胃镜辅助腹腔镜改良Heller手术治疗贲门失弛缓症
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摘要
目的:探讨胃镜辅助下腹腔镜改良Heller手术治疗贲门失弛缓症的疗效及并发症。方法:为35例贲门失弛缓症患者行胃镜辅助腹腔镜改良Heller术,观察术后症状的解除及并发症情况,随访最少1年,观察术后短期疗效。结果:手术时间60~200 min,出血量10~200 ml。术后住院4~7 d,无一例中转开腹,术后症状均有明显改善。2例患者术中损伤食管黏膜,镜下修补后未出现食管瘘。术后2个月复查钡餐,均未见梗阻,食管扩张较前改善;复查24 h食管pH值基本正常,pH<4的时间占(1.4%±2.7%),pH监测的患者中5例(14.3%)提示有病理性酸反流,仅1例患者有轻度症状,保守治疗后症状缓解。术前食管测压显示食管下括约肌压力升高,术后2个月复查压力明显下降。随访1年以上,1例于术后5个月出现食管梗阻,扩张治疗后好转。结论:胃镜辅助腹腔镜改良Heller手术治疗贲门失弛缓症效果明显,并发症少,可在临床上推广应用。
Objective:To investigate the effects and complications of the gastroscopy-assisted laparoscopic modified Heller operation for the treatment of achalasia of cardia.Methods:Retrospective analysis was conducted on the clinical data of 35 patients with achalasia of cardia who received gastroscopy-assisted laparoscopic modified Heller operation.The alleviation of postoperative symptoms and complications were observed.All patients were followed up for at least one year to observe the short-term effects.Results:The operation time was 60-200 min.Blood loss during operation was 10-200 ml.The time of hospitalization was 4-7 d.No conversion to open surgery was required.After operation all patients achieved significant alleviation of symptom.Two patients suffered from intraoperative esophageal mucosa injury and underwent laparoscopic repair,no esophagostoma was found after operation.All patients were reexamined by barium meal in two months after operation,no obstruction was found and esophageal expansion was improved.Most patients had normal 24 h pH in follow-up.The time of pH less than 4 accounted for(1.4% ± 2.7%).The 24 h pH indicated that 5 patients(14.3%)suffered from pathological acid reflux,however,only one patient had mild symptom and relieved after conservative therapy.Pressure of the lower esophageal sphincter increased before operation and decreased significantly in 2 months after the surgery.After more than 1 year,only one patient had esophageal obstruction recurrence and improved after gastroscopic expanding treatment.Conclusions:The results of gastroscopy-assisted laparoscopic modified Heller operation for achalasia of cardia is significant,the procedure can be promoted and applied in clinical practice with limited complications.
Objective:To investigate the effects and complications of the gastroscopy-assisted laparoscopic modified Heller operation for the treatment of achalasia of cardia.Methods:Retrospective analysis was conducted on the clinical data of 35 patients with achalasia of cardia who received gastroscopy-assisted laparoscopic modified Heller operation.The alleviation of postoperative symptoms and complications were observed.All patients were followed up for at least one year to observe the short-term effects.Results:The operation time was 60-200 min.Blood loss during operation was 10-200 ml.The time of hospitalization was 4-7 d.No conversion to open surgery was required.After operation all patients achieved significant alleviation of symptom.Two patients suffered from intraoperative esophageal mucosa injury and underwent laparoscopic repair,no esophagostoma was found after operation.All patients were reexamined by barium meal in two months after operation,no obstruction was found and esophageal expansion was improved.Most patients had normal 24 h pH in follow-up.The time of pH less than 4 accounted for(1.4% ± 2.7%).The 24 h pH indicated that 5 patients(14.3%)suffered from pathological acid reflux,however,only one patient had mild symptom and relieved after conservative therapy.Pressure of the lower esophageal sphincter increased before operation and decreased significantly in 2 months after the surgery.After more than 1 year,only one patient had esophageal obstruction recurrence and improved after gastroscopic expanding treatment.Conclusions:The results of gastroscopy-assisted laparoscopic modified Heller operation for achalasia of cardia is significant,the procedure can be promoted and applied in clinical practice with limited complications.
引文
[1]Sadowski DC,Ackah F,Jiang B,et al.Achalasia:incidence,prevalence and survival.A population-based study[J].Neurogastroenterol Motil,2010,22(9):e256-e261.
[2]Gennaro N,Portale G,Gallo C,et al.Esophageal achalasia in the Veneto region:epidemiology and treatment.Epidemiology and treatment of achalasia[J].J Gastrointest Surg,2011,15(3):423-428.
[3]Park W,Vaezi MF.Etiology and pathogenesis of achalasia:the current understanding[J].Am J Gastroenterol,2005,100(6):1404-1414.
[4]Eckardt AJ,Eckardt VF.Current clinical approach to achalasia[J].World J Gastroenterol,2009,15(32):3969-3975.
[5]Anselmino M,Perdikis G,Hinder RA,et al.Heller myotomy is superior to dilatation for the treatment of early achalasia[J].Arch Surg,1997,132(3):233-240.
[6]Pellegrini C,Wetter LA,Patti M,et al.Thoracoscopic esophagomyotomy.Initial experience with a new approach for the treatment of achalasia[J].Ann Surg,1992,216(3):291-296.
[7]董新伟.完全胸腔镜下手术治疗贲门失弛缓症的疗效[J].中国老年学杂志,2013,33(4):944-945.
[8]李怀业,王锦光.电视胸腔镜下行食管肌层切开手术治疗贲门失弛缓症32例[J].临床军医杂志,2010,38(2):165,228.
[9]王相增,佟赞,李延茂,等.腹腔镜Heller肌切开联合胃底折叠术在贲门失弛缓症治疗中的应用[J].腹腔镜外科杂志,2009,14(9):660-662.
[10]陈向来,彭金华,杨崛圣,等.胸腹腔镜下治疗贲门失弛缓症的临床对比研究[J].广东医学,2011,32(12):1586-1588.
[11]黄宇清,崔健,刘军,等.贲门失驰缓症腔镜外科治疗现状[J].中华胸心血管外科杂志,2009,25(6):430-432.
[12]徐丽丽.胸腔镜下行Heller手术治疗贲门失迟缓症的围手术期护理[J].现代临床护理,2012,11(2):35-36.
[13]滕寅,张舰,刘文,等.胸腔镜下食管下段肌层切开术治疗贲门失弛缓症[J].贵阳医学院学报,2012,37(1):96-97.
[14]魏宁,胡文滕,蔡谦谦,等.腹腔镜Heller手术治疗贲门失弛缓症疗效和安全性的Meta分析[J].中国循证医学杂志,2016,16(5):573-578.
[15]李辉.原发性食管功能障碍性疾病[M].北京:人民卫生出版社,1999:75-111.
[16]刘文彪,张玉和,汪超,等.成人食管胃连接部的解剖学观测[J].武警后勤学院学报(医学版),2003,12(2):90-92.
[17]Raiser F,Perdikis G,Hinder RA,et al.Heller myotomy via minimal-access surgery.An evaluation of antireflux procedures[J].Arch Surg,1996,131(6):593-597.
[18]Mattioli S,Di Simone MP,Bassi F,et al.Surgery for esophageal achalasia.long-term results with three different techniques[J].Hepatogastroenterology,1996,43(9):492-500.
[19]El Hak NG,Hamdy E,Abdalla T,et al.Laparoscopic Heller myotomy for achalasia:analysis of successes and failures[J].Hepatogastroenterology,2012,59(117):1450-1454.
[20]秦鸣放,赵宏志.胃食管结合部常见良性疾病的腹腔镜治疗[J].中国微创外科杂志,2010,10(1):63-66.
[21]Del Genio A,Izzo G,Di Martino N,et al.Intraoperative esophageal manometry:our experience[J].Dis Esophagus,1997,10(4):253-261.
[22]杨建,徐肇敏.动力学监测在贲门失弛缓症中的诊断价值探讨[J].江苏医药,2000,26(7):538-539.
[23]倪春鸿,李兆申.贲门失弛缓症治疗研究进展[J].国际消化病杂志,1998,18(1):3-5.
[2]Gennaro N,Portale G,Gallo C,et al.Esophageal achalasia in the Veneto region:epidemiology and treatment.Epidemiology and treatment of achalasia[J].J Gastrointest Surg,2011,15(3):423-428.
[3]Park W,Vaezi MF.Etiology and pathogenesis of achalasia:the current understanding[J].Am J Gastroenterol,2005,100(6):1404-1414.
[4]Eckardt AJ,Eckardt VF.Current clinical approach to achalasia[J].World J Gastroenterol,2009,15(32):3969-3975.
[5]Anselmino M,Perdikis G,Hinder RA,et al.Heller myotomy is superior to dilatation for the treatment of early achalasia[J].Arch Surg,1997,132(3):233-240.
[6]Pellegrini C,Wetter LA,Patti M,et al.Thoracoscopic esophagomyotomy.Initial experience with a new approach for the treatment of achalasia[J].Ann Surg,1992,216(3):291-296.
[7]董新伟.完全胸腔镜下手术治疗贲门失弛缓症的疗效[J].中国老年学杂志,2013,33(4):944-945.
[8]李怀业,王锦光.电视胸腔镜下行食管肌层切开手术治疗贲门失弛缓症32例[J].临床军医杂志,2010,38(2):165,228.
[9]王相增,佟赞,李延茂,等.腹腔镜Heller肌切开联合胃底折叠术在贲门失弛缓症治疗中的应用[J].腹腔镜外科杂志,2009,14(9):660-662.
[10]陈向来,彭金华,杨崛圣,等.胸腹腔镜下治疗贲门失弛缓症的临床对比研究[J].广东医学,2011,32(12):1586-1588.
[11]黄宇清,崔健,刘军,等.贲门失驰缓症腔镜外科治疗现状[J].中华胸心血管外科杂志,2009,25(6):430-432.
[12]徐丽丽.胸腔镜下行Heller手术治疗贲门失迟缓症的围手术期护理[J].现代临床护理,2012,11(2):35-36.
[13]滕寅,张舰,刘文,等.胸腔镜下食管下段肌层切开术治疗贲门失弛缓症[J].贵阳医学院学报,2012,37(1):96-97.
[14]魏宁,胡文滕,蔡谦谦,等.腹腔镜Heller手术治疗贲门失弛缓症疗效和安全性的Meta分析[J].中国循证医学杂志,2016,16(5):573-578.
[15]李辉.原发性食管功能障碍性疾病[M].北京:人民卫生出版社,1999:75-111.
[16]刘文彪,张玉和,汪超,等.成人食管胃连接部的解剖学观测[J].武警后勤学院学报(医学版),2003,12(2):90-92.
[17]Raiser F,Perdikis G,Hinder RA,et al.Heller myotomy via minimal-access surgery.An evaluation of antireflux procedures[J].Arch Surg,1996,131(6):593-597.
[18]Mattioli S,Di Simone MP,Bassi F,et al.Surgery for esophageal achalasia.long-term results with three different techniques[J].Hepatogastroenterology,1996,43(9):492-500.
[19]El Hak NG,Hamdy E,Abdalla T,et al.Laparoscopic Heller myotomy for achalasia:analysis of successes and failures[J].Hepatogastroenterology,2012,59(117):1450-1454.
[20]秦鸣放,赵宏志.胃食管结合部常见良性疾病的腹腔镜治疗[J].中国微创外科杂志,2010,10(1):63-66.
[21]Del Genio A,Izzo G,Di Martino N,et al.Intraoperative esophageal manometry:our experience[J].Dis Esophagus,1997,10(4):253-261.
[22]杨建,徐肇敏.动力学监测在贲门失弛缓症中的诊断价值探讨[J].江苏医药,2000,26(7):538-539.
[23]倪春鸿,李兆申.贲门失弛缓症治疗研究进展[J].国际消化病杂志,1998,18(1):3-5.