减重代谢手术前后规范化胃镜检查的分析研究

目的从消化内镜医生角度来分析减重手术前后消化道腔内的特征及远期随诊。 方法回顾性分析2020年6月1日至2021年11月30日经首都医科大学附属复兴医院减重患者132例,对比手术前后7 620张胃镜图片。 结果减重手术前的胃镜检查显示,52例(39.4%)发现存在滑动型食管裂孔疝、27例(20.4%)存在反流性食管炎、19例(14.4%)存在胃体黏膜网格样充血水肿、胃窦黏膜颗粒样改变、十二指肠肠绒毛短缩。减重手术后胃镜检查显示,溃疡病腹腔镜袖状胃切除术(LSG)后发生率约2.9%(1例)、腹腔镜Roux-en-Y胃旁路术(LRGB)后发生率约5.3%(1例);均未发生吻合口炎。 结论对减重手术1年后的胃镜检查随访未发现消化道息肉及肿瘤倾向,针对肥胖症的治疗及防控多学科协作任重道远。     

Transepithelial leak in Barrett's esophagus patients: the role of proton pump inhibitors

AIM: To determine if the observed paracellular sucrose leak in Barrett’s esophagus patients is due to their proton pump inhibitor (PPI) use.METHODS: The in vivo sucrose permeability test was administered to healthy controls, to Barrett’s patients and to non-Barrett’s patients on continuous PPI therapy. Degree of leak was tested for correlation with presence of Barrett’s, use of PPIs, and length of Barrett’s segment and duration of PPI use.RESULTS: Barrett’s patients manifested a near 3-fold greater, upper gastrointestinal sucrose leak than healthy controls. A decrease of sucrose leak was observed in Barrett’s patients who ceased PPI use for 7 d. Although initial introduction of PPI use (in a PPI-naïve population) results in dramatic increase in sucrose leak, long-term, continuous PPI use manifested a slow spontaneous decline in leak. The sucrose leak observed in Barrett’s patients showed no correlation to the amount of Barrett’s tissue present in the esophagus.CONCLUSION: Although future research is needed to determine the degree of paracellular leak in actual Barrett’s mucosa, the relatively high degree of leak observed with in vivo sucrose permeability measurement of Barrett’s patients reflects their PPI use and not their Barrett’s tissue per se.     

Management strategies of Barrett's esophagus

Barrett’s esophagus is a condition resulting from chronic gastro-esophageal reflux disease with a documented risk of esophageal adenocarcinoma. Current strategies for improved survival in patients with Barrett''s adenocarcinoma focus on detection of dysplasia. This can be obtained by screening programs in high-risk cohorts of patients and/or endoscopic biopsy surveillance of patients with known Barrett’s esophagus (BE). Several therapies have been developed in attempts to reverse BE and reduce cancer risk. Aggressive medical management of acid reflux, lifestyle modifications, antireflux surgery, and endoscopic treatments have been recommended for many patients with BE. Whether these interventions are cost-effective or reduce mortality from esophageal cancer remains controversial. Current treatment requires combinations of endoscopic mucosal resection techniques to eliminate visible lesions followed by ablation of residual metaplastic tissue. Esophagectomy is currently indicated in multifocal high-grade neoplasia or mucosal Barrett’s carcinoma which cannot be managed by endoscopic approach.     

Erosive Esophagitis and Barrett's Esophagus in Taiwan (A Higher Frequency than Expected)

In contrast to Western countries, erosiveesophagitis has been considered less common, Barrett'sesophagus presumed less frequent, and hiatal herniaextremely uncommon in the Orient. However, accelerated modernization and adoption of Western customshave resulted in marked life-style changes in manyAsians in the Orient that may potentially affect thefrequency of erosive esophagitis and Barrett's esophagus in this population. Our aim was to determinethe current frequency of erosive esophagitis, Barrett'sesophagus, and other gastroesophageal reflux diseasecomplications in self-referred Chinese patients undergoing upper gastrointestinal endoscopy inTaipei, Taiwan. Between July 1991 and June 1992, 464consecutive patients underwent endoscopy for a varietyof upper gastrointestinal symptoms at a major medical center. The presence of erosive esophagitis,strictures, Barrett's esophagus, and hiatal hernia wasrecorded. The extent of mucosal injury was determined byusing the Savary-Miller grading system. Sixty-six (14.5%) patients were found to have erosiveesophagitis, 9 (2%), Barrett's esophagus, and 32 (7%)hiatal hernias. Erosive esophagitis showed amale-to-female preponderance of 3.1:1. Disease severityincreased with age and peaked during the sixth andseventh decades. We concluded that in contrast toprevious experience, the Chinese population in Taiwanappears to have a higher frequency of erosiveesophagitis, Barrett's esophagus, and hiatal hernia.Increased fat consumption, aging, and other possiblefactors are suggested as possible mechanisms.     

Accuracy of transnasal endoscopy with a disposable esophagoscope compared to conventional endoscopy

AIM: To assess feasibility of unsedated esophagoscopy using a small-caliber disposable transnasal esophagosco-py and to compare its accuracy with standard endoscopy.METHODS: We prospectively included subjects who were referred for upper endoscopy. All subjects un-derwent transnasal endoscopy with E.G. Scan~(TM). The disposable probe has a 3.6 mm gauge and at its distal end there is a 6 mm optical capsule, with a viewing angle of 125°. Patients underwent conventional endos-copy after the completion of E.G. Scan~(TM). We describe the findings detected by the E.G. Scan~(TM) and calculate the diagnostic accuracy, sensitivity, specificity, positive predictive value, negative predictive value and Kappa index for esophageal diagnosis.RESULTS: A total of 96 patients(54 women), mean age of 50.12 years(14 to 79), were evaluated. In all cases we were able to perform esophagoscopy with E.G.Scan~(TM). The average realization time was 5 min. A total of 58 alterations were detected in the esophagus, 49 gastric abnormalities and 13 duodenal abnormalities. We found that for esophageal varices, E.G. Scan~(TM) has sensitivity, specificity and diagnostic accuracy of 95%, 97% and 97%, respectively. Kappa coefficients were 0.32 for hiatal hernia, 0.409 for erosive gastroesopha-geal reflux disease, 0.617 for Barrett's esophagus, and 0.909 for esophageal varices.CONCLUSION: Esophagoscopy with E.G. Scan? is a well-tolerated, fast and safe procedure. It has an ap-propriate diagnostic accuracy for esophageal varices when compared with conventional endoscopy.     

Frequency,histopathological findings,and clinical significance of cervical heterotopic gastric mucosa (gastric inlet patch): a prospective study in 300 patients

The frequency and clinical significance of heterotopic gastric mucosa in the upper esophagus is not sufficiently known. Heartburn or dysphagia could result from mucin and/or acid production in this area. We undertook a prospective study in 300 patients with special attention of the endoscopist to this area. Moreover, clinical symptoms were determined by questionnaire before performing endoscopy. A total of 33/300 (11%) of patients had at least one histologically proven gastric inlet patch without gender or age preference. In 20/33 (61%) cases, the heterotopic gastric mucosa was classified as mixed type, in 8/33 (24%) as oxyntic, and in 5/33 (15%) as mucoid. Helicobacter pylori was present in none of the cases. There was no significant association to the presence of a hiatal hernia, reflux esophagitis, Barrett's esophagus, or gastric/duodenal ulcer. Moreover, there was no association to the reported grade of heartburn in the upper or lower part of the esophagus, recurrent hoarseness, or dysphagia. When thorougly performed, heterotopic gastric mucosa is a quite frequent finding in endoscopy of the upper gastrointestinal tract. The presence of this gastric mucosa in the upper third of the esophagus seems to be rarely the cause of clinical symptoms and little prone to complications.     

Screening pre-bariatric surgery patients for esophageal disease with esophageal capsule endoscopy

AIM:To determine if esophageal capsule endoscopy(ECE)is an adequate diagnostic alternative to esophagogastroduodenoscopy(EGD)in pre-bariatric surgery patients.METHODS:We conducted a prospective pilot study to assess the diagnostic accuracy of ECE(PillCam ESO2,Given Imaging)vs conventional EGD in pre-bariatric surgery patients.Patients who were scheduled for bariatric surgery and referred for pre-operative EGD were prospectively enrolled.All patients underwent ECE followed by standard EGD.Two experienced gastroenterologists blinded to the patient’s history and the findings of the EGD reviewed the ECE and documented their findings.The gold standard was the findings on EGD.RESULTS:Ten patients with an average body mass index of 50 kg/m2were enrolled and completed the study.ECE identified 11 of 14(79%)positive esophageal/gastroesophageal junction(GEJ)findings and 14of 17(82%)combined esophageal and gastric findings identified on EGD.Fisher’s exact test was used to compare the findings and no significant difference was found between ECE and EGD(P=0.64 for esophageal/GEJ and P=0.66 for combined esophageal and gastric findings respectively).Of the positive esophageal/GEJ findings,ECE failed to identify the following:hiatal hernia in two patients,mild esophagitis in two patients,and mild Schatzki ring in two patients.ECE was able to identify the entire esophagus in 100%,gastric cardia in0%,gastric body in 100%,gastric antrum in 70%,pylorus in 60%,and duodenum in 0%.CONCLUSION:There were no significant differences in the likelihood of identifying a positive finding using ECE compared with EGD in preoperative evaluation of bariatric patients.     

Cervical inlet patch-optical coherence tomography imaging and clinical significance

AIM: To demonstrate the feasibility of optical coherence tomography (OCT) imaging in differentiating cervical inlet patch (CIP) from normal esophagus, Barrett’s esophagus (BE), normal stomach and duodenum.METHODS: This study was conducted at the Veterans Affairs Boston Healthcare System (VABHS). Patients undergoing standard esophagogastroduodenoscopy at VABHS, including one patient with CIP, one representative patient with BE and three representative normal subjects were included. White light video endoscopy was performed and endoscopic 3D-OCT images were obtained in each patient using a prototype OCT system. The OCT imaging probe passes through the working channel of the endoscope to enable simultaneous video endoscopy and 3D-OCT examination of the human gastrointestinal (GI) tract. Standard hematoxylin and eosin (H and E) histology was performed on biopsy or endoscopic mucosal resection specimens in order to compare and validate the 3D-OCT data.RESULTS: CIP was observed from a 68-year old male with gastroesophageal reflux disease. The CIP region appeared as a pink circular lesion in the upper esophagus under white light endoscopy. OCT imaging over the CIP region showed columnar epithelium structure, which clearly contrasted the squamous epithelium structure from adjacent normal esophagus. 3D-OCT images obtained from other representative patients demonstrated distinctive patterns of the normal esophagus, BE, normal stomach, and normal duodenum bulb. Microstructures, such as squamous epithelium, lamina propria, muscularis mucosa, muscularis propria, esophageal glands, Barrett’s glands, gastric mucosa, gastric glands, and intestinal mucosal villi were clearly observed with OCT and matched with H and E histology. These results demonstrated the feasibility of using OCT to evaluate GI tissue morphology in situ and in real-time.CONCLUSION: We demonstrate in situ evaluation of CIP microstructures using 3D-OCT, which may be a useful tool for future diagnosis and follow-up of patients with CIP.     

Impairment of secondary peristalsis in Barrett’s esophagus by transnasal endoscopy-based testing

AIM:To investigate dysfunctions in esophageal peristalsis and sensation in patients with Barrett’s esophagus following acid infusion using endoscopy-based testing.METHODS:First,physiological saline was infused into the esophagus of five healthy subjects,at a rate of 10 mL/min for 10 min,followed by infusion of HCl.Esophageal contractions were analyzed to determine whether the contractions observed by endoscopy and ultrasonography corresponded to the esophageal peristaltic waves diagnosed by manometry.Next,using nasal endoscopy,esophageal sensations and contractions were investigated in patients with,as well as controls without,Barrett’s esophagus using the same infusion protocol.RESULTS:All except one of the propulsive contractions identified endoscopically were recorded as secondary peristaltic waves by manometry.Patients with long segment Barrett’s esophagus(LSBE)tended to have a shorter lag time than the control group,although the difference did not reach statistical significance(88±54s vs 162±150 s respectively,P=0.14).Furthermore,patients with LSBE had significantly fewer secondary contractions following the infusion of both saline and HCl than did either the control group or patients with short segment Barrett’s esophagus(4.1±1.2 vs 8.0±2.8,P<0.001 and 7.3±3.2,P<0.01,respectively,following saline infusion;5.3±1.2vs 8.4±2.4 and 8.1±2.9 respectively,P<0.01 for both,following infusion of HCl).CONCLUSION:Using nasal endoscopy and a simple acid-perfusion study,we were able to demonstrate disorders in secondary peristalsis in patients with LSBE.     

食管裂孔疝合并胃食管反流病合并胃间质细胞瘤的外科治疗

目的探讨食管裂孔疝合并胃食管反流病合并胃间质细胞瘤患者的围手术期处理及安全性。 方法统计新疆维吾尔自治区人民医院2012年10月至2015年1月收治的17例食管裂孔疝合并胃食管反流病合并胃间质细胞瘤患者的病案资料,均采用腹腔镜下微创手术,其中单纯食管裂孔疝缝合者13例,生物补片修补者3例,强生PHY补片修补者1例。抗反流术式中行Nissen式胃底折叠术者8例,Dor式胃底折叠术者6例,Toupet式胃底折叠术者3例。病理结果提示极低危险度胃间质细胞瘤8例,低度危险度者4例,中度危险度者3例,高度危险度者1例,极高危险度者1例,回顾性总结分析该类患者围手术期的处理措施。 结果本组患者无围手术期死亡,术后无严重并发症发生,术后患者反流症状均较术前明显改善,反流时间、反流次数、酸反流时间百分比、长反流次数及DeMeester评分较术前明显降低(P<0.05),术后GERD Q量表评分较术前明显减低(P<0.05);LES压力较术前明显提高(P<0.05)。术后切口感染1例,慢性疼痛1例,给予换药、理疗后好转。2例患者术后出现进食哽噎,1例患者术后出现腹泻,嘱其少量多餐、细嚼慢咽,1个月后症状消失。合并贫血患者术后血红蛋白恢复至95 g/L,术后随访中位数10个月,无复发病例。 结论食管裂孔疝合并胃食管反流病合并胃间质细胞瘤患者病情较复杂使得手术风险大,难度高,但只要作好充分的术前准备,采用恰当的手术方式,术中谨慎、细致操作,针对性的处理术后出现的各种问题,仍是安全可行的。     

The potential impact of contemporary developments in the management of patients with gastroesophageal reflux disease undergoing an initial gastroscopy

BACKGROUND:

Recent developments may alter the approach to patients presenting with gastroesophageal reflux disease (GERD)-like symptoms. A newly proposed Montreal consensus definition of Barrett’s esophagus includes all types of esophageal columnar metaplasia, with or without intestinal-type metaplasia. There is also increasing recognition of eosinophilic esophagitis (EE) in patients with GERD-like symptoms.

OBJECTIVE:

To quantify the impact of these developments on a multiphysician general gastroenterology practice in a tertiary care medical centre.

METHODS:

Medical charts of all patients having an initial gastroscopy for GERD-like symptoms over a one-year period were reviewed retrospectively, and audits of their endoscopic images and esophageal biopsies were performed.

RESULTS:

Of the 353 study participants, typical symptoms of heartburn and acid reflux were present in 87.7% and 23.2%, respectively. Less commonly, patients presented with atypical symptoms (eg, dysphagia in 9.4%). At endoscopy, 26% were found to have erosive esophagitis and 12% had endoscopically suspected esophageal metaplasia. Histological evaluation was available for 65 patients. Ten of the 65 biopsied patients (15%) met traditional criteria for Barrett’s esophagus (ie, exhibiting intestinal-type metaplasia), whereas 49 (75%) fulfilled the newly proposed consensus definition of Barrett’s esophagus. Five patients (7.7%) met the study criteria for EE (more than 20 eosinophils per high-power field), four of whom had not been previously recognized.

CONCLUSIONS:

Among patients presenting with GERD-like symptoms, the prevalence of Barrett’s esophagus may increase markedly if the Montreal definition is adopted. In addition, growing awareness of EE may lead to an increase in the prevalence of this diagnosis. Prospective studies of the management implications of these findings are warranted.     

Evaluation of upper gastrointestinal system in acromegaly

PurposeAcromegaly causes multiple comorbidities, including gastrointestinal disorders. The present study evaluated the frequency of hiatal hernia and other upper gastrointestinal pathologies in patients with acromegaly, given that visceromegaly and reduced nitric oxide levels in acromegaly may impact diaphragm and lower esophageal sphincter function and thus possibly the development of hiatal hernia.MethodsThirty-nine acromegaly patients followed our center for the previous 6 months were recruited. Upper gastrointestinal endoscopy was performed once in all patients to evaluate hiatal hernia, esophagitis, gastroduodenitis and ulcer.ResultsTwenty-three patients were male and 16 female. Upper gastrointestinal endoscopy found hiatal hernia, esophagitis and gastroduodenitis or gastric ulcer in 3 (7.6%), 2 (1.7%) and 31 (79.4%) patients, respectively. Pathologic examination of gastric antrum biopsy found intestinal metaplasia in 12 (30.7%) patients, and Helicobacter pylori was positive in 13 (33.3%). There were no significant correlations between age, gender, disease duration or preoperative adenoma size on the one hand and hiatal hernia or other endoscopic findings on the other. Similarly, neither surgical success nor recurrence was associated with endoscopic findings.ConclusionsThe study showed that prevalence of gastritis, duodenitis, peptic ulcer and intestinal metaplasia is higher and prevalence of hiatal hernia lower in acromegaly patients than in the healthy population. Various unknown disease-related pathophysiological conditions may play a role; there is a need for further studies.     

The role of the endoscopist in a multidisciplinary obesity center

The endoscopist plays an integral role in the multidisciplinary treatment of patients with obesity who are undergoing bariatric surgery, particularly in the prevention and treatment of postoperative complications. Although still controversial, routine preoperative EGD should be considered in all bariatric patients, especially those undergoing RYGB, regardless of the presence or absence of symptoms. Endoscopists need to work in close coordination with their bariatric surgery colleagues in all phases of care to maximize the yield and safety of endoscopy in this patient population.     

Barrett's esophagus: prevalence and size of hiatal hernia

OBJECTIVE: Barrett's esophagus is caused by gastroesophageal reflux and predisposes to adenocarcinoma. Hiatal hernia may cause reflux. The prevalence and size of hernias in patients with Barrett's esophagus was investigated. METHODS: Axial hernia length and the width of the diaphragmatic hiatus were measured prospectively at endoscopy. RESULTS: A 2-cm or longer hernia was found in 96% of 46 patients with Barrett's esophagus, in 42% of 103 controls (p < 0.001), and in 72% of 18 patients with short segment Barrett's esophagus (p < 0.05 vs controls). A hernia was found in 71% of 31 controls with esophagitis and in 29% of 72 controls without esophagitis (p < 0.001). Of 54 controls with neither esophagitis or reflux symptoms, 20% had a hernia. Mean hernia length was 3.95 cm in Barrett's esophagus, and 2.81 cm in controls (p < 0.005). Mean hiatus width was 3.52 cm in patients with Barrett's esophagus and hernia, and 2.24 cm in controls with hernia. Hernia length was similar in patients with and without esophagitis, and in short segment Barrett's esophagus. CONCLUSIONS: Most patients with Barrett's esophagus have hiatal hernia; their hernias are longer and the hiatal openings wider than in controls with or without esophagitis. Hiatal hernia likely contributes to the development of Barrett's esophagus.     

Effect of hiatal hernia on esophageal manometry and pH-metry in gastroesophageal reflux disease

An increased frequency of reflux events and a prolonged acid clearance have been shown in gastroesophageal reflux (GER) patients with a hiatal hernia as compared to those without. The objective of the present study was to further investigate esophageal motility and patterns of reflux in GER patients, in relation to the presence or absence of hiatal hernia. Esophageal manometry and ambulatory 24-hr esophageal pH-metry were used in 42 patients with GER and 18 controls. Eighteen of the patients were considered to have a nonreducing hiatal hernia on endoscopy. Hiatal hernia patients showed a higher extent of reflux (total composite score,P=0.016; total reflux time,P=0.008, reflux time in supine position,P=0.024; reflux time in upright position,P=0.008), a lower frequency of reflux events (P=0.005), a more severe esophagitis on endoscopy (P<0.01) and a lower amplitude of peristalsis at 5 cm proximal to LES (P=0.0009) as compared to patients without hiatal hernia. The amplitude of peristalsis at the distal esophagus was inversely related to the extent of reflux (P=0.024). Acid clearance was also significantly prolonged in the hernia subgroup (P=0.011). Although LES resting pressure did not differ significantly between the two subgroups of patients, it was inversely related to the extent of reflux in the patients with hiatal hernia (P=0.0005). It is concluded, that GER patients with hiatal hernia present with an increased amount of reflux and more severe esophagitis, which results in more severely impaired esophageal peristalsis as compared to patients without hernia. Prolonged acid clearance and impaired esophageal emptying observed in patients with hiatal hernia could be the result of both the presence of the hernia itself and the reduced peristaltic activity of the esophagus.     

Diagnosis of Type‐I hiatal hernia: a comparison of high‐resolution manometry and endoscopy

Sliding Type‐I hiatal hernia is commonly diagnosed using upper endoscopy, barium swallow or less commonly, esophageal manometry. Current data suggest that endoscopy is superior to barium swallow or esophageal manometry. Recently, high‐resolution manometry has become available for the assessment of esophageal motility. This novel technology is capable of displaying spatial and topographic pressure profiles of gastroesophageal junction and crural diaphragm in real time. The objective of the current study was to compare the specificity and sensitivity of high‐resolution manometry and endoscopy in the diagnosis of sliding hiatal hernia in patients with gastroesophageal reflux disease. Data were analyzed retrospectively for 83 consecutive patients (61% females, mean age 52 ± 13.2 years) with objective gastroesophageal reflux disease who were considered for laparoscopic antireflux surgery between January 2006 and January 2009 and had preoperative high‐resolution manometry and endoscopy. Manometrically, hiatal hernia was defined as separation of the gastroesophageal junction >2.0 cm from the crural diaphragm. Intraoperative diagnosis of hiatal hernia was used as the gold standard. Sensitivity, specificity and likelihood ratios of a positive test and a negative test were used to compare the performance of the two diagnostic modalities. Forty‐two patients were found to have a Type‐I sliding hiatal hernia (>2 cm) during surgery. Twenty‐two patients had manometric criteria for a hiatal hernia by high‐resolution manometry, and 36 patients were described as having a hiatal hernia by preoperative endoscopy. False positive results were significantly fewer (higher specificity) with high‐resolution manometry as compared with endoscopy (4.88% vs. 31.71%, P= 0.01). There were no significant differences in the false negative results (sensitivity) between the two diagnostic modalities (47.62% vs. 45.24%, P= 0.62). Analysis of likelihood ratios of a positive and negative test demonstrated that high‐resolution manometry is better than endoscopy both to rule out and rule in a hiatal hernia. A significant discordance was also observed between the two tests (P= 0.033). High‐resolution manometry has better specificity and ability to rule out an overt Type‐I sliding hiatal hernia (greater likelihood ratio of a positive test) in patients with GERD. Because of high false negative results, both high‐resolution manometry and endoscopy are unreliable for ruling in a hiatal hernia. Negative result for a hiatal hernia by either modality mandates additional testing.     

Mechanical Gastritis as Cause of Upper Gastrointestinal Hemorrhage

Mechanical gastritis is confirmed as one of the causes of upper gastrointestinal hemorrhage, which is created directly by retching and vomiting in a patient with an esophageal hiatal hernia. Five cases of mechanical gastritis are reported in this paper. The clinical presentation of mechanical gastritis and the Mallory-Weiss syndrome may mimic each other. Upper gastrointestinal endoscopy showed the gastric mucosa to be propelled into the esophagus during nausea. This mucosa showed erosions and superficial ulcerations. The mucosa appeared ‘congested’ at and just below the cardia. It is suggested that the friction and compression of the gastric mucosa prolapsing through a constriction ring of the diaphragm into the hiatal hernia during retching and vomiting may cause mechanical trauma to the gastric mucosa, resulting in gastritis, erosions, and hemorrhage.     

腹腔镜食管裂孔疝修补联合胃底折叠术在西藏基层医院的临床应用

目的探讨在西藏基层医院开展腹腔镜食管裂孔疝修补联合胃底折叠术的疗效及可行性。 方法回顾分析2017年7月至2019年6月于林芝市人民医院普外科41例行腹腔镜食管裂孔疝修补联合胃底折叠术患者的临床资料。记录手术时间、术中出血量、术中并发症、术后住院时间以及术后并发症等情况。计量资料使用均数±标准差表示;计数资料以例数或百分比表示. 结果所有患者均顺利完成腹腔镜手术,平均手术时间为（108.0±33.3）min,平均出血量为（22.7±18.5）ml,术后平均住院时间为（3.5±2.1）d。平均随访14个月,未见复发病例。 结论在西藏基层医院开展腹腔镜食管裂孔疝修补联合胃底折叠术安全有效,适宜推广应用。     

儿童开腹与腹腔镜食管裂孔疝修补＋胃底折叠术的疗效比较

目的比较儿童开腹与腹腔镜食管裂孔疝（HH）修补+胃底折叠术的疗效及安全性。 方法回顾性分析2008年1月至2018年1月新疆维吾尔自治区人民医院收治的经上消化道造影检查诊断为HH的42例患儿。其中20例行开腹HH修补＋胃底折叠术（开腹手术组）,22例行腹腔镜HH修补＋胃底折叠术（腹腔镜手术组）。记录并比较2组患儿的切口长度、手术时间、术中出血量、术后进食时间、术后住院时间,同时观察2组患儿术后疼痛及并发症发生情况,并比较2组患儿术后并发症发生率。 结果腹腔镜手术组患儿切口长度短于开腹手术组患儿［（2.2±0.3）cm vs （7.5±1.1）cm］,且差异有统计学意义（t=20.833,P<0.05）;但2组患儿手术时间、术中出血量差异均无统计学意义［（115.4± 20.5）min vs （104.2±18.6）min,（2.9±0.3）ml vs （3.1±0.5）ml,t=1.552、1.857,P均>0.05］。腹腔镜手术组患儿术后进食时间、术后住院时间均短于开腹手术组患儿［（1.3±0.3）d vs （2.2±0.4）d,（5.2±1.6）d vs （9.3±1.1）d］,且差异均有统计学意义（t=8.182、9.753,P均<0.05）。2组患儿术后并发症发生率差异无统计学意义［9.1% （2/22）vs 5.0% （1/20）,χ²=0.264,P>0.05］。开腹与腹腔镜HH修补＋胃底折叠术均为小儿HH安全、有效的治疗方法。与开腹手术比较,腹腔镜手术术后禁食时间短,术后恢复快,更美观。     

The role of endoscopy in early postoperative haemorrhage

Diagnostic as well as therapeutic endoscopy has a decisive role in management of early postoperative haemorrhage. Endoscopy combines easy access to the upper and lower gastrointestinal tract and application of an array of interventional tools. In near future, even the small bowel will be accessible for diagnostic and therapeutic measures due to the advent of double-balloon enteroscopy. Thus, the endoscopist increasingly replaces the surgeon for diagnosis and therapy of postsurgical bleeding. Published data on frequency and aetiology of postoperative haemorrhage are scarce and mainly casuistic. Sources of gastrointestinal bleeding associated with surgery may be: anastomotic ulcers, mucosal ischaemia, 'stress' ulcers, reflux-induced lesions, coagulopathies (e.g. in sepsis or after organ transplantation) and aortoenteric fistula after bypass surgery. The endoscopist will frequently identify the culprit lesion and guide further management of the patient (e.g. endoscopic approach, repeated surgery, interventional radiology). All accessible lesions in postoperative haemorrhage should primarily be treated by endoscopic means, except aortoenteric fistulas. There is even a place for repeated endoscopy in recurrent bleeding. In the face of lacking controlled data, the endoscopist often has to rely on his personal experience in the selection of therapeutic options.