食管胃垂瓣吻合在贲门癌术后抗反流的临床研究

目的评价食管胃垂瓣吻合术式在贲门癌术后抗反流的作用。方法将40例贲门癌患者随机分成研究组和手术对照组,每组20例,吻合方式分别采用食管胃垂瓣吻合术和传统食管胃吻合方式。在术后3个月分别采用24 h pH监测及胃镜检查,观察术后胃食管反流情况。另选10例健康人设为正常对照组。结果术后近期研究组及手术对照组pH各项监测指标均高于正常对照组(P0.05),手术对照组高于研究组(P0.05);两组反流性食管炎分级及组织学食管黏膜炎症程度均高于正常对照组(P0.05),而手术对照组高于研究组(P0.05)。结论食管胃垂瓣吻合术后也有一定的反流现象,但和传统手术相比,食管胃垂瓣吻合术具有明显抗反流作用。     

胃食管吻合术后胃食管反流的研究

目的 研究食管癌和贲门癌术后不同位置的食管胃吻合口和时间因素对胃食管反流程度的影响。方法 对39例食管癌和贲门癌术后病人进行24h食管pH监测、电子胃镜检查，其中食管胃弓上吻合组（A组）21例，弓下吻合组（B组）18例。结果 （1）A组DeMeester评分和反流性食管炎评分均明显低于B组（P〈0．05）。（2）随着时间的推移A组和B组DeMeester评分无明显的改变（P〉0．05）。结论 不同位置的食管胃吻合口影响胃食管反流程度，食管胃吻合口位置越高胃食管反流和反流性食管炎程度越轻。时间因素对胃食管反流程度无明显的影响。     

黏膜瓣式食管胃吻合术抗反流的食管动力学研究

目的寻找一种实用有效的抗反流食管胃吻合术式。方法将食管癌和贲门癌患者464例随机分为黏膜瓣式食管胃吻合术组(A组,175例)、器械食管胃吻合术组(B组,151例)和单纯手工缝合食管胃一层吻合术组(C组,138例)。应用同位素测定胃食管反流指数和24h监测pH值,进行3组间的食管运动功能比较。结果同位素测定胃食管反流指数显示,A组反流阳性率为0,B组为33.3%,C组为6.7%。食管运动功能及24h监测pH显示,A组检测各项指标均接近正常值,B、C组与正常值比较,差异具有统计学意义(P<0.05)。结论黏膜瓣式食管胃吻合术式具有优异的抗反流功能,并能有效地防止食管癌、贲门癌术后反流性食管炎的发生。     

经食管床胃食管吻合术后胃食管反流与胃排空的临床研究

目的 客观评价食管中段癌切除经食管床主动脉弓上胃食管吻合术对术后胃食管反流和胃排空的影响。方法 将40例食管中段癌患者随机分成两组，食管床吻合组（n=20）：采用经食管床主动脉弓上胃食管吻合术；左胸腔内吻合组（n=20）：采用经左侧胸腔主动脉弓前胃食管吻合术；另选10名无消化系统疾病的健康志愿者作为正常对照组。于术后3个月进行24h食管pH监测，放射性核素胃排空检查，观察术后胃食管反流和胃排空情况。结果 所有患者手术均成功，无手术死亡，术后无吻合口漏和狭窄。术后3个月左胸腔内吻合组和食管床吻合组患者均有不同程度的反流，DeMeester总评分、24h酸反流次数、〉5min的反流次数、最长反流持续时间、pH（4．00的总时间和pH（4．00占总时间的百分比均高于正常对照组（P〈0．01）；食管床吻合组DeMeester总评分、24h酸反流次数、最长反流持续时间、pH（4．00的总时间、pH（4．00占总时间的百分比均低于左胸腔内吻合组（P〈0.01）。术后近期各时间段左胸腔内吻合组和食管床吻合组胃排空百分数（GE）均较正常对照组低（P〈0.01）；食管床吻合组GE于实验餐进入胃后30、60、90、120、180和240min均高于左胸腔内吻合组（P〈0. 01）。结论经食管床主动脉弓上吻合术后胃食管反流和胃排空延迟客观存在，但较传统手术方式有所减轻，其机制可能是机械因素所致。     

食管粘膜层经隧道食管胃吻合术的临床研究

目的食管癌手术后吻合口瘘和吻合口狭窄的并发症已明显下降,而反流性食管炎已成为影响术后患者生活质量的主要并发症。为此设计了食管粘膜层经胃壁肌层下隧道行食管胃吻合术。方法食管粘膜层经隧道食管胃吻合术１７５例,其中２０例与同期隧道式食管胃吻合术２０例进行对比研究。术后６～１２个月,行食管压力测定、食管镜检查、组织活检和食管内反流液ｐＨ值测定。结果２组患者术后均无吻合口瘘发生,无手术死亡。结论该术式具有明显地抗反流作用,可预防反流性食管炎的发生     

管状胃－食管吻合术与全胃－食管吻合术对食管中段癌患者术后胃食管反流的对比研究

目的探讨管状胃－食管吻合术与全胃－食管吻合术对食管中段癌术后患者胃食管反流(GER)的影响。 方法回顾性分析2014年1月—2017年1月在新疆维吾尔自治区人民医院胸外科行食管癌切除术的56例食管中段癌患者的临床资料,其中观察组(管状胃－食管吻合术)患者27例,对照组(全胃－食管吻合术)患者29例,术后2周进行24 h胃－食管腔pH值监测,术后2周和1、3、6个月依据胃食管反流病调查问卷(GerdQ)评分表对患者的GER相关症状进行评分,比较两组患者术后GER发生情况。 结果所有患者获得随访,观察组和对照组术后2周时24 h酸反流次数、最长酸反流时间和pH值<4的总时间均显著少于对照组,差异有统计学意义(P<0.05);术后1、3、6个月时,观察组GerdQ评分均显著低于对照组,差异也有统计学意义(P<0.05)。 结论管状胃－食管吻合术可显著降低食管中段癌患者术后GER的发生及严重程度。     

食管、贲门癌切除食管胃分层吻合术患者生命质量评价

目的 探讨食管、贲门癌切除食管胃分层吻合术的手术效果，评价患者手术后生命质量。方法 根据手术方式不同将264例食管、贲门癌患者分为两组，食管胃分层吻合组：162例，行食管、贲门癌切除，食管胃黏膜连续缝合，食管胃分层吻合术；器械吻合组：102例，行食管、贲门癌切除，食管胃吻合器吻合术。均用欧洲癌症研究与治疗组织(EORTC)QLQ—C30和自制量表对患者术后3—6个月生命质量进行测评，并进行比较。结果 食管胃分层吻合组有137份问卷、器械吻合组有77份问卷符合评分要求。食管胃分层吻合组在体力功能和情感功能维度得分高于器械吻合组(P＜0．05)，吞咽困难维度、胃食管反流症状维度得分低于器械吻合组(P＜0．05)，其他维度两组比较差别无显著性意义(P＞0．05)。结论 食管胃分层吻合术后患者体力功能和情感功能优于器械吻合术，吞咽困难、反流症状少于器械吻合术，生命质量高于器械吻合术。     

食管胃瓣膜式吻合术对抗返流作用的临床研究

目的:探讨食管胃瓣膜式吻合术在下段食管癌切除术后抗吻合口反流中的作用. 方法:2009年5月至2011年5月,对31例食管下段癌行癌肿切除,食管-胃肌瓣胃腔内瓣膜式吻合术,年龄34-76岁,男25例,女6例.其中3例食管下段癌行弓上吻合,余28例均行弓下吻合.结果:全组无近期手术死亡,无明显返酸、嗳气、烧心、胸痛等返流症状发生.术后8-14天对全部患者行上消化道造影,影像学表现吻合口处极象正常人的贲门管存在,通畅无狭窄;患者倒立位,亦无造影剂返流.术后14天至1.5年对全部患者行吻合口上5cm的食管、吻合口、吻合口下5cm的胃腔内测压及食管内24小时pH的测定并行内镜检查,结果显示食管胃吻合口上方的压力明显高于吻合口下方,24小时食管pH监测结果表明不存在病理性胃食管返流,胃镜检查全部患者吻合口上方的食管粘膜清亮、光洁,无潮红、充血、糜烂、溃疡等食管炎的征象发生.结论:食管-胃肌瓣胃腔内瓣膜式吻合术是抗食管胃吻合术后吻合口返流行之有效的手术方法.     

胃食管吻合术后胃食管反流症状的特征与相关因素的关系

目的探讨胃食管吻合术后胃食管反流症状的特征与相关因素的关系,以降低胃食管反流的发生率。方法回顾性分析239例食管、贲门癌切除胃食管吻合术后胃食管反流症状及与吻合平面、胃镜下表现和吻合口狭窄的关系。结果108例出现胃食管反流症状,发生率45.2%(108/239),主动脉弓下胃食管反流症状的发生率大于主动脉弓上反流症状发生率(70.7%vs.31.8%,P<0.01)。影响生活的反流症状(≥6分)发生率为25.5%,主动脉弓下吻合反流症状程度较主动脉弓上吻合重(43.9%vs.15.9%,P<0.01)。胃镜RE分级0 级、 级出现反流症状的发生率分别为41.7%(63/151)和50.0%(44/88),两者比较差异无统计学意义(χ2=1.541,P=0.214),反流症状的严重程度与RE分级无相关性(r=0.080,P=0.276)。在有症状的反流患者中吻合口狭窄发生率为37%(40/108),无症状的反流患者中未发现吻合口狭窄,两者比较差异有统计学意义(χ2=49.262,P=0.000)。吻合口狭窄与有胃食管反流症状呈正相关(r=0.480,P=0.048)。结论食管胃吻合术后只有部分患者出现反流症状,主动脉弓下吻合反流症状多于主动脉弓上吻合,且程度较重。反流症状的严重程度及发生率与RE分级无关。吻合口狭窄与胃食管反流相关。     

自带抗反流装置管型胃在SiewertⅡ型和Ⅲ型食管胃结合部腺癌中临床疗效分析

目的分析腹腔镜辅助下近端胃切除自带抗反流装置管型胃在SiewertⅡ型和Ⅲ型食管胃结合部腺癌(AEG)中临床疗效。方法回顾性分析2017年6月至2019年6月59例行腹腔镜辅助下近端胃切除的SiewertⅡ型和Ⅲ型AEG患者临床资料。其中2018年7月之前30例行传统管型胃食管吻合(A组),2018年7月及以后29例行自带抗反流装置管型胃食管吻合(B组)。应用SPSS 19.0统计软件进行分析,围术期指标及RDQ评分等计量资料以(±s)表示,采用独立t检验;术后胃食管反流症状、反流性食管炎(RE)、胃食管反流病(GERD)等计数指标比较采用χ²检验,P<0.05为差异有统计学意义。结果两组患者在术后胃食管反流症状、RE及GERD发生率比较上差异无统计学意义(P>0.05);两组术后3个月、6个月RDQ评分分别为(8.83±4.00)分比(4.28±3.16)分、(8.60±4.09)分比(4.83±3.04)分,A组明显高于B组,差异有统计学意义(P<0.05)。结论自带抗反流装置管型胃食管吻合较传统管型胃食管吻合具有更好抗术后反流的疗效,且费用相对低、操作简单安全,值得临床推广。     

滑动型食管裂孔疝的外科治疗

目的 探讨滑动型食管裂孔疝手术治疗的方法与效果。方法 对经X线钡餐及胃镜检查确诊的52例滑动型食管裂孔疝并食管炎患者行手术治疗,其中Nissen手术47例、Hill手术3例、Boerema手术1例、Rampal手术1例,于术前、术后进行24h食管pH值和食管压力监测。以健康志愿者30例为对照组,行24h食管pH值和食管压力监测。结果 手术组患者术前均存在食管下括约肌的松弛和酸反流,术后则明显改善。52例随访患者中疗效优者33例(63％)、良者14例(27％)、欠佳者3例(2例吞咽困难、1例反流,占6％)、差者2例(2例复发,占4％)。结论 应完善术前检查及正确、严格掌握手术指征,以取得良好的手术疗效;术式以经腹短松式Nissen术为最佳。     

Gastroesophageal reflux disease: symptoms versus pH monitoring results.

OBJECTIVES: The reason why some patients with gastroesophageal reflux disease (GERD) have symptoms of upper aerodigestive system irritation, while others mainly have gastroenterologic symptoms, is not well established. This retrospective case series study was designed to examine the existence of a correlation between symptoms and reflux characteristics, based on data obtained from esophageal pH monitoring. METHODS: The study population consisted of 139 patients; 97 patients presented with laryngopharyngeal symptoms of GERD, including unexplained hoarseness, throat clearing, chronic cough, laryngospasm, globus, throat pain, and 42 patients presented with gastroenterologic symptoms, including heartburn and regurgitation. The results of 24-hour, double-channel ambulatory esophageal pH monitoring were analyzed comparing 2 symptom groups. The incidence of abnormal acid reflux at the upper and lower esophageal segments and the effects of upright and supine positions on reflux parameters were evaluated. RESULTS: The incidence of laryngopharyngeal reflux was significantly higher in the laryngopharyngeal symptom group than in the other (52% versus 38%). The patients with laryngopharyngeal reflux from both groups showed no significant differences in terms of number of acid reflux episodes, percentage of times pH was 4, and esophageal acid clearance. Upright and supine parameters did not show significant differences between the patient groups. Upright acid reflux episodes were, however, common in both groups at the lower esophageal and laryngopharyngeal segments. CONCLUSION: Recent studies suggesting that otolaryngologic patients commonly show upright, daytime reflux with normal esophageal clearance and that typical GERD patients commonly have supine, nocturnal reflux with prolonged esophageal clearance are not supported by this study. This study indicates that acid reflux parameters and positional changes are not sufficient to explain why patients with GERD experience different symptoms. The regional symptoms of GERD may be attributed to the impairment of epithelial resistance, motor activity, and buffering systems for the esophageal antireflux barrier.     

Allergic esophagitis in children: a clinicopathological entity

Infiltration of esophageal epithelium by eosinophils is seen in reflux esophagitis and allergic gastroenteritis. This study was performed to identify differences between patients with acid reflux esophagitis and those with non-acid reflux, possibly allergic, esophagitis. Intraepithelial eosinophils were demonstrated in posttherapy esophageal biopsy specimens in 28 children treated for gastroesophageal reflux disease (GERD). These patients were divided into three groups based on their response to treatment and the results of esophageal pH probe monitoring. Eleven patients (Group A) had incomplete clinical response and normal pH probe monitoring results. Ten patients (Group B) had incomplete response but did not have pH probe monitoring. These two groups formed the index population. Seven patients (Group C) had clinical improvement with GERD therapy and abnormal pH probe monitoring characteristic of GERD; they constituted the control population. Clinical, laboratory, and pathologic features were evaluated to detect differences between index and control populations. Dysphagia, food impaction, failure to thrive, peripheral eosinophilia, and abnormal allergen skin test results were detected only in Group A and B patients. Biopsy specimens of the distal 9 cm of the esophagus, after GERD therapy, contained larger numbers of eosinophils in Groups A and B than in Group C as shown on high-power fields (HPF) (A: 31/HPF +/- 19.5; B: 28/HPF +/-23.7; versus C: 5/HPF +/-6.7; p = 0.009). Eosinophil aggregates were identified only in Groups A and B (p = 0.07). Eosinophils located preferentially in the superficial layers of the squamous epithelium were noted only in Groups A and B (p = 0.02). Group A and B patients demonstrated clinical improvement when given antiallergic therapy. The authors identified a group of pediatric patients characterized by an allergic history, lack of adequate response to GERD therapy, normal esophageal pH probe monitoring results, and large numbers of eosinophils in esophageal biopsy specimens obtained after GERD treatment. On the basis of these features, the authors propose that these patients represent examples of allergic esophagitis.     

Esophageal dysmotility and gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) produces a spectrum of symptoms ranging from mild to severe. While the role of the lower esophageal sphincter in the pathogenesis of GERD has been studied extensively, less attention has been paid to esophageal peristalsis, even though peristalsis governs esophageal acid clearance. The aim of this study was to evaluate the following in patients with GERD: (1) the nature of esophageal peristalsis and (2) the relationship between esophageal peristalsis and gastroesophageal reflux, mucosal injury, and symptoms. One thousand six consecutive patients with GERD confirmed by 24-hour pH monitoring were divided into three groups based on the character of esophageal peristalsis as shown by esophageal manometry: (1) normal peristalsis (normal amplitude, duration, and velocity of peristaltic waves); (2) ineffective esophageal motility (IEM; distal esophageal amplitude < 30 mm Hg or >30% simultaneous waves); and (3) nonspecific esophageal motility disorder (NSEMD; motor dysfunction intermediate between the other two groups). Peristalsis was classified as normal in 563 patients (56%), IEM in 216 patients (21%), and NSEMD in 227 patients (23%). Patients with abnormal peristalsis had worse reflux and slower esophageal acid clearance. Heartburn, respiratory symptoms, and mucosal injury were all more severe in patients with IEM. These data show that esophageal peristalsis was severely impaired (IEM) in 21% of patients with GERD, and this group had more severe reflux, slower acid clearance, worse mucosal injury, and more frequent respiratory symptoms. We conclude that esophageal manometry and pH monitoring can be used to stage the severity of GERD, and this, in turn, should help identify those who would benefit most from surgical treatment.     

Ambulatory pH: monitoring with a wireless system

Background Currently, pH monitoring is the gold standard for assessing esophageal acid exposure in patients with gastroesophageal reflux disease (GERD). The shortcomings of 24-h pH-monitoring wires led to the development of a 48-h, catheter-free pH measurement system using the telemetry technique with the BRAVO capsule. This prospective study aimed to compare conventional 24-h pH monitoring with the BRAVO catheter-free pH-monitoring system in patients with GERD, patients after antireflux surgery, and a healthy control group. Methods A sample of 133 participants were enrolled in the current trial and divided into three subgroups. Group 1 consisted of 10 healthy volunteers. Group 2 consisted of 123 patients with symptomatic gastroesophageal reflux and endoscopic signs of esophagitis. Group 3 consisted of 43 GERD patients (extracted from group 2) who underwent a laparoscopic 360° “floppy” Nissen fundoplication. All the patients underwent both conventional 24-h pH monitoring and BRAVO catheter-free pH monitoring. The data for both methods were recorded and compared in line with the different patient groups regarding their validity and reliability. Additionally, all the patients were interviewed with a standardized questionnaire concerning their subjective perception of the two different methods. Results Both the 24-h pH monitoring and the 48-h BRAVO catheter-free pH monitoring could be successfully performed for all the patients. During measurement, 122 of the patients (92%) continued working or performing daily activities. A significant difference could not be found regarding objective outcome between the two measurement methods in the three patient groups. The two methods showed comparable results in terms of data and measurement reliability. The validity also was comparable, with no significant differences within the groups. Concerning the patients’ subjective estimation of the two methods, the patients reported reduced regular activities and a higher level of discomfort during measurement with the conventional 24-h pH-monitoring system (p < 0.001 and p< 0.0001, respectively). Conclusion Both conventional 24-h pH monitoring and the 48-h catheter-free pH monitoring are valid and reliable recording devices for measuring esophageal acid exposure. However, from the patients’ point of view, the BRAVO capsule affords less discomfort in the throat and allows more normal daily activities.     

Gastroesophageal Reflux Disease and Antireflux Surgery—What Is the Proper Preoperative Work-up?

Background

Many surgeons feel comfortable performing antireflux surgery (ARS) on the basis of symptomatic evaluation, endoscopy, and barium esophagography. While esophageal manometry is often obtained to assess esophageal peristalsis, pH monitoring is rarely considered necessary to confirm the diagnosis of gastroesophageal reflux disease (GERD).

Aims

The aim of this study was to analyze the sensitivity and specificity of symptoms, endoscopy, barium esophagography, and manometry as compared to pH monitoring in the preoperative evaluation of patients for ARS.

Patients and Methods

One hundred and thirty-eight patients were referred for ARS with a diagnosis of GERD based on symptoms, endoscopy, and/or barium esophagography. Barium esophagography, esophageal manometry, and ambulatory 24-h pH monitoring were performed preoperatively in every patient.

Results

Four patients were found to have achalasia and were excluded from the analysis. Based on the presence or absence of gastroesophageal reflux on pH monitoring, the remaining 134 patients were divided into two groups: GERD+ (n?=?78, 58 %) and GERD? (n?=?56, 42 %). The groups were compared with respect to the incidence of symptoms, presence of reflux and hiatal hernia on esophagogram, endoscopic findings, and esophageal motility. There was no difference in the incidence of symptoms between the two groups. Within the GERD+ group, 37 patients (47 %) had reflux at the esophagogram and 41 (53 %) had no reflux. Among the GERD? patients, 17 (30 %) had reflux and 39 (70 %) had no reflux. A hiatal hernia was present in 40 and 32 % of patients, respectively. Esophagitis was found at endoscopy in 16 % of GERD+ patients and in 20 % of GERD? patients. Esophageal manometry showed no difference in the pressure of the lower esophageal sphincter or quality of peristalsis between the two groups.

Conclusions

The results of this study showed that (a) symptoms were unreliable in diagnosing GERD, (b) the presence of reflux or hiatal hernia on esophagogram did not correlate with reflux on pH monitoring, (c) esophagitis on endoscopy had low sensitivity and specificity, and (d) manometry was mostly useful for positioning the pH probe and rule out achalasia. Ambulatory 24-h pH monitoring should be routinely performed in the preoperative work-up of patients suspected of having GERD in order to avoid unnecessary ARS.     

胃食管反流病患者伴有或不伴有食管黏膜损伤与食管上、下括约肌压力相关性研究

目的研究伴或不伴食管黏膜损伤的胃食管反流病（gastroesophageal reflux disease,GERD）患者在食管动力方面的差异。 方法回顾性分析2015年1月至2017年12月,解放军总医院就诊的有反酸、烧心、胸痛等症状的患者,24 h食管pH监测Demeester积分≥14.72分,根据内镜检查结果分为糜烂性反流病（ERD）组和非糜烂性反流病（NERD）组,比较2组患者食管动力学指标的变化。 结果NERD组与ERD组UESP平均值数值相似,差异无统计学意义（P=0.168）。其余指标UESRP平均值、LESP最小值、LESP平均值、LESRP平均值、LESRP最大值、DCI中NERD组均高于ERD组,差异均有统计学意义（P<0.001）。NERD组平均年龄明显小于ERD组,差异有统计学意义（P<0.000 1）。NERD组患者身高较ERD组偏低,体重较轻,身体质量指数（body mass index,BMI）也较小,差异有统计学意义（P<0.000 1）。 结论随着年龄的增大或BMI的增加,可能增加GERD患者食管黏膜损伤的风险。此外,糜烂性反流病患者较非糜烂性反流病的上、下食管括约肌动力障碍更严重。     

腹腔镜下食管裂孔疝修补联合胃底折叠术治疗食管裂孔疝及长期疗效的评估

目的观察分析腹腔镜下食管裂孔疝修补联合Nissen/Dor胃底折叠术治疗食管裂孔疝临床疗效及食管测压与pH值监测对长期疗效的预估意义。 方法回顾性分析2018年1月至2020年1月于河北北方学院附属第二医院收治的120例食管裂孔疝患者的临床资料,其中64例行腹腔镜下食管裂孔疝修补联合Nissen胃底折叠术（Nissen组）,56例行腹腔镜下食管裂孔疝修补联合Dor胃底折叠术（Dor组）。术后随访1年,对比观察2组患者手术情况、住院时间、术后并发症、记录食管测压及pH检测等指标变化情况、Gerd Q、DeMeester评分等。 结果Nissen组术程以及术中出血量明显高于Dor组（P<0.05）,2组总住院时间差异无统计学意义（P>0.05）。2组患者术后总并发症发生率比较,差异无统计学意义（P>0.05）;2组患者术后1年食管反流情况与DeMeester评分较术前均得到明显改善。Nissen组在减少反流次数、长反流次数和最长反流时间方面均优于Dor组（P<0.05）。2组在反流时间、酸反流时间百分比与DeMeester评分比较,差异均无统计学意义（P>0.05）;术后2组患者食管下括约肌压力、静息呼吸平均值、食管残余压较术前均显著提升（P<0.05）,但2组间术后比较无明显差异（P>0.05）。术后2组患者食管松弛率、无效吞咽与Gerd Q评分均较术前也均明显降低,但2组间差异无统计学意义（P>0.05）。 结论腹腔镜疝修补术联合Nissen或Dor胃底折叠术治疗食管裂孔疝均有明显效果,临床应根据患者自身情况选择合适的手术方式。