腹腔镜改良Heller肌切开术联合胃底折叠术（Dor／Toupet）治疗贲门失弛缓症的临床疗效对比

Comparison of laparoscopic modified Heller myotomy with （ Dor vs. Toupet） fundoplication for achalasia

目的探讨两种抗返流胃底折叠术（Dor／Toupet）联合腹腔镜改良Heller肌切开术治疗贲门失弛缓症中临床效果的差别。方法选择经腹腔镜行改良Heller＋Dor术及改良Heller＋’Foupet术患者43例，比较其GERD症状敏感度分数，检测手术前后食管静息LES压力、残余LES压力、食管远端收缩期压力指标；术后随访12个月，比较患者各项症状改善情况及食管末端24hpH值。结果两组患者术后食管测压较术前明显改善，差异有统计学意义（P〈0．05），Toupet组和Dor组术后组间差异无统计学意义（P〉0．05）；患者术后1年相关症状改善情况、食管pH监测各项指标动态发现较术前明显改善（P〈0．05），组间患者症状改善比较，Toupet组吞咽困难、胸痛及烧心症状改善情况优于Dor组（P〈0．05），而恶心／呕吐、胀气／暖气、咳嗽／声嘶、哮喘等症状差异无统计学意义（P〉0．05）。术后1年Toupet组病理性返流次数、最长返流时间、pH〈4．0时间、De—Meester积分均低于Dor组（P〈0．05）。结论两种抗返流胃底折叠术（Dor／Toupet）联合腔镜Heller肌切开术治疗贲门失弛缓症均能明显改善患者症状，减少胃酸返流次数及时间，同时Toupet术式组在1年后症状改善及pH监测相关指标较Dor术式组更具优势。

Objective To compare the outcomes of laparoscopic modified Heller myotomy com- bined with Dor vs. Toupet fundoplication for achalasia. Methods Forty-three patients undergoing laparo- scopic Dor/Toupet fundoplication following modified Heller myotomy were seleeted. Symptomatic GERD scores were compared between the two groups ; Basal LES pressure, residual LES pressure, and amplitude distal contractions were observed preoperatively and postoperatively in all patients. Follow-up data were collected at 12 months, including symptomatic evaluation and 24 h pH testing. Results Postoperative data of esophageal manometry were improved in all patients compared with the preoperative status（ P 〈 O. 05 ） , but they were similar between the Dor and Toupet groups（ P 〉 0.05 ） ; DeMeester scores and 24 h pH after 12 months were improved significantly compared with preoperative status in all patients （P 〈 0.05 ）. In the Toupet group the recovery of symptoms including dysphagia, heartburn, and chest pain was better than the Dor group （ P 〈 0.05 ） , while other symptoms had no statistically significant differences. Conclusion Lap- aroseopic modified Heller myotomy provides significant improvement in dysphagia and regurgitation symp- toms in aehalasia patients regardless of the type of partial fundoplication. The Toupet approach has more advantages over Dor approach in terms of symptom after 12 months and 24 h pH test results.