良性气道狭窄的药物治疗

气道损伤时,伤口愈合过程异常是导致肥厚性瘢痕形成和气道管腔狭窄的原因,愈合过程可分为3个阶段：炎症期、增生期及成熟期.针对不同愈合阶段,所应用的预防和治疗瘢痕形成及气道狭窄的药物是不同的.具体包括：抗生素和类固醇、丝裂霉素、紫杉醇、5-氟尿嘧啶/氟羟强的松龙结合物、卤夫酮、抗反流药物、免疫抑制剂、生长因子等.本文综述了上述药物在细胞、动物及临床试验中治疗气道狭窄的作用、安全性及应用前景.     

Surgical Reintervention After Failed Antireflux Surgery: A Systematic Review of the Literature

Background  Outcome and morbidity of redo antireflux surgery are suggested to be less satisfactory than those of primary surgery. Studies reporting on redo surgery, however, are usually much smaller than those of primary surgery. The aim of this study was to summarize the currently available literature on redo antireflux surgery. Material and Methods  A structured literature search was performed in the electronic databases of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. Results  A total of 81 studies met the inclusion criteria. The study design was prospective in 29, retrospective in 15, and not reported in 37 studies. In these studies, 4,584 reoperations in 4,509 patients are reported. Recurrent reflux and dysphagia were the most frequent indications; intraoperative complications occurred in 21.4% and postoperative complications in 15.6%, with an overall mortality rate of 0.9%. The conversion rate in laparoscopic surgery was 8.7%. Mean(±SEM) duration of surgery was 177.4 ± 10.3 min and mean hospital stay was 5.5 ± 0.5 days. Symptomatic outcome was successful in 81.1% and was equal in the laparoscopic and conventional approach. Objective outcome was obtained in 24 studies (29.6%) and success was reported in 78.3%, with a slightly higher success rate in case of laparoscopy than with open surgery (85.8% vs. 78.0%). Conclusion  This systematic review on redo antireflux surgery has confirmed that morbidity and mortality after redo surgery is higher than after primary surgery and symptomatic and objective outcome are less satisfactory. Data on objective results were scarce and consistency with regard to reporting outcome is necessary.     

Absence of gastroesophageal reflux disease in a majority of patients taking acid suppression medications after Nissen fundoplication

Recent studies have shown that many patients use acid suppression medications after antireflux surgery. The aim of this study was to determine the frequency of gastroesophageal reflux disease in a cohort of surgically treated patients with postoperative symptoms and a high prevalence of acid suppression medication use. The study group consisted of 86 patients who had symptoms following Nissen fundoplication that were sufficient to merit evaluation with 24-hour distal esophageal pH monitoring. All completed a detailed symptom questionnaire. The mean postoperative follow-up period was 28 months (median 18 months). Thirty-seven patients (43%) were taking acid suppression medications after fundoplication. Only 23% (20 of 86) of all the patients and only 24% (9 of 37) of those taking acid suppression medications had abnormal esophageal acid exposure on the 24-hour pH study. Heartburn and regurgitation were the only symptoms that were significantly associated with an abnormal pH study. Endoscopic assessment of the fundoplication was the most significant factor associated with an abnormal pH study. Multivariable logistic regression analysis showed that patients with a disrupted, abnormally positioned fundoplication had a 52.6 times increased risk of abnormal esophageal acid exposure. Most patients who use acid suppression medications after antireflux surgery do not have abnormal esophageal acid exposure, and the use of these medications is thus often inappropriate. Because of the limited predictive power of symptoms, objective evidence of reflux disease should be obtained before prescribing acid suppression medication for patients who have undergone antireflux surgery. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Ga., May 20–23, 2001.     

回肠折叠包埋式输尿管抗返流吻合的临床应用

为证实回肠折叠包埋式输尿管抗返流的低压回肠代膀胱术的实用价值，自１９９２年８月－１９９５年１月，对１２例膀胱癌患者施行回肠折叠包埋式输尿管抗返流的低压回肠代膀胱术，随访３－２９个月，患者可获得近似生理状态的排尿，无尿失禁及残余尿。术后定期膀胱造影，未发现明显输尿管返流。回肠折叠包埋式输尿管抗返流吻合，操作简单，效果可靠，值得临床应用。     

Incidence of Antireflux Surgery in Finland 1988-1993: Influence of Proton-Pump Inhibitors and Laparoscopic Technique

Background: The advent of proton-pump inhibitors, and subsequently of the laparoscopic technique, can be assumed to have influenced the use of antireflux surgery in gastro-oesophageal reflux disease. Methods: Data on antireflux operations carried out in Finland in 1988-93 were obtained from national statistics, and the number of operations performed laparoscopically in 1993 was ascertained by a questionnaire to all relevant units. The rates per 100,000 population in the catchment areas were calculated. Results: Antireflux surgery almost always implied fundoplication. During 1993, 784 fundoplications and 43 other antireflux procedures were performed in Finland (total population around 5 million). The fundoplication rate per 100,000 population rose from 8.8 to 15.4 between 1988 and 1993. The increase was minimal (8.1-8.2) in 1990-91 when the first proton-pump inhibitor, omeprazole, was introduced, but remarkably greater (12.8-15.4) in 1992-93, when the laparoscopic technique became popular. Differences in fundoplication rates were six to tenfold between health service districts and even larger between hospitals. Conclusions: The numbers of antireflux operations in Finland were almost static when proton-pump inhibitors were introduced, but rapidly increased after the advent of the laparoscopic technique. Remarkable discrepancies were found in the incidence of fundoplication between different areas and hospitals.     

Risk factors affecting the Barrett's metaplasia-dysplasia-neoplasia sequence

Esophageal adenocarcinoma has the fastest growing incidence rate of any cancer in the United States, and currently carries a very poor prognosis with 5 years relative survival rates of less than 15%. Current curative treatment options are limited to esophagectomy, a procedure that suffers from high complication rates and high mortality rates. Metaplasia of the esophageal epithelium, a condition known as Barrett's esophagus(BE), is widely accepted as the precursor lesion for adenocarcinoma of the esophagus. Recently, radiofrequency ablation has been shown to be an effective method to treat BE, although there is disagreement as to whether radio-frequency ablation should be used to treat all patients with BE or whether treatment should be reserved for those at high risk for progressing to esophageal adenocarcinoma while continuing to endoscopically survey those with low risk. Recent research has been targeted towards identifying those at greater risk for progression to esophageal adenocarcinoma so that radio-frequency ablation therapy can be used in a more targeted manner, decreasing the total health care cost as well as improving patient outcomes. This review discusses the current state of the literature regarding risk factors for progression from BE through dysplasia to esophageal adenocarcinoma, as well as the current need for an integrated scoring tool or risk stratification system capable of differentiating those patients at highest risk of progression in order to target these endoluminal therapies.     

Recurrent Symptoms after Fundoplication with a Negative pH Study—Recurrent Reflux or Functional Heartburn?

Introduction  A small cohort of patients present after antireflux surgery complaining of recurrent heartburn. Over two thirds of these patients will have a negative 24-h pH study. The aim of our study is to determine whether these patients have an associated functional disorder or abnormal cytokine activity and to examine the reproducibility of pH testing. Methods  A prospective analysis was carried out on a cohort of patients who had undergone a fundoplication and postoperative pH testing for recurrent heartburn: group A—patients with recurrent heartburn and a negative 24-h pH study and group B (control group)—patients with recurrent heartburn and a positive pH study. Questionnaires, a blood sample, and repeat pH testing were completed. Results  Sixty-nine patients were identified. Group A’s depression score (8.6 ± 4.1) was significantly higher than group B’s (5.9 ± 4.2; P = 0.03). Cytokine levels were similar in both groups. Forty-seven of 49 (96%) patients who underwent repeat pH testing had a negative study. Symptom-reflux correlation was highly significant (P < 0.001). Conclusion  Some patients with recurrent heartburn and a negative pH study have associated functional or psychiatric comorbidities such as depression. Reproducibility of 24-h pH testing in these patients is excellent.     

How I Do It: Laparoscopic Heller Myotomy with Toupet Fundoplication for Achalasia

Achalasia, an esophageal motility disorder characterized by aperistalsis and failure of lower esophageal sphincter (LES) relaxation, is most effectively treated by surgical ablation of the LES. In this report, we describe our technique of laparoscopic extended Heller myotomy with Toupet partial posterior fundoplication. The technical details of this procedure include careful division of the longitudinal and circular muscle fibers of the LES anteriorly, including extension of the myotomy 3 cm distal to the esophagogastric junction onto the gastric cardia. The Toupet procedure, involving a posterior wrap of the gastric fundus which is secured to both edges of the myotomy as well as to the crura of the hiatus, is added to prevent post-myotomy gastroesophageal reflux. From a recently published report, mean dysphagia scores remained low (3 out of 10 severity on a visual analog scale) and symptoms of reflux were reported minimally in a series of 63 patients followed for a median of 45 months. This technique provides excellent and durable relief of dysphagia associated with achalasia while minimizing post-myotomy acid reflux symptoms.     

Mortality,Reoperation, and Hospital Stay Within 90 Days of Primary and Secondary Antireflux Surgery in a Population-Based Multinational Study

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