进一步认识食管裂孔疝治疗的特殊性

Further understanding the specificity of treatment for hiatal hernia

食管裂孔疝(HH)是一类特殊的疝病,虽在结构上与其他疝病有共性,但在临床诊疗过程中更多体现的是其特殊性,众多问题有待探讨和解决。首先,HH的诊断既要注重症状的鉴别,同时更需要结合胃镜、消化道造影、CT检查以及食管高分辨测压测酸结果来综合考量。其次,HH是胃食管反流病常见病因,但单纯进行HH的机械修补往往不能达到改善症状的效果,故抗反流手术被广泛认可。第三,腹腔镜HH修补术已被广泛接受和开展,传统的胃底折叠术和一些创新术式均取得不错的疗效,而机器人手术虽有一定技术优势,但受限于费用等因素,在国内仍开展不多。第四,HH修补材料的争论一直存在,对于缺损较大、膈肌薄弱病人,推荐采用补片进行修补,但不宜过大,需适形剪裁,合成材料与生物材料各有利弊,酌情选用。第五,合并肥胖的HH病人较多,其治疗更为复杂,一期行HH修补+减重手术的方式也被广泛接受,目前需要更多的临床证据加以验证。

Hiatal hernia(HH)is a special type of hernia.Although it shares structural similarities with other hernia diseases,its specificity is more reflected in clinical diagnosis and treatment,and many problems need to be explored and solved.Firstly,the diagnosis of HH should not only focus on distinguishing symptoms,but also comprehensively consider the results of gastroscopy,GI,CT,and high-resolution esophageal pressure and acid measurement;Secondly,HH is a common cause of GERD,but mechanical repair of esophageal hiatus alone often cannot achieve the effect of improving symptoms,so anti-reflux surgery is widely recognized.Laparoscopic HH repair surgery has been widely accepted nowadays,and traditional and some innovative fundoplication techniques have achieved good therapeutic effects.However,although da Vinci robotic surgery has certain technical advantages,it is still not widely carried out in China due to high cost.The debate over HH repair materials has always existed.For patients with large defects and weak diaphragmatic muscles,it is recommended to use meshes for hernia repair,but it should not be too large and requires conformal cutting,Synthetic materials and biological materials have their own advantages and disadvantages,which should be chosen according to discretion.There are many obese patients with concomitant HH,and their treatment is more complex.The combination of HH repair and weight loss surgery is widely accepted,and more clinical evidence is needed to verify it.