Background: Gastro-oesophageal reflux (GOR) is a physiological problem in infancy that can become pathological and life-threatening in certain cases. Fundoplication has been shown previously to be effective in the control of this problem when medical therapy fails. Methods: A retrospective review of the hospital records and the Department of Paediatric Surgery database was carried out, in order to demonstrate the Prince of Wales Children Hospital's (POWCH) experience with 106 fundoplications between February 1989 and March 1993. Results: There was a failure rate of 7.5% and a long-term mortality rate of 7.8%. The children most at risk of mortality and morbidity are shown to be the neurologically impaired. The special problems associated with these children as compared with neurologically normal children with pathological GOR are discussed and the literature reviewed. Conclusion: Fundoplication is shown to be a safe operation that can be life-saving in certain circumstances. 相似文献
Background. We explored the efficacy of laparoscopic fundoplication (LF) in patients with uncomplicated, medically recalcitrant pathologic gastroesophageal reflux disease (GERD) for whom we previously would have recommended open surgical repair.
Methods. From January 1994 to January 1998, we performed LF on 150 patients (80 men and 70 women) with GERD recalcitrant to maximal medical therapy. No patient suffered from esophageal stricture or epithelial dysplasia; however 16% (24 of 150) had benign Barrett’s mucosa. Preoperative esophageal manometry and 24-hour pH testing were obtained in 93% (139 of 150) and 89% (134 of 150) of patients, respectively. Nissen LF (n = 123), Toupet LF (n = 26), or Dor LF (n = 1) were accomplished over a large (54 F) intraesophageal bougie. Preoperative (1 month) and postoperative (>6 month) symptom scoring were assessed on a 0 to 10 scale. Thirty-eight patients with a greater than 6-month postoperative period had manometry and pH studies performed.
Results. The laparoscopic approach was successful in 99% (148 of 150) of patients, and there has been no mortality. Operative time was 160 ± 59 minutes. Open conversion was required for 2 patients: because of difficulty with dissection owing to adhesions in 1 case and due to perforation in another. Reoperation was required for 5 patients (1 paraesophageal, 2 dysphagia, 2 recurrent reflux). Major postoperative complications involved stroke and pancreatitis in 1 patient each. Mean hospital stay was 2.6 ± 1.2 days, full activity resumed by 7 days. Postoperative esophageal pH testing among 38 patients tested more than 6 months after operation demonstrated normal esophageal acid exposure in all but 2. GERD symptoms were relieved at 1 month, 6 months, and after 1 year in 95% (128 of 135), 94% (99 of 105), and 93% (65 of 70) of patients, respectively.
Conclusions. Intermediate-term results with LF suggest this to be a reasonable approach to surgical management of medically recalcitrant uncomplicated GERD. Thoracic surgeons interested in GERD should become familiar with minimally invasive surgical approaches. 相似文献
There is a growing body of evidence that laparoscopic surgery is physiologically less injurious than open surgery. We hypothesized that the open technique results in a greater impairment of peritoneal and systemic defense mechanisms than does the laparoscopic technique. Nissen fundoplication, standardized in technique and duration, was performed in 16 pigs. The procedure was performed through a standard midline incision (OPEN, n=8) or with laparoscopic technique and CO2 pneumoperitoneum (LAP, n=8). The peritoneal cavity was instilled with 400 cc of normal saline, either alone (not contamined, n=8) or containing 109E. coli/ml (contaminated, n=8). Quantitative cultures, cell count, and flow cytometry were performed on blood and peritoneal fluid samples obtained at timed intervals. We found that host defense processes were better preserved after LAP than by OPEN surgery. Peritoneal and systemic monocyte class II antigen expression, and serum tumor necrosis factor-alpha activity was greater in the OPEN group compared with the LAP group, but peritoneal bacterial clearance was more efficient in the LAP group. These data may illustrate a potential benefit of laparoscopic surgery in cases of peritoneal contamination.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, TN, USA, 18–19 April 1994Dr. Collet is from the University of Bordeaux, France, and was a visiting Research Fellow 相似文献
Three patients with achalasia, who were successfully managed by laparoscopic Heller myotomy and Nissen fundoplication, are described. Each patient had failed to respond to two pneumatic dilatations of the oesophagus. 相似文献
Background The addition of a Dor antireflux procedure reduces the risk of pathologic gastroesophageal reflux (GER) by ninefold following
laparoscopic Heller myotomy for achalasia. It is not clear, however, how these benefits compare with the increased cost of
the fundoplication. The objective of this study was to estimate the cost-effectiveness of Heller myotomy plus Dor fundoplication
compared with Heller alone in patients with achalasia.
Methods We conducted a cost–utility analysis using the Markov simulation model to examine the two treatment alternatives. The model
estimated the total expected costs of each strategy over a 10-year time horizon. Data for the model were derived from our
randomized clinical trial. The strategies were compared using the method of incremental cost-effectiveness analysis.
Results The incidence of pathologic GER was 47.6% (10 of 21 patients) in the Heller group and 9.1% (2 of 22 patients) in the Heller
plus Dor group using an intention-to-treat analysis (p = 0.005). Heller plus Dor was associated with a significant reduction in the risk of GERD (relative risk 0.11; 95% confidence
interval 0.02–0.59; p = 0.01). The cost of surgery was significantly higher for Heller plus Dor than for Heller alone (mean difference $942; p = 0.04), secondary to a longer operating room time (mean difference 40 min; p = 0.01). At a time horizon of 10 years, when proton pump inhibitor (PPI) therapy costs are considered, the cost–utility analysis
demonstrates that Heller plus Dor surgery is associated with a total cost of $6,861 per patient and a quality-adjusted life
expectancy of 9.9 years, whereas Heller-alone surgery is associated with a cost of $9,541 per patient and a quality-adjusted
life expectancy of 9.5 years.
Conclusions In achalasia patients, Heller myotomy plus Dor fundoplication is preferred to Heller alone because it is both more effective
in preventing postoperative GERD and more cost-effective at a time horizon of 10 years.
Presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) meeting, Hollywood, FL, USA, 13–16 April
2005 相似文献
Laparoscopic fundoplication has emerged as an effective treatment for gastro-oesophageal reflux disease. The majority of patients who have undergone antireflux surgery report an improvement in reflux symptoms and in quality of life. However, some patients are dissatisfied with the outcome of antireflux surgery, and attempts have been made by surgeons to improve the results of this surgery. Careful case selection based on objective evidence of acid reflux, refinement of the surgical technique and 'tailoring' the wrap to suit the patient by selective use of a partial fundoplication may help to optimize the outcome from laparoscopic antireflux surgery. 相似文献
Twelve patients with gastroesophageal reflux following repair of esophageal atresia are presented. Reflux produced recurrent stricture, failure to thrive, repeated pneumonitis, and in one patient, respiratory arrest and nearly death. Treatment consists of positional therapy or fundoplication operation both of which seem less successful in this combination of lesions than with GER and a normal esophagus. There was one death as a late postoperative complication of fundoplication. 相似文献
Background: It has been suggested that antireflux surgery may cause an improvement in esophageal motor function (EMF) and lead to reduced
postoperative dysphagia.
Methods: We evaluated the changes in dysphagia symptom scores and esophageal and lower esophageal sphincter (LES) pressures in patients
before (n= 381), at 6 months (n= 260), and at 24 months (n= 97) after laparoscopic fundoplication.
Results: There was a significant increase in LES basal and nadir pressure following surgery in all patients and an improvement in
EMF only in patients with poor preoperative esophageal motor function. A total of 76% of the patients reported no dysphagia
or an improved dysphagia score 6 and 24 months after surgery. This improvement was more marked in patients with poor EMF.
An improvement in EMF did not correlate with the improvement in dysphagia score reported by other patients. Patients with
increased dysphagia scores 2 years after surgery had significantly higher LES basal and nadir pressures as compared to other
patients.
Conclusions: Laparoscopic Nissen fundoplication is associated with an overall reduction in dysphagia scores and leads to an improvement
in esophageal motor function in patients with poor preoperative esophageal motility. Tightness and inadequate relaxation of
the wrap during swallowing may be a determinant of long-term dysphagia.
Received: 5 May 1997/Accepted: 19 August 1997 相似文献
OBJECTIVE: The capacity of fundoplication to prevent esophageal adenocarcinoma is controversial. Development of cancer is associated with proliferation and anti‐apoptosis, for which little data exist as to their response to fundoplication. Therefore, we wanted to clarify the effect of fundoplication on the magnitude of Ki‐67 and B‐cell lymphoma 2 (Bcl‐2) during 48 months of follow up. METHODS: Ki‐67 and Bcl‐2 were assessed quantitatively from biopsies of the esophagogastric junction (EGJ) and from the distal and proximal esophagus of 20 patients with gastroesophageal reflux disease (GERD) treated by fundoplication. An upper gastrointestinal endoscopy was performed preoperatively and postoperatively at 6 months for 20 patients and 48 months for 16 patients, respectively. Ki‐67 and Bcl‐2 were compared to those of 7 controls. RESULTS: Compared to the preoperative level, Ki‐67 was elevated in the distal (P = 0.012) and proximal (P = 0.007) esophagus at 48 months. Compared to control values, Ki‐67 was lower at 6 months in the EGJ (P = 0.037) and the proximal esophagus (P = 0.003) and higher at 48 months in the distal esophagus (P = 0.002). Compared to control values, Bcl‐2 was lower at 6 months in the EGJ (P = 0.038). Correlations between Ki‐67 and Bcl‐2 were positive in the EGJ (P > 0.001) and in the distal (P = 0.001) and proximal esophagus (P = 0.013). CONCLUSION: Proliferative activity after fundoplication increased during long‐term follow up in the distal esophagus despite a normal fundic wrap and objective healing of GERD. 相似文献