儿童先天性食管裂孔疝的疗效探讨

Discuss on the effect of congenital hiatus hernia in children

目的 探讨腹腔镜胃底折叠术治疗儿童先天性食管裂孔疝患儿术中、术后并发症、疗效及其预后情况. 方法 回顾性分析2003年2月至2013年3月上海新华医院和2000年10月至2013年3月上海儿童医学中心共136例腹腔镜下行Nissen或Thal胃底折叠术的先天性食管裂孔疝患儿,均于手术后3个月至5年内随访,对两种手术方式的疗效及预后进行统计学分析. 结果 除4例中转开腹手术外,其余均在腹腔镜下完成胃底折叠术,其中Nissen胃底折叠术72例,Thal胃底折叠术60例.手术平均年龄为（1.57±1.90）岁,平均体重为（9.12 ±5.63） kg.腹腔镜下Nissen术的平均手术时间为（2.93±0.89）h,术后平均住院天数（8.32±6.12）d.腹腔镜下Thal术的平均手术时间为（2.76 ±0.89）h,术后住院天数为（6.95-±3.10）d,均无明显统计学差异.术后随访,Nissen术后呕吐10例（13.9％）,胃食管反流3例（4.2％）,轻度食管狭窄但无临床症状19例（26.4％）,吞咽困难5例（6.9％）,需行食管扩张术4例（5.6％）,术后复发2例（2.8％）.Thal术后呕吐9例（15.0％）,胃食管反流13例（21.7％）,轻度食管狭窄但无临床症状6例（10.0％）,吞咽困难4例（6.7％）,需行食管扩张术1例（1.7％）,术后复发3例（5.0％）. 结论 长期随访中,腹腔镜下Nissen胃底折叠术和Thal胃底折叠术的术后复发率无显著性差异.而术后胃食管反流的发生率Thal术高于Nissen术,食管狭窄的发生率Nissen高于Thal术,差异均有统计学意义.说明该手术存在学习曲线,手术医生的熟练程度和并发症的发生率密切相关.

Objetive To investigate the intraoperative and postoperative complications,efficacy and outcome of laparoscopic fundoplication for esophageal hiatal hernia in children.Methods Retrospectively analyzed for total 136 children with esophageal hiatal hernia underwent laparoscopic Nissen or Thal fundoplication from February 2003 to March 2013 in Shanghai Xinhua Hospital and from October 2000 to March 2013 in Shanghai Children＇s Medical Center.The duration of follow-up was from 3 months to 5 years,evaluate these 2 types of laparoscopic fundoplications statistically.Results Except 4 cases converted to open surgery,all the cases completed laparoscopic fundoplications procedures among which 72 cases underwent a Nissen and 60 underwent a Thal fundoplication.The mean age was 1.57 ± 1.90 years old,the mean height was 9.12 ±5.63 kg.The group of Nissen laparoscopic fundoplications,the average operation time was 2.93 ± 0.89 hours,the length of hospital stay was 8.32 ± 6.12 days compared The group of Thal laparoscopic fundoplications,the average operation time was 2.76 ±0.89 hours,the length of hospital stay was 6.95 ±3.10 days,There was no statistical difference between both two.During the follow-up after operation,there were 10 patients （13.9％） with vomiting,3 patients （4.2％） with gastroesophageal reflux,19 patients（26.4％） with esophageal mild stenosis but no symptoms,5 patients （6.9％） with dysphagia,4 patients（5.6％） need esophageal dilatation,2 patients （2.8％） recurrent in Nissen group.In the Thal group,there were 9 patients （15.0％） with vomiting,13 patients （21.7％） with gastroesophageal reflux,6 patients（10.0％） with esophageal mild stenosis but no symptoms,4 patients （6.7％）with dysphagia,1 patient（1.7％） need esophageal dilatation,3 patients（5.0％） recurrent.Conclusion There was no statistical difference of recurrence between laparoscopic Nissen and Thal fundoplication in the long-term outcomes.There were statistical differences for a higher rate of gastroesophageal reflux in Thal group and a higher rate of esophageal stenosis in the Nissen group.There was learning curve for the surgery.The incidence rate of complications is significantly related to the proficiency of a surgeon.