【作者】 王秋生； 刘隆； 申占龙； 董雷； 周东海； 冀涛；

【Author】 WANG Qiu - sheng, LIU Long, SHEN Zhan - long,DONG Lei, ZHOU Dong - hai ,JI Tao(Department of Minimally Invasive Surgery, the PeoplesHospital of Peking University, Beijing 100044, P. R. China)

【机构】 北京大学人民医院微创外科；

【摘要】 目的探索3种腹腔镜胃底折叠术治疗胃食管反流病及贲门失弛缓症行Heller肌切开后抗反流术的安全性与可行性。方法1995年12月～2005年3月对55例胃食管反流病人和6例贲门失弛缓症病人共施行腹腔镜抗反流手术61例。其中男23例、女38例,平均55岁。单纯反流性食管炎11例;滑动型食管裂孔疝伴反流性食管炎38例,旁疝型食管裂孔疝伴反流性食管炎1例,混合型食管裂孔疝伴反流性食管炎5例,贲门失弛缓症6例。术前常规行胃镜与上消化道钡餐检查者61例,加行食管测酸、测压检查者50例。腹腔镜单纯胃底折叠术11例(Nissen式1例、Toupet式10例)。腹腔镜食管裂孔疝修补+胃底折叠术44例(Nissen式12例、Toupet式32例)。Heller肌切开+Dor胃底折叠术6例。其中在腹腔镜下还联合实施了胆囊切除术4例,腹腔粘连松解4例,腹股沟隐性疝高位缝扎1例,食管下段血管瘤、胆囊及阑尾切除1例,胆囊及左肾切除1例,Heller-Dor术+肝血管瘤和胆囊切除1例。结果全组病人平均手术120 min(60-360min),术中平均出血15 mL(10～100 mL),术后日平均引流20 mL(10～100 mL),平均住院7 d(5～12 d)。其中前10例使用电刀者平均用时210 min(180-360 min),中转开腹1例;后51例使用超声刀者平均用时100min(60-180 min)。术中脾被膜划破出血2例,13例Nissen式胃底折叠术后有1例出现吞咽困难,1个月后缓解。53例随访病人中51例不再需要服药。其中6例Heller肌切开Dor胃底折叠术病人术后第2天即可顺畅进食,且无反流。结论与传统的经胸或开腹手术相比,腹腔镜抗反流手术治疗胃食管反流病和贲门失弛缓症行Heller肌切开后病人具有心肺干扰小、麻醉难度低、创伤小、痛苦轻、并发症少、住院时间短、康复快和疗效好等突出优点。经过不断改进手术设计和加强训练可使手术时间迅速缩短一半以上(由180-360 min降至60-180 min)。手术疗效方面Toupet式胃底折叠术优于Nissen式胃底折叠术,Hellet肌切开后加行Dor胃底折叠术可有效地起到抗反流作用。更多还原

【Abstract】 [Objective] To investigate the safety and efficiency of laparoscopic antireflux surgery for patients with gastroesophageal reflux disease and post of modified Heller’s myotomy. [Methods] Between December 1995 and March 2005 , 55 patients with gastroesophageal reflux disease and 6 patients with cardia achalasia underwent laparoscopic antireflux surgery. Among them, 23 were male and 38 were female with an average age of 55 years old (20 -78). Besides 11 cases of simple esophagitis, esophagitis accompanied by sliding hiatal hernia were 38 cases, paraesopliageal hernia 1 case and combined hernia 5 cases, respectively. Cardia achalasia were 6 cases. All patients had upper GI barium series and esophagogastroscopy to rule out esophageal carcinoma and short esophagus. Esophageal manometry and 24 hours ambulatory pH studies were performed in 50 patients. Eleven patients were merely performed fundoplication( Nissen 1, Toupet 10) laparoscopically, and 44 patients were also performed laparoscopic hiatal hemiorraphy in combination (Nissen 12, Toupet 32). Six patients were operated by modified Heller’s myotomy with Dor fundoplication. In addition, 12 patients had combined laparoscopic cholecystectomy(4) , adhesiolysis(4) , occult inguinal herniorraphy(1) , excision of esophageal hemangioma, gallbladder and appendix (1) , cholecystectomy and left nephrectomy (1) , Heller - Dor operation with cholecystectomy and excision of hepatic hemangioma (1). [Results] The operating time in average was 120 minutes (60 - 360) , operative blood loss in average was 15 mL (10 -100) , postoperative drainage in average was 20 mL (10-100) , postoperative hospitalization in average was 7 days (5-12). In the group of initial 10 cases with electrocautery, the average operating time was 210 minutes (180 -360) , and 1 patient was converted to open surgery due to poor exposure by gasless technique. In the group of latest 51 cases with harmonic scalpel, the average operating time was 100 minutes (60-180) , 2 patient occurred spleenic rupture. One patient occurred postoperative dysphagia, and disappeared 1 month later. Among the 53 patients of follow-up, 51 were not need any medication. [Conclusion] Laparoscopic antireflux surgery has the advantages of less disturbance to the heart and lung, decreasing the difficulty of general anesthesia, minimally invasive, less pain and less complication, shorter hospitalization and faster convalescence. In term of the surgical efficiency, toupet fundoplication was superior to nissen fundoplication. Dor fundoplication is effective against reflux for patients underwent hellers myotomy.更多还原