The role of fundoplication in the treatment of type II paraesophageal hernia
The role of fundoplication in the treatment of type II paraesophageal hernia
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DOI：
10.1016/s0022-5223(96)70319-7
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发表时间：
1996-03-01
影响因子：
6
通讯作者：
Bremner, CG
中科院分区：
文献类型：
--
作者：
Fuller, CB;Hagen, JA;Bremner, CG
目的：胃底折叠术在单纯II型食管旁裂孔疝患者中的作用仍存在争议，传统的观点认为，由于下食管括约肌位于腹部，它是有能力的，胃底折叠术是不必要的，很少有研究使用客观评估来指导抗反流手术的增加。1991年5月至1994年7月，连续治疗了15例II型食管旁疝患者，所有患者均具有单纯II型疝的X线标准，术前评估包括上肠镜检查，食管测压，和24小时动态pH监测，如果存在以下任何标准，则认为下食管括约肌功能不全：静息压小于7 mm Hg，总括约肌长度小于2 cm，或腹内长度小于1 cm，73%的患者的手术主要症状与疝相关：6例患者出现吞咽困难或餐后腹痛，4例患者出现腹胀或呕吐，1例患者出现出血。4例患者出现胃食管反流的典型症状：烧心和反流各2例。结果：大多数患者存在胃食管反流的客观证据，5例患者（31%）存在食管损伤的证据：食管炎3例，狭窄1例，食管溃疡1例。15例患者中有11例（69%）通过24小时pH监测检测到病理性食管酸暴露，12例患者（75%）有食管下括约肌缺陷，通常是由于腹腔内长度不足（8/12，66%），14例患者进行了疝复位、小腿闭合和Nissen胃底折叠术（一名患者等待手术），所有病例的症状缓解效果均非常好，在平均14个月的随访中，没有患者疝复发（范围2 - 39个月），结论：客观评价显示，胃食管反流伴随II型食管旁疝的患者比例很高，通常是由于食管下括约肌功能不全，适当的治疗包括疝复位、小腿缝合和胃底折叠术。
Objectives: The role of fundoplication in patients with pure type II paraesophageal hiatal hernia remains controversial, Conventional thinking suggests that because the lower esophageal sphincter is located within the abdomen, it is competent, and fundoplication is unnecessary, Few studies have used objective evaluation to guide the addition of an antireflux procedure, Methods: Fifteen consecutive patients with type II paraesophageal hernia were treated between May 1991 and July 1994, All had radiographic criteria of pure type II hernias, Preoperative evaluation included upper intestinal endoscopy, esophageal manometry, and 24-hour ambulatory pH monitoring, The lower esophageal sphincter was considered incompetent if any of the following criteria were present: a resting pressure less than 7 mm Hg, an overall sphincter length less than 2 cm, or an intraabdominal length less than 1 cm, Primary symptoms responsible for surgery were related to the hernia in 73% of patients: dysphagia or postprandial abdominal pain in six patients, abdominal distension or vomiting in four patients, and bleeding in one patient, Symptoms typical of gastroesophageal reflux were present in four patients: heartburn and regurgitation in two each, Results: Objective evidence of gastroesophageal reflux was present in the majority of patients, Five patients (31%) had evidence of esophageal injury: esophagitis in three patients, stricture in one, and esophageal ulcer in one, In 11 of 15 patients (69%), pathologic esophageal acid exposure was detected by 24-hour pH monitoring, Twelve patients (75%) had a defective lower esophageal sphincter, usually the result of an inadequate intraabdominal length (8/12, 66%), Hernia reduction, crural closure, and Nissen fundoplication were performed in 14 patients (one patient awaits surgery), Symptomatic relief was excellent in all cases, No patient has had hernia recurrence at an average of 14 months' follow-up (range 2 to 39 months), Conclusion: Objective evaluation reveals that gastroesophageal reflux accompanies type II paraesophageal hernia in a high proportion of patients, usually because of an incompetent lower esophageal sphincter, Appropriate treatment includes reduction of the hernia, crural closure, and fundoplication in most, if not all, patients.