食管肌层切开术联合胃底折叠术治疗食管运动功能障碍性疾病的远期疗效

目的 比较食管肌层切开术加不同胃底折叠术式治疗贲门失弛缓症或弥漫性食管痉挛的远期效果.方法 1978年1月至1998年10月,共64例贲门失弛缓症或弥漫性食管痉挛患者经左胸行Heller手术+抗反流手术.其中21例加行Nissen全胃底折叠术(Nissen组),43例加行BelseyⅣ式部分胃底折叠术(Belsey组).患者于手术前后行影像学、食管核素排空、食管压力测定和内窥镜检查及24 h pH值监测.结果 全组无手术死亡及严重并发症.术后6年随访,Nissen组吞咽困难(P=0.025)及核素潴留(P=0.044)的发生率高于Belsey组.两种术式均可降低食管下括约肌的压力梯度.Nissen组术后食管直径较术前增加(P=0.012),而Belsey组增加不明显(P=0.695).两组烧心与反酸症状均少见.Nissen组有8例患者、Belsey组有1例患者因复发性吞咽困难需行二次手术(P＜0.01).结论 在治疗贲门失弛缓症或弥漫性食管痉挛患者时,加行全胃底折叠术可能并不适宜,而部分胃底折叠术可以提供满意的抗反流效果,且不会显著影响食管排空功能.

Long-term result of total versus partial fundoplication following esophagomyotomy for primary esophageal motor disorders

OBJECTIVE: To compare the long-term results of total and partial fundoplication on myotomized esophagus. METHODS: From January 1978 to October 1998, 64 patients with achalasia or diffuse esophageal spasm underwent esophagomyotomy and antireflux operation via left thoracotomy. Twenty-one patients underwent Nissen total fundoplication (Nissen group) and 43 patients underwent Belsey Marker IV partial fundoplication (Belsey group). Clinical, radiologic, radionuclide transit, manometric, 24-hour pH monitoring and endoscopic assessments were performed before and after the operation. RESULTS: There was no operative death and major complications for either group. At over 6 years follow-up and compared to Belsey group, patients in Nissen group revealed a higher frequency of dysphagia (P = 0.025) and more radionuclide material retention (P = 0.044). Both operative procedures reduced the lower esophageal sphincter pressure gradient. However, in Nissen group, the esophageal diameter observed on radiology was significantly increased from 3.9 cm preoperatively to 5.5 cm postoperatively (P = 0.012), while it kept the same for Belsey group (from 5.4 to 5.3 cm, P = 0.695). Reoperation in order to relieve the recurrent dysphagia and esophageal obstruction was performed on 8 patients in Nissen group and 1 in Belsey group (P < 0.01). CONCLUSION: When treating achalasia or diffuse esophageal spasm by esophageal myotomy and an antireflux operation, a total fundoplication is not appropriate, whereas a partial fundoplication provides proper antireflux effect without significant esophageal emptying difficulty.