腹腔镜治疗食管裂孔疝术后吞咽困难的比较

目的:探讨食管裂孔疝行腹腔镜裂孔修补术加Nissen360°胃底折叠术和Toupet270°胃底折叠术后吞咽困难的发生率.方法:回顾分析天津市南开医院2012-02/2014-02采用腹腔镜技术治疗的64例食管裂孔疝患者资料,其中行腹腔镜Nissen360°胃底折叠术32例,行腹腔镜Toupet270°胃底折叠术32例.对两组术后吞咽困难的发生率、术后反酸发生率、手术时间、术中出血量、术后Demeester评分及术后住院时间进行观察,并进行统计学分析.结果:术后Nissen组有6例出现吞咽困难,这6例吞咽困难病例均未使用补片修补,予对症治疗3 mo后,4例吞咽困难仍不能缓解,行胃镜下扩张术后症状缓解;有1例术后出现轻度反酸,经抑酸治疗后症状缓解.术中Toupet组有1例巨大食管裂孔疝使用补片修补,术后Toupet组未出现吞咽困难病例,有2例患者出现轻度反酸,经抑酸、促进胃动力治疗后症状消失.术后吞咽困难的发生率Nissen组高于Toupet组,比较有统计学差异(P0.05).两组间手术时间、术中出血量、术后反酸的发生率、术后Demeester评分及术后住院时间差异无统计学意义(P0.05).结论:食管裂孔疝患者行Nissen360°胃底折叠术术后吞咽困难的发生率高于行Toupet270°胃底折叠术.     

腹腔镜Nissen和Toupet胃底折叠术治疗食管裂孔疝合并胃食管反流病的术后效果评价

目的探讨腹腔镜Nissen和Toupet胃底折叠术治疗食管裂孔疝合并胃食管反流病的疗效和术后并发症。 方法回顾性分析2014年7月至2016年7月,在中国医科大学附属盛京医院行腹腔镜下食管裂孔疝修补联合胃底折叠术的57例食管裂孔疝合并胃食管反流病患者的临床资料,其中24例行Nissen胃底折叠术式(Nissen组),33例行Toupet胃底折叠术式(Toupet组)。观察并比较2组患者的术后抗反流效果及发生术后并发症情况。 结果57例均顺利完成腹腔镜下手术,无中转开腹,手术时间68～115 min,平均手术时间(75.8±6.4)min;术中出血量15～30 ml,平均出血量(22±5)ml;2组患者均使用补片行食管裂孔疝修补术;术后24 h进流食,术后平均住院日(10.5±3)d。2组患者手术时间,出血量,住院日无明显差别。57例患者均得到随访,随访时间为6个月至2.5年,平均随访时间为18个月。术后均未出现反酸,烧心等胃食管反流病典型症状,无复发病例。Nissen组术后有2例(8.2%)患者出现吞咽困难,Toupet组术后有8例(24.2%)出现吞咽困难,Toupet组术后并发症发生率明显高于Nissen组。术前伴有胃食管反流病的患者行胃镜检查均有不同程度的食管炎症,所有患者术后均复查胃镜、食管测压及食管24 h pH值监测。复查结果显示,2组患者术后较术前食管下括约肌压力均有明显改善,食管下括约肌长度也均明显延长。 结论腹腔镜下Nissen术式在术后出现吞咽困难发生率上少于Toupet术式,但2种术式抗反流效果无明显差异。     

食管球囊联合超细胃镜扩张贲门失弛缓症1例

对1例中年贲门失弛缓症患者于超细胃镜直视下应用食管球囊预扩张一次的基础上,将胃镜插至胃底反转对球囊定位后再次扩张.扩张口径满意,无穿孔；症状缓解,随访1mo无复发.     

聚丙烯补片在腹腔镜下食管裂孔疝修补联合胃底折叠术的临床应用

目的探讨聚丙烯补片在腹腔镜下食管裂孔疝修补联合胃底折叠术治疗食管裂孔疝合并胃食管反流病的临床疗效。 方法回顾性分析新疆维吾尔自治区人民医院2013年5月至2015年3月,住院治疗并使用聚丙烯补片(强生PHY补片)行腹腔镜下食管裂孔疝修补术联合胃底折叠术的38例患者临床资料,总结上述患者术前、术后6个月24 h食管pH监测、高分辨率食管测压、胃食管反流病调查问卷(GERD-Q)量表评分及术后并发症特点。 结果全部患者手术顺利无中转术式等情况,其中Nissen术式27例,Toupet术式8例,Dor术式3例。术后患者反流症状均较术前明显改善,术后反流时间、反流次数、DeMeester评分、GERD-Q量表评分等较术前明显降低,差异有统计学意义(P<0.05),术后出现吞咽困难3例,腹部胀气2例,随访过程中无严重并发症发生,无复发。 结论使用聚丙烯补片行腔镜食管裂孔疝修补联合胃底折叠术是治疗食管裂孔疝的有效方法,具有微创、恢复快、并发症少、复发率低等特点。     

先天性食管闭锁术后吻合口狭窄的内镜下放射状切开术联合球囊扩张术治疗初探

目的 评估内镜下放射状切开术联合球囊扩张术治疗先天性食管闭锁术后吻合口狭窄的疗效及安全性。 方法 2017年1—6月,因先天性食管闭锁术后吻合口狭窄在济南市儿童医院接受内镜下放射状切开术联合球囊扩张术治疗的患儿共4例,采用回顾性分析方法,对4例患儿的治疗及随访情况进行总结和分析。 结果 内镜下放射状切开术用时35～65 min,其中3例术程顺利,另一例术中出现呼吸困难经停止内镜操作及加压给氧后好转,4例术后3周的吞咽困难评分在2～3分,较术前的3～4分均有降低。在内镜下放射状切开术后随诊过程中,1例术后3周吞咽困难再次反复,予球囊扩张治疗后吞咽困难缓解;其余3例均在内镜下放射状切开术后3周辅以球囊扩张术1～2次,球囊扩张术过程顺利,无不良反应发生。4例随访2～3个月,上消化道造影显示造影剂可顺利通过狭窄部位,吞咽困难评分下降至0～1分。 结论 内镜下放射性切开术治疗先天性食管闭锁术后吻合口狭窄的短期疗效显著,但易出现再次狭窄,联合球囊扩张治疗后,既能做到选择性切开狭窄又能对狭窄部位瘢痕组织进行均匀扩张,从而达到更好的扩张治疗效果,同时又能有效避免穿孔并发症的发生。     

基层医院开展腹腔镜下食管裂孔疝修补术的前景分析

目的评价基层医院开展腹腔镜下食管裂孔疝修补术的临床效果及前景分析。 方法回顾性分析2013年5月至2017年1月库车县人民医院行腹腔镜下食管裂孔疝修补术的8例患者的手术效果及预后。 结果8例患者均采用腹腔镜食管裂孔疝修补术加胃底折叠术(Nissen)360°胃底折叠术,其中2例使用双面合成补片,2例使用生物补片,术后反流性食管炎症状如：胸骨后灼烧样疼痛、反酸、嗳气完全缓解。无中转开腹、手术并发症、死亡。术后随访12～48个月,8例患者术后均无复发症状。复查胃镜,食管炎症及溃疡完全治愈。 结论腹腔镜食管裂孔疝修补术在具备腹腔镜设备条件及技术水平的基层医院有广阔的应用前景。     

食管裂孔疝围手术期加速康复护理体会

目的食管裂孔疝的加速康复护理围手术期的护理措施的优化。 方法回顾分析在接受腹腔镜下食管裂孔疝修补+胃底折叠术治疗的食管裂孔疝的32例患者围手术期的系统性护理措施,总结食管裂孔疝围手术期的快速康复护理要点。 结果32例患者均顺利完成手术,术后胃管留置（22.4±3.5）h、腹腔引流管（30.2±4.6）h、1例出现气胸的胸腔闭式引流69 h;恢复排气时间（21.3±2.4）h、排便时间（37.6±3.2）h、进食时间为（23.5±2.6）h;并发症发生率方面出现吞咽困难2例、气胸1例。 结论围手术期的优化护理措施,一定程度上加快了食管裂孔疝患者术后康复。     

腹腔镜食管裂孔疝修补联合胃底折叠术20例临床分析

目的探讨腹腔镜手术治疗食管裂孔疝的可行性、临床应用价值及安全性。 方法选取2012年3月至2017年9月,淄博市中心医院行腹腔镜食管裂孔疝修补联合胃底折叠术20例患者的临床资料,并评价其临床和预后效果。 结果20例患者均顺利完成腹腔镜手术,无中转开腹病例,行Nissen术患者16例、Toupet术4例,20例患者均使用不吸收线修补,7例患者使用U型补片。手术时间95~180 min,平均150 min;术中出血量30~70 ml,平均40 ml;术后24~48 h进流质饮食,术后临床症状均得到有效缓解,无严重并发症及死亡病例,1例胸骨后疼痛患者术后当晚症状消失,3例患者术后3 d出现吞咽困难及进固体食物时轻度哽噎感,经饮食教育2周后症状均得到缓解;4例患者术后1周出现腹泻,给予对症治疗后1周症状缓解;3例患者术后2周反酸症状复发,应用抑酸药物后症状缓解;术后住院时间3~7 d,平均4.1 d;20例患者均得到随访,随访时间3个月至5年,平均2.6年,无死亡病例,无解剖学复发病例,手术结果满意率95.0%。 结论腹腔镜微创手术治疗食管裂孔疝,充分体现了创伤小、恢复快、安全可行、疗效可靠的特点,具有推广价值。     

老年食管裂孔疝102例临床特点

目的 探讨老年食管裂孔疝诊断及治疗特点.方法 回顾性分析手术治疗的102例老年食管裂孔疝患者的临床资料,包括年龄、病程、合并疾患、食管裂孔疝类型、手术方式、围术期并发症等.结果 本组平均年龄(70.8+13.7)岁;病程1个月～10年;合并基础疾病70例(68.63％).食管裂孔疝分型:Ⅰ型46例、Ⅱ型30例、Ⅲ型17例、Ⅳ型9例.早期术式为经胸或经腹食管裂孔疝修补术加胃底折叠术共70例;腹腔镜手术26例,其中Nissen术式10例,Toupet术式16例.36例患者采用巴德补片行疝修补术.全组病人无手术相关死亡.开放经胸或经腹手术病人术后出现肺部感染12例( 12/70,17.14％),肺不张2例,反酸5例(5/70,7.14％);腹腔镜术后肺部感染2例(2/26,7.69％),反酸2例(2/26,7.69％).腹腔镜术后肺部感染发生率显著低于开放手术(P＜0.05),反酸则无明显差异(P＞0.05).本组病例术后均无明显吞咽不畅等症状.结论 老年食管裂孔疝患者临床表现多样,容易误诊;术前应完善胃镜等各项检查;补片修补可显著降低术后复发率.腹腔镜食管裂孔疝修补术及胃底折叠术是一种安全有效的手术方式.     

基层县医院开展腹腔镜治疗滑动型食管裂孔疝合并反流性食管炎十例报道

目的探讨基层医院开展腹腔镜手术治疗滑动型食管裂孔疝合并反流性食管炎手术的疗效及可行性。 方法收集2009年3月至2014年12月,焉耆县人民医院诊断为滑动型食管裂孔疝合并反流性食管炎的10例患者,采用腹腔镜探查并行食管裂孔疝修补同时行胃底折叠术。 结果10例手术顺利完成,无中转开腹,平均手术时间113 min,平均出血量45.5 ml,平均住院时间7.6 d,术后1、6个月行胃镜复查显示患者的食管炎治愈,食管及胃溃疡病灶较前明显好转,术后随访11～18个月未出现疝复发及胃食管反流症状。 结论对于滑动型食管裂孔疝合并反流性食管炎患者可以采用腹腔镜食管裂孔疝修补联合胃底折叠术抗反流治疗,在有腹腔镜条件及中转开腹经验的县级医院可以开展,其手术创伤小、手术效果较理想,值得临床推广。     

Outcome of floppy Nissen fundoplication with intraoperative manometry to treat sliding hiatal hernia

SUMMARY.  The aim of this study was to evaluate the effectiveness of floppy Nissen fundoplication with intraoperative esophageal manometry. Between February 1992 and July 2004, there were 102 patients with sliding hiatal hernia undergoing transabdominal Nissen fundoplication. They were divided into three groups: 27 patients were in the Nissen group (CNF), 44 in the floppy Nissen group (FNF, including 5 with laparoscopic Nissen fundoplication), and 31 in the intraoperative-esophageal-manometry group (INF, 13 with laparoscopic Nissen fundoplication). There were no operation-related deaths. Operation-related complications occurred in five patients within 1 month after operation: In CNF, two patients suffered from dysphagia and one from regurgitation; in FNF, one patient had slight dysphagia and two had regurgitation; in INF, there was no one who complained about dysphagia or regurgitation, but pneumothorax occurred in one case. After more than 2 years of follow-up, two patients, in CNF, suffered from severe dysphagia, one recurred and two with abnormal 24 h pH monitoring. In FNF, one patient had dysphagia, one recurred and three had abnormal 24 h pH monitoring; in INF, two patients had acid reflux on 24 h pH monitoring. The postoperative lower esophageal sphincter pressure was in the normal range in 30 of 31 patients (96.5%). The normal rate of postoperative tests in CNF, FNF and INF were 81.5%, 86.4% and 93.5%, respectively. Both the Nissen fundoplication and the floppy Nissen fundoplication are effective approaches to treat patients with sliding hiatal hernia. Intraoperative manometry is useful in standardizing the tightness of the wrap in floppy Nissen fundoplication and may contribute to reducing or avoiding the occurence of postoperative complications.     

腹腔镜抗反流手术术后并发症的处理

目的探讨腹腔镜抗反流手术术后并发症的评估及处理方法。 方法回顾性分析2005年9月至2014年4月,新疆维吾尔自治区人民医院施行腹腔镜抗反流手术725例患者的临床资料,并对并发症患者进行治疗分析。 结果725例患者均成功完成食管裂孔疝修补＋胃底折叠术。术后并发症患者45例,其中吞咽困难21例,食管裂孔疝复发(折叠的胃底疝入胸腔)4例,症状复发14例,胃肠胀气综合征6例。随访6个月至9年,平均36.6个月。 结论腹腔镜抗反流手术并发症的发生率及其后果主要与术前评估、术者经验、围手术期饮食指导和患者的依从性相关。     

Feasibility of esophagogastric junction distensibility measurement during Nissen fundoplication

Increased esophagogastric junction distensibility has been implicated in the development of gastroesophageal reflux disease (GERD). Previous authors have demonstrated a reduction in distensibility following anti‐reflux surgery, but the changes during the operation are not clear. Our study aimed to ascertain the feasibility of measuring intraoperative distensibility changes and to assess if this would have potential to modify the operation. Seventeen patients with GERD were managed in a standardized manner consisting of preoperative assessment with symptom scoring, endoscopy, 24 hours pH studies, and manometry. Patients then underwent laparoscopic Nissen fundoplication with intraoperative distensibility measurement using an EndoFLIP EF‐325 functional luminal imaging probe (Crospon Ltd, Galway, Ireland). This device utilizes impedance planimetry technology to measure cross‐sectional area and distensibility within a balloon‐tipped catheter. This is inflated at the esophagogastric junction to fixed distension volumes. Thirty‐second median cross‐sectional area and intraballoon pressure measurements were recorded at 30 and 40 mL balloon distensions. Measurement time points were initially after induction of anesthesia, after pneumoperitoneum, after hiatal mobilization, after hiatal repair, after fundoplication, and finally pre‐extubation. Postoperatively, patients continued on protocol and were discharged after a two‐night stay tolerating a sloppy diet. Patients with a hiatus hernia on high‐resolution manometry had a significantly higher initial esophagogastric junction distensibility index (DI) than those without. Hiatus repair and fundoplication resulted in a significant overall reduction in the median DI from the initial to final recordings (30 mL balloon distension reduction of 3.26 mm²/mmHg (P = 0.0087), 40 mL balloon distension reduction of 2.39 mm²/mmHg [P = 0.0039]). There was also a significant reduction in the DI after pneumoperitoneum, hiatus repair, and fundoplication at 40 mL balloon distension. Two individual cases in the series highlight the utility of the system in potentially changing the operation. After fundoplication, patient 7 recorded a DI of 0.47 mm²/mmHg, the lowest in our series, and subsequently required reoperation because of significant symptoms of dysphagia. Patient 12 had a fundoplication that appeared visually too tight and was converted intraoperatively to a Lind 270° wrap resulting in a change in the DI from 0.65 to 0.89 mm²/mmHg. Laparoscopic Nissen fundoplication results in a significant reduction in the distensibility of the esophagogastric junction. The EndoFLIP system is able to demonstrate significant changes during the operation and may help guide intraoperative modification. Larger multicenter studies with long‐term follow up would be beneficial to develop a target range of distensibility associated with good outcome.     

Dysphagia after laparoscopic Nissen fundoplication

OBJECTIVE: To investigate the frequency and severity of dysphagia during the first 8 weeks after laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease. So far, there have been no studies reporting data on day-to-day occurrence of dysphagia after laparoscopic fundoplication in a consecutive series of patients. This may explain why the frequency of dysphagia varies greatly in the literature (4-100%). MATERIAL AND METHODS: Forty consecutive patients, undergoing elective laparoscopic Nissen fundoplication, completed a standard dysphagia registration diary each day during the first 8 weeks after surgery. Patients who preoperatively had suffered from dysphagia were excluded. Thus, none of the patients had dysphagia in the 2-month period before surgery. Ten patients undergoing elective cholecystectomy served as controls. Data were quantified, and a score value of 4 or more was considered bothersome. RESULTS: Thirty-seven patients (93%) experienced some degree of dysphagia during the observation period. Sixteen patients (44%) had at least one day with annoying dysphagia. The dysphagia started 1-2 days after surgery, was most prominent during the first few weeks, and subsided in nearly all cases after 5-6 weeks. Two patients with persistent dysphagia were treated once with balloon dilatation. None of the patients in the control group had dysphagia. CONCLUSIONS: Nearly all patients experience some degree of dysphagia after laparoscopic Nissen fundoplication, and in nearly half of the patients it is considered annoying. However, even severe dysphagia usually disappears within 5-6 weeks. These results suggest a conservative attitude for the first 1-2 months after surgery. The data may also serve as a background for preoperative information to the patients.     

Dysphagia after laparoscopic Nissen fundoplication

Objective. To investigate the frequency and severity of dysphagia during the first 8 weeks after laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease. So far, there have been no studies reporting data on day-to-day occurrence of dysphagia after laparoscopic fundoplication in a consecutive series of patients. This may explain why the frequency of dysphagia varies greatly in the literature (4–100%). Material andmethods. Forty consecutive patients, undergoing elective laparoscopic Nissen fundoplication, completed a standard dysphagia registration diary each day during the first 8 weeks after surgery. Patients who preoperatively had suffered from dysphagia were excluded. Thus, none of the patients had dysphagia in the 2-month period before surgery. Ten patients undergoing elective cholecystectomy served as controls. Data were quantified, and a score value of 4 or more was considered bothersome. Results. Thirty-seven patients (93%) experienced some degree of dysphagia during the observation period. Sixteen patients (44%) had at least one day with annoying dysphagia. The dysphagia started 1–2 days after surgery, was most prominent during the first few weeks, and subsided in nearly all cases after 5–6 weeks. Two patients with persistent dysphagia were treated once with balloon dilatation. None of the patients in the control group had dysphagia. Conclusions. Nearly all patients experience some degree of dysphagia after laparoscopic Nissen fundoplication, and in nearly half of the patients it is considered annoying. However, even severe dysphagia usually disappears within 5–6 weeks. These results suggest a conservative attitude for the first 1–2 months after surgery. The data may also serve as a background for preoperative information to the patients.     

Simple suture or prosthesis hiatal closure in laparoscopic repair of paraesophageal hernia: a retrospective cohort study

Laparoscopic repair of paraesophageal hernia (PEH) involves removal of the hernia sac, cruroplasty, and fundoplication. Mesh application to cruroplasty seems to reduce hernia recurrence rate, but may be associated with dysphagia. The aim of the study was to review the clinical and laboratory outcomes of a series of patients with PEH after laparoscopic repair. Patients with PEH, who had laparoscopic repair and 1‐year postoperative follow‐up, were included in the study. Pre‐ and postoperative testing included symptom questionnaires, barium esophagogram, pH‐monitoring, barium swallow testing. In the first half cases, suturing of large hernia gaps was reinforced with prosthesis (PR), whereas in the second half only suture cruroplasty (SC) was performed. Sixty‐eight patients (36 male) with PEH were included in the study. There were no conversions to open. Postoperatively, dysphagia grading was significantly correlated to esophageal transit time (P < 0.001). There were seven recurrences; one paraesophageal and six wrap migrations. Also, four cases with stenosis were identified all in the PR group. Dysphagia was more common (P= 0.05) and esophageal transit more delayed (P= 0.034) after PR than after SC. Two revisions, one for esophageal stenosis and one for recurrent PEH, derived from the SC group. Reflux was more common after Toupet fundoplication than after Nissen fundoplication (NF) (P= 0.031) in patients with impaired esophageal motility. Laparoscopic repair of PEH with SC is associated with satisfactory clinical outcomes and low rate of wrap migration, at least similar to PR hiatal repair. NF is effective as an antireflux procedure in all cases.     

生物补片在腹腔镜下食管裂孔疝修补术的临床疗效分析

目的探讨生物补片在腹腔镜下食管裂孔疝修补术治疗食管裂孔疝的临床疗效。 方法回顾性收集自2014年5月至2017年3月在新疆维吾尔自治区人民医院住院治疗并使用生物补片行腹腔镜下食管裂孔疝修补术患者12例临床资料,总结上述患者术前及术后12个月反流情况及术后并发症等。 结果12例患者均手术顺利无中转术式等情况,术后患者反流症状均较术前明显改善,术前反流时间、反流次数、DeMeester评分、GERD-Q量表评分等比术后明显降低,差异有统计学意义(P<0.05),术后出现早期吞咽困难2例,随访过程中无严重并发症发生,无复发。 结论使用生物补片进行腔镜食管裂孔疝修补联合胃底折叠术是治疗食管裂孔疝的有效方法,短期随访结果说明生物补片加强修补食管裂孔疝是安全、有效的,长期疗效需进一步研究证实。