指部分胃组织通过膈食管裂孔凸入胸腔。在某些患者，腹腔内其他脏器也可随同疝入胸腔。食管裂孔疝属膈疝中最常见的一种，占90％以上。食管裂孔疝的发病率因应用的诊断技术和诊断标准不同而有差别。钡剂透视检查结果可因腹部加压情况及体位而异。胃经膈裂孔疝至膈上多少厘米可称之为裂孔疝，似难确定。用电影照相和测压技术检查，吞咽时食管下括约肌经膈向头端运动1～4cm属于正常，有放射学医师认为，经改变体位、腹部加压及其它操作方法，可使90％的人出现滑动型疝的征象。呕吐时，腹壁强力收缩和     

Isolated colonic hernia through the esophageal hiatus

We report on a 75-year-old woman with an isolated colonic hernia through the esophageal hernia. The patient had suffered from cough, palpitation and dyspnea. A chest X-ray showed a colon loop gas in the mediastinum. Simultaneous barium swallow and enema showed the herniation of the only transverse colon into the mediastinum and displacement of the distal esophagus by the migrated colon. The patient underwent an open-mesh cruroplasty and a Hill's posterior gastropexy. The postoperative clinical course was uneventful. The patient has cessation of the symptoms. To our knowledge, there are only five reports presenting patients with isolated colonic hernia through the esophageal hiatus, including our case.     

Symptomatic esophageal hiatus sliding hernia

Digestive Diseases and Sciences - 1. The clinical, endoscopic, and radiologic findings in 100 patients with symptomatic sliding esophageal hiatus hernia have been presented and correlated. 2. The...     

Functional esophageal disorders

The functional esophageal disorders include globus, rumination syndrome, and symptoms that typify esophageal diseases (chest pain, heartburn, and dysphagia). Factors responsible for symptom production are poorly understood. The criteria for diagnosis rest not only on compatible symptoms but also on exclusion of structural and metabolic disorders that might mimic the functional disorders. Additionally, a functional diagnosis is precluded by the presence of a pathology-based motor disorder or pathological reflux, defined by evidence of reflux esophagitis or abnormal acid exposure time during ambulatory esophageal pH monitoring. Management is largely empirical, although efficacy of psychopharmacological agents and psychological or behavioral approaches has been established for several of the functional esophageal disorders. As gastroesophageal reflux disease overlaps in presentation with most of these disorders and because symptoms are at least partially provoked by acid reflux events in many patients, antireflux therapy also plays an important role both in diagnosis and management. Further understanding of the fundamental mechanisms responsible for symptoms is a priority for future research efforts, as is the consideration of treatment outcome in a broader sense than reduction in esophageal symptoms alone. Likewise, the value of inclusive rather than restrictive diagnostic criteria that encompass other gastrointestinal and non-gastrointestinal symptoms should be examined to improve the accuracy of symptom-based criteria and reduce the dependence on objective testing.     

Long-term results following thoracoscopic surgery for esophageal leiomyoma in four patients

For esophageal leiomyoma, surgical enucleation is accepted as the standard procedure when the tumor is symptomatic or large in size without malignant findings. The aim of this study is to clarify the long-term results following thoracoscopic surgery. Four patients with esophageal leiomyoma were subjected to thoracoscopic surgery. The indications for surgical resection of esophageal leiomyoma were as follows: 1) tumor size greater than 3cm or appearance of enlargement; 2) symptomatic patients. In one case of a larger tumor, hand-assisted thoracoscopic surgery was performed in order to ensure both minimal invasion and a wide operative area. There was no mortality and one postoperative complication. No local recurrence, port site recurrence, pleural dissemination or distant metastases were detected between 35 and 96 months after the operation. The advantages of thoracoscopic surgery for esophageal leiomyoma include its safety and long-term prevention of recurrence.     

Functional esophageal disorders

Functional esophageal disorders represent processes accompanied by typical esophageal symptoms (heartburn, chest pain, dysphagia, globus) that are not explained by structural disorders, histopathology-based motor disturbances, or gastroesophageal reflux disease. Gastroesophageal reflux disease is the preferred diagnosis when reflux esophagitis or excessive esophageal acid exposure is present or when symptoms are closely related to acid reflux events or respond to antireflux therapy. A singular, well-defined pathogenetic mechanism is unavailable for any of these disorders; combinations of sensory and motor abnormalities involving both central and peripheral neural dysfunction have been invoked for some. Treatments remain empirical, although the efficacy of several interventions has been established in the case of functional chest pain. Management approaches that modulate central symptom perception or amplification often are required once local provoking factors (eg, noxious esophageal stimuli) have been eliminated. Future research directions include further determination of fundamental mechanisms responsible for symptoms, development of novel management strategies, and definition of the most cost-effective diagnostic and treatment approaches.     

Hiatus hernia and esophageal contraction abnormalities

The relationship of hiatus hernia to esophageal motility pattern was examined in patients referred for evaluation of esophageal symptoms. Results from standard esophageal motility studies were compared with findings on barium radiography of the upper gastrointestinal tract. Of 169 patients without radiographic evidence of esophagitis, 53 (31 percent) had normal motility of the esophageal body, whereas 116 (69 percent) demonstrated esophageal contraction abnormalities, a classification that includes the pattern of diffuse esophageal spasm at the severest extreme. Hiatus hernia was significantly more common in those with contraction abnormalities (25 percent) than in those with normal patterns (8 percent) (p = 0.01). Hiatus hernia increased in prevalence with increasing severity of contraction abnormalities, such that hiatus hernia was present in nearly half of patients with the pattern typifying diffuse esophageal spasm. Thus, hiatus hernia and esophageal contraction abnormalities are associated once other associations with hiatus hernia (e.g., esophagitis and scleroderma) have been excluded. These findings may help explain the recognized relationship of esophageal symptoms to hiatus hernia in patients without significant gastroesophageal reflux.     

腹腔镜疝修补联合Nissen胃底折叠术治疗食管裂孔疝

食管裂孔疝是一种常见的消化系统疾病,通常伴有胃食管反流。近年来食管裂孔疝发病率呈上升的趋势。食管裂孔疝带来的食管症状及食管外症状严重影响着患者的身心健康。由于内科治疗的局限性,手术治疗食管裂孔疝越来越受到外科医师的关注。食管裂孔疝手术旨在修补缺损,通过胃底折叠恢复食管下端括约肌的作用,达到抗反流的效果。腹腔镜技术以其安全、有效及方便等优势而成为治疗食管裂孔疝的首选方法。本文对近年来我院腹腔镜疝修补联合Nissen胃底折叠术治疗食管裂孔疝的经验作一总结。     

Impairment of esophageal emptying with hiatal hernia

Concurrent videofluoroscopy and manometry were used to analyze esophageal emptying during barium swallows in 22 patients with axial hiatal hernias and in 14 volunteers. Subjects were divided into three groups: (a) volunteers with maximal phrenic ampullary length less than 2 cm (controls); (b) patients or volunteers with maximal ampullary/hiatal hernia length greater than or equal to 2 cm that reduced between swallows (reducing-hernia group); and (c) patients with hernias that did not reduce between swallows. Complete esophageal emptying without retrograde flow was achieved in 86% of test swallows in the controls, 66% in the reducing-hernia group, and 32% in the nonreducing-hernia group (P less than 0.05). Impaired emptying in the reducing-hernia group was attributable to "late retrograde flow," whereby barium squirted retrograde from the hernia during emptying. Impaired emptying in the nonreducing-hernia group was attributable to "early retrograde flow" that occurred immediately after LES relaxation. The nonreducing-hernia group also had longer acid clearance times than the controls (P less than 0.05). We conclude that gastroesophageal junction competence is severely impaired in patients with nonreducing hiatal hernias, suggesting a mechanism whereby this subgroup of hiatal hernia is involved in the pathogenesis of reflux disease.