Total fundoplication is the operation of choice for patients with gastroesophageal reflux and defective peristalsis
Total fundoplication is the operation of choice for patients with gastroesophageal reflux and defective peristalsis
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DOI：
10.1007/s00464-001-8327-z
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发表时间：
2002-06-01
影响因子：
3.1
通讯作者：
Pellegrini, CA
中科院分区：
文献类型：
--
作者：
Oleynikov, D;Eubanks, TR;Pellegrini, CA
背景：传统上，胃食管反流病（GERD）伴有胃蠕动功能缺陷（DP）的患者可行部分胃底复制术。由于有报道称，与完全吻合吻合相比，部分吻合吻合在控制胃酸反流方面效果较差，因此在1997年，我们停止对DP患者进行部分吻合吻合，转而采用软性完全吻合吻合。本研究分析了我们新策略的结果，并将其与我们以前的方法进行了比较。方法：我们在1994年至1997年期间对39例DP患者（远端振幅bbb40 %的燕子）进行了部分眼底复制，在1997年至2000年期间对57例患者进行了完全眼底复制。86例患者术前完成症状评分，40例患者术后完成血压测量和24小时pH监测。症状评分来源于0-4分的标准问卷。结果：两组胃灼热评分均有改善（术前2.8分；术后0.65分；p < 0.05）。部分眼底复制组术前吞咽困难1.1分，术后吞咽困难0.62分（p = NS）；全眼底复制组术前吞咽困难1.2分，术后吞咽困难0.3分（p < 0.05）。此外，全底扩张组中没有患者出现新的吞咽困难，也没有患者需要扩张。两组手术后远端食管酸暴露正常化（DeMeester中位评分：72.3 vs 11.3, p < 0.05，部分底翻；57.1 vs 6.3, p < 0.05，全部底翻）。食管远端振幅术前平均27.8 mmHg，部分吻合组为35.6 mmHg (p = NS)，完全吻合组术前平均28.2 mmHg，术后平均49.0 mmHg （p < 0.005）。2例既往部分眼底复制的患者需要转换为完全眼底复制。两组术后均不需要扩张。结论：我们的研究表明，部分和全部底瓣复制都能有效地控制胃蠕动缺陷患者的胃反流症状。吞咽困难在完全盆腔复制后明显改善，而在部分盆腔复制后无明显改善。虽然两种手术均使胃酸反流恢复到正常范围内，但全盆腔手术的效果更为明显。完全（而非部分）底叠使食管蠕动幅度显著增加，这可能解释了吞咽过程中主观改善的原因。因此，对于胃食管反流和蠕动不良的患者，应选择复底治疗。
Background: Partial fundoplication has traditionally been indicated for patients with gastroesophageal reflux disease (GERD) who have defective peristalsis (DP). Because partial fundoplication had been reported to be a less effective means of controlling acid reflux than total fundoplication, in 1997 we stopped performing partial fundoplication for patients with DP and switched to a floppy total fundoplication. This study analyzes the results of our new strategy and compares it to our former approach.Methods: We performed a partial fundoplication in 39 patients with DP (distal amplitude > 40% of swallows) between 1994 and 1997 and a total fundoplication in 57 patients between 1997 and 2000. Symptoms scores derived from a standard questionnaire with a scale of 0-4, manometry, and 24-h pH monitoring were completed preoperatively in 86 patients and postoperatively in 40 patients.Results: Heartburn scores improved in both groups (preoperative, 2.8; postoperative, 0.65; p < 0.05). Dysphagia was 1.1 preoperatively and 0.62 postoperatively (p = NS) in the partial fundoplication group and 1.2 preoperatively and 0.3 postoperatively (p < 0.05) in the total fundoplication group. Furthermore, none of the patients in the total fundoplication group developed new dysphagia and none required dilatation. Distal esophageal acid exposure normalized in both groups after operative treatment (median DeMeester score:72.3 vs 11.3, p < 0.05, For partial fundoplication; 57.1 vs 6.3, p < 0.05, For total fundoplication). Distal esophageal amplitudes averaged 27.8 mmHg preoperatively and 35.6 mmHg (p = NS) in the partial fundoplication group, they averaged 28.2 mmHg preoperatively vs 49.0 mmHg postoperatively (p < 0.005) in the total fundoplication group. Two patients with a previous partial fundoplication required a conversion to a total fundoplication. No postoperative dilation was required in either group.Conclusions: Our study shows that both a partial and a total fundoplication are effective in controlling the symptoms of GERD in patients with defective peristalsis. Dysphagia improves significantly after total fundoplication but not after partial fundoplication. Although both operations brought acid reflux to within normal limits, the effect was more pronounced with total fundoplication. Total, but not partial, fundoplication produced a significant increase in amplitude of esophageal peristalsis, which may explain the subjective improvement during deglution. Therefore, fundoplication should be the treatment of choice in patients with GERD and defective peristalsis.