食管裂孔疝修补——力求结构与功能的统一

Repair of hiatal hernia deserves union of anatomy and function of esophagus

食管裂孔疝是一种常见病，常与胃食管反流病相伴。现阶段，由于诊断水平的限制，我国食管裂孔疝的检出率一直处于低水平。如何提高此类患者的检出诊断率、提高其生活质量，是影像和临床医生的重要课题。运用外科手段修补食管裂孔疝的由来已久，但对于该手术的本质和重建食管抗反流的机制，仍需要进一步加强认识。食管裂孔疝手术的目的不仅在于修补缺陷，更应关注如何恢复食管下端高压区或食管下端括约肌的作用，重建胃内和腹内压力抵抗或屏障功能。手术关键原理是通过手术折叠，恢复食管胃结合部位的结构、食管下端括约肌正常的解剖位置以及折叠后食管下端括约肌的长度，并且妥善缝合固定，防止其再次向胸内移位，才能最大程度恢复、保持食管下端括约肌的抗反流功能，使手术达到结构与功能的统一。未来多学科诊疗模式以及患者个体化、精准化的治疗方案，是食管裂孔疝研究的重要方向。本文就食管裂孔疝的历史、现状以及手术治疗理念做一回顾，并对未来的发展做一展望。

Hiatal hernia is a common disease, which is always complicated with gastro-esophageal reflux. However, owing to restriction of diagnosis ability, the finding of hiatal hernia is still at low level in China. How to increase the finding or diagnosis of this disease and improve the life quality of patients, is an important task of radiologists and hernial surgeons. Surgery has been integrated into the therapy of hiatal hernia for a long time, but most surgeons still need to improve their recognition about its essence and the anti-reflux mechanism of lower esophagus. The purpose of surgery of hiatal hernia is not only to repair the defect, but to recover the anatomic structure and function of lower esophagus, as well as to rebuild anti-reflux barrier in stomach at the mean time. The key principle of surgery is to recover structure of GEJ, location of LES and the length of lower esophagus through fundoplication and firm fixation, which prevent it from dislocating to thoracic cavity. By adhering to the principle of this, we can combine the anatomy and function in repair of hiatal hernia, and recover and keep the anti-reflux function of LES utmost. MDT, specialized precision program and standardization will play more and more important roles in hiatal hernia therapy in the future. In this article, we made a review about the diagnosis and therapy history of hiatal hernia, as well as prospected the progress in the near future.