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

Evaluation of laparoscoopic Nissen and Toupet fundopication in the treatment of gastroesophageal hiatal hernia complicated with gastroesophageal reflux disease

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 p H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。

Objective To discuss the effect and postoperative complications of gastroesophageal reflux disease with hiatus hernia after fundoplication treatment of laparoscopic Nissen and Toupet. Methods Review the 57 patients with laparoscopic esophageal hiatal hernia complicated with gastroesophageal reflux disease which be treated with Nissen and Toupet fundoplication from July 2014 to July 2016 in Shengjing Hospital affiliated to China Medical University, 24 patients underwent Nissen surgery （ group Nissen）, 33 patients underwent Toupet operation（group Toupet）. Observed and compare the anti reflux effect and postoperative complications of the two groups. Results 57 cases were successfully completed laparoscopically, without laparotomy, the average operation time was （75. 8 ± 6. 4 ） minutes（the total operation time was 68 minutes ~ 115 minutes）; the average amount of bleeding was （22 ±5） ml （the amount of bleeding was 15 to 30 ml） ; patch repair was used in the two methods; after 24 hours into the liquid,the mean postoperative hospitalization was （ 10. 5 ± 3 ） d. 57cases were followed up for a period of 6 months to 2. 5 years（ mean, 18 months） . None of the patients had regurgitation, heartburn and other typical symptoms of gastroesophageal reflux disease after the surgery. In group Nissen,dysphagia occurred in 2 patients（ 8. 2% ） ; In group Toupet, dysphagia occurred in 8 patients （24. 2% ）. The incidence of postoperative complications in group Toupet was significantly higher than that in group Nissen. All patients with gastroesophageal reflux disease underwent gastroscopy before operation. They had different degrees of esophageal inflammation. All patients reexamined gastroscopy,esophageal manometry an esophageal 24 hours PH monitor. Review results showed ： the pressure of the lower esophageal sphincter was significantly increased in the two groups after operation ; the length of the lower esophageal sphincter was also significantly prolonged. Conclusion laparoscopic Nissen surgery in the postoperative incidence of choke is better than the Toupet operation. But there was no significant difference between them.