腹腔镜Nissen胃底折叠术治疗胃食管反流病110例报告

目的探讨胃食管反流病（gastroesophageal reflux disease,GERD）的临床表现、腹腔镜Nissen胃底折叠术的治疗效果。方法回顾性分析2007年1月～2008年12月共110例行腹腔镜Nissen胃底折叠术的GERD临床资料。18例以反酸、烧心、嗳气、反食、胸痛等食管内症状为主,92例表现为咳嗽、咳痰、喘息等呼吸道症状为主（6例无反酸、烧心等消化道症状）。结果中转开腹1例,余均成功实施腹腔镜Nissen胃底折叠术。手术时间30～245min,平均67.8min;术中出血量5～450ml,平均28.8ml;术后住院时间2～8d,平均4.1d。术后102例获得6～24个月随访,平均13个月,8例失访。其中66例仅接受电话随访。102例按照症状频次、程度问卷表对其症状进行评分,参考反流性疾病问卷（reflux diagnostic questionnaire,RDQ）评分标准症状评分,术后6个月反酸、烧心、胸痛、咳嗽、喘息、憋气、咽异物感、喉部发紧、声音嘶哑的评分均明显下降（P〈0.05）。87例手术有效,15例手术无效。术后62例（60.8%）出现进食困难,经饮食训练2～6周后60例消失,2例症状严重,经胃镜扩张后缓解。1例术后2个月食管裂孔疝复发,再次腹腔镜手术修补。36例术后3个月选择性地进行了胃镜、24h食管pH监测和食管压力监测复查。28例食管炎患者复查胃镜,25例恢复正常,1例从Ⅲ级转为Ⅰ级,1例从Ⅱ级转为Ⅰ级,1例无变化;31例复查24h食管pH值监测,DeMeester评分恢复正常30例,1例从中度降至轻度;18例复查食管测压,下食管括约肌（LES）静息压从术前的1.2～34.1（中位数14.3）mmHg升至14.3～33.0（中位数20.0）mmHg（Z=3.72,P=0.000）。结论腹腔镜Nissen胃底折叠术是治疗GERD的有效方法,具有微创、损伤小、病人恢复快和操作安全的优点,对诊断明确的以食管外症状为主要表现的GERD特别值得提倡。

Laparoscopic Nissen Fundoplication in the Treatment of Gastroesophageal Reflux Disease:Report of 110 Cases

Objective To explore the clinical manifestations of patients with gastroesophageal reflux disease （GERD） and evaluate the therapeutic efficacy of the laparoscopic Nissen fundoplication （LNF） for the disease. Methods Retrospectively analyzed our database of 110 patients, who underwent LNF for GERD from January 2007 to December 2008. Of the patients, 18 cases suffered mainly from esophagus symptoms including acid reflux, heartburn, belching, food reflux, and chest pain; in the other 92 patients, the predominant manifestations are respiratory symptoms like cough, phlegm and dyspnea （6 of the patients had nodigestive syndromes at all）. Results All the patients, except one case, received LNF without conversion to laparotomy. The operation time ranged from 30 to 245 minutes with a mean of 67.8 minutes; the patients had blood loss ranged from 5 to 450 ml with a mean of 28.8 ml. They were discharged from our hospital in 2 to 8 days （mean, 4.1 days） after the surgery. Afterwards, 102 of them achieved a follow-up for 6 to 24 months （mean, 13 months; 66 of them received follow-up by interviews over the phone）; the other eight patients were lost. During the follow-up, a questionnaire regarding to the frequency and gravity of symptoms were conducted in the 102 patients; a symptoms score was then made refer to the criteria for Reflux Diagnostic Questionnaire （RDQ） Score. The score showed that the symptoms including acid reflux, heartburn, chest pain, cough, dyspnea, lump sensation in the pharynx, tight throat sensation, and hoarseness are improved significantly （P0.05）. The operation was effective in 87 of the 102 patients, and non-effective in the other 15. Sixty-two patients （62/102, 60.8%） developed dysphagia after the surgery, and was cured after 2- to 6-week training in 60 patients; the other two patients were cured after dilation by gastroscopy. One patient showed recurrent esophageal hiatal hernia in two months after the operation, and received a second laparoscopic treatment for repair. Thirty-six patients received selective re-examination by gastroscopy, or 24-hour esophageal pH or pressure monitoring in three months after the operation; 28 of them, who had esophagitis, received re-examination by gastroscopy, which showed normal results in 25 cases, improvement in two cases （from grade Ⅲ to grade Ⅰ in one case, and from grade Ⅱ to grade Ⅰ in another）, and no improvement in one case; 24-hour esophageal pH were monitored in 31 patients, the examination showed normal DeMeester score in 30 of them, and improvement from moderate to mild disease in the other one; 18 patients received 24-hour esophageal pressure monitor, which showed the resting pressure of the LES elevated from a medium of 14.3 mm Hg （ranged from 1.2 to 34.1） to a medium of 20.0 mm Hg （raged from 14.3 to 33.0）（Z=3.72, P=0.000）.Conclusion LNF is an effective treatment for GERD with minimal invasion, high safety and quick recovery, especially for the patients with extraesophageal symptoms of reflux.