高选择保护性迷走神经切断术在腹腔镜胃底折叠手术中的应用

Application of Highly Selective Protective Vagotomy in Laparoscopic Gastric Fundoplication Surgery

目的探讨高选择保护性迷走神经切断术在腹腔镜胃底折叠手术(短松Nissen术式)中应用的安全性、可行性及有效性。方法回顾分析我院2014年1月~2019年12月78例胃食管反流病(gastroesophageal reflux disease,GERD)合并食管裂孔疝行腹腔镜食道裂孔疝修补+胃底折叠术(短松Nissen术式)的临床资料,分为传统手术组和迷走神经保护组,比较2组手术时间、术中出血量、术后住院时间、术后并发症发生率和术后6个月胃食管反流病调查问卷(GERD Q量表)评分、DeMeester评分、食管下括约肌静息压力(lower esophageal sphincter pressure,LESP)、反流症状控制情况。结果2组手术均顺利完成,均无术中脏器损伤发生。2组手术时间差异无显著性[(85.5±13.9)min vs.(88.3±18.6)min,t=0.729,P=0.468];术中出血量差异无显著性[(18.6±8.6)ml vs.(18.1±8.5)ml,t=-0.221,P=0.825];术后排气时间差异无显著性(2.0±0.7)d vs.(1.8±1.0)d,t=-1.227,P=0.224]。传统手术组术后住院时间明显长于迷走神经保护组[(9.4±3.0)d vs.(8.2±2.1)d,t=-2.172,P=0.033]。传统手术组术后30 d内手术并发症发生率36.8%(14/38),明显高于迷走神经保护组12.5%(5/40)(χ^(2)=6.267,P=0.012)。传统手术组术后6个月治愈率86.8%(33/48),迷走神经保护组85.0%(34/40),2组疗效比较差异无显著性(Z=-0.232,P=0.816)。传统手术组与迷走神经保护组术后6个月GERD Q量表评分、DeMeester评分、LESP差异均无显著性[(5.6±0.9)分vs.(5.8±0.8)分,t=1.232,P=0.222;(4.1±2.2)分vs.(4.2±2.2)分,t=0.261,P=0.795;(23.2±3.5)mm Hg vs.(23.5±3.8)mm Hg,t=0.412,P=0.681]。结论高选择保护性迷走神经切断术应用于腹腔镜胃底折叠术(短松Nissen术式)中,保护迷走神经安全、可行、有效。

Objective To investigate the safety,feasibility,and efficacy of highly selective protective vagotomy in laparoscopic fundoplication.Methods Clinical data of 78 patients who underwent laparoscopic hiatal hernia repair plus fundoplication(short floppy Nissen procedure)for gastroesophageal reflux disease and hiatus hernia from January 2014 to December 2019 in our hospital were retrospectively analyzed.The patients were divided into two groups:the traditional operation group and the vagus nerve protection group.The operation time,blood loss during operation,hospital stay after operation and the incidence of postoperative complications were compared between the two groups.The GERD Q score,DeMeester score,lower esophageal sphincter pressure(LESP),and control of reflux symptoms at 6 months after operation in the two groups were analyzed.Results Both groups of surgeries were successfully completed,and there were no serious intraoperative side injuries.There was no significant difference between the traditional operation group and the vagus nerve protection group in operation time[(85.5±13.9)min vs.(88.3±18.6)min,t=0.729,P=0.468],intraoperative blood loss[(18.6±8.6)ml vs.(18.1±8.5)ml,t=-0.221,P=0.825],and postoperative transanal exhaust time[(2.0±0.7)d vs.(1.8±1.0)d,t=-1.227,P=0.224].The postoperative hospital stay in the traditional surgical group was significantly longer than that in the vagus nerve protection group[(9.4±3.0)d vs.(8.2±2.1)d,t=-2.172,P=0.033].The incidence of surgical complications within 30 d after surgery in the traditional surgical group was 36.8%(14/38),which was significantly higher than that in the vagus nerve protection group[12.5%(5/40),χ^(2)=6.267,P=0.012].The traditional surgical group had a cure rate of 86.8%(33/48)at 6 months after surgery,which was not significantly different from the vagus nerve protection group[85.0%(34/40),Z=-0.232,P=0.816].There were no significant differences in GERD Q score,DeMeester score,LESP between the two groups at 6 months after surgery[(5.6±0.9)points vs.(5.8±0.8)points,t=1.232,P=0.222;(4.1±2.2)points vs.(4.2±2.2)points,t=0.261,P=0.795;(23.2±3.5)mm Hg vs.(23.5±3.8)mm Hg,t=0.412,P=0.681].Conclusion It is safe,feasible,and effective to apply the highly selective protective vagotomy in laparoscopic short floppy Nissen fundoplication to protect the vagus nerve.