儿童腹腔镜下胃底折叠术10年小结

目的探讨腹腔镜下不同胃底折叠术治疗儿童胃食管反流性疾病的疗效。方法回顾性分析2000年10月～2011年2月10年中2个儿童医疗中心收治儿童胃食管反流性疾病81例(上海儿童医学中心30例,新华医院51例)临床资料,包括食管裂孔疝76例,单纯严重胃食管反流5例。男49例,女32例。年龄25天～11岁。2例有食管裂孔疝修补手术史。采用5个5 mm trocar分别经脐和两上腹、两侧中腹部进腹,保留脾胃韧带完成食管裂孔疝修补和胃底折叠术。结果79例镜下完成手术(包括Nissen-Rossetti术37例,Thal术42例),2例中转开放手术。出院前均行食管钡餐(GI)复查,37例Nissen-Rossetti术后9例轻～中度食管下端狭窄,1～2次扩张后缓解症状;42例Thal术后7例存在轻度反流。术后69例获随访,时间2个月～7年,平均26个月。2例食管裂孔疝术后1个月复发,再次镜下手术,1例证实膈肌脚尼龙缝合线松脱,1例裂孔关闭不够,仍有一较小旁疝形成,均再次镜下修补,术后恢复好;1例术后出现发作性腹痛伴呕吐;1例智力发育障碍者术后吞咽功能退化,顽固性拒食,长期鼻胃管喂养;2例胃食管轻～中度反流伴有胃动力差。其余63例术后生长发育好,术前临床症状消失。结论①腹腔镜下胃底折叠术治疗各种原因导致的儿童胃食管反流是一种安全有效的手术途径。②对于食管裂孔疝,选择镜下Thal术可有效减少术后食管狭窄的发生。③对于严重胃食管反流,选择Nissen-Rossetti术,术后抗反流效果更确切,与传统的Nissen术相比,保留胃短血管的Nissen-Rossetti术操作更简便。

Overview of a 10-year Experience on Laparoscopic Fundoplication in Children with Gastroesophageal Reflux Diseases

Objective This retrospective study reports our experience on laparoscopic partial and total fundoplication in children with gastroesophageal reflux diseases(GERD) during the past ten years in two children’s medical centers.MethodsFrom October 2000 to February 2011,81 children(49 male and 32 female,aged from 25 days to 11 years) with GERD,including 76 cases of hiatal hernia and 5 cases of severe simple GERD,received treatment in Shanghai Children’s Medical Center(30 cases) and Shanghai Xinhua Hospital(51 cases).Two of the patients had history of hiatal hernia repair.We placed five 5-mm trocars through the umbilicus,and both sides at the upper and middle abdomen,to finish hiatal hernia and fundoplication with the gastrolienal ligament preserved.Results Laparoscopic procedures were completed in 79 cases,including 37 cases of Nissen-Rossetti procedures,and 42 cases of Thal procedures,the other 2 patients were converted to open surgery.All the patients received reexamination by GI before being discharged,which showed mild to moderate lower esophageal stricture in 9 patients who underwent Nissen-Rossetti(the patients were then cured by balloon catheter dilatation),and mild reflux in 7 patients who received the Thal.We followed 69 of the patients for 2 months to 7 years with a mean of 26 months.During the follow-up,one patient had abdominal pain and vomit,and two patients showed recurrent hiatal hernia in one month and thus received a second laparoscopic surgery.The two cases of recurrent hernia were caused by loosened suture or incomplete closure,both the patients recovered well after the second operation.One patient,who had mental development disorder,developed dysphasia and thus had received nasogastric feeding for 3 years.Conclusions Laparoscopic fundoplication is a safe and effective approach for gastroesophageal reflux in children.With the Thal procedure,the rate of postoperative esophageal stricture is reduced in patients with hiatal hernia.Whereas,for patients with simple severe GERD,Nissen-Rossetti procedure is more effective.The Nissen-Rossetti procedure with the short gastric vessel preserved is more convenient than the traditional Nissen procedure.