Hiatal Hernia, Lower Esophageal Sphincter Incompetence, and Effectiveness of Nissen Fundoplication in the Spectrum of Gastroesophageal Reflux Disease
Hiatal Hernia, Lower Esophageal Sphincter Incompetence, and Effectiveness of Nissen Fundoplication in the Spectrum of Gastroesophageal Reflux Disease
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DOI：
10.1007/s11605-008-0754-x
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发表时间：
2009-04-01
影响因子：
3.2
通讯作者：
DeMeester, Tom R.
中科院分区：
文献类型：
--
作者：
Lord, Reginald V. N.;DeMeester, Steven R.;DeMeester, Tom R.
胃食道反流病(GERD)是一系列疾病，包括非糜烂性反流病(NERD)、糜烂性反流病(ERD)和巴雷特食道(BE)。在许多研究中，不同阶段患者的治疗结果有所不同。特别是，据报道，抑酸药物疗法对NERD和Barrett‘s食道患者的疗效较差。这项研究的目的是调查(1)机械因素，包括裂孔疝和下食道括约肌(LES)功能在GERD频谱中的作用和(2)Nissen胃底折叠术的结果。从pH异常后接受腹腔镜Nissen胃底折叠术的患者的记录中，我们确定了50名有症状的连续患者，每个GERD阶段：(1)NERD，(2)轻度ERD，定义为食管炎，通过抑酸治疗治愈，(3)严重ERD，定义为食管炎，尽管药物治疗，但仍持续存在，和(4)BE。排除标准为：正常的远端食管酸暴露、在别处进行的食道pH监测、不到1年前或胃底折叠术前的抗反流手术、以及命名的食道运动障碍或远端低幅度运动障碍。无法联系到参与研究的患者也被排除在外。所有患者均完成了详细的术前问卷调查；术前行上消化道内窥镜检查、静态测压和远端食道pH监测；术后至少1年进行访谈。平均随访期36.7个月。唯一显著的术前症状差异是，与NERD患者相比，BE患者有更多的中重度或重度吞咽困难。严重的ERD或BE患者的食道裂孔疝气患病率显著较高，LES压力较低，食管酸暴露较多。大多数重度ERD或BE患者存在裂孔疝气和低血压LES，但仅有少数NERD或轻度ERD患者存在。手术治疗在所有类型的GERD患者中都有同样出色的症状结果。与轻度ERD和NERD相比，严重的ERD和BE与机械抗反流屏障的丧失显著相关，这反映在裂孔裂孔疝气和LES测量上。通过腹腔镜尼森胃底折叠术重建抗反流屏障和减少腹股沟疝气，在所有患者中都能提供同样出色的症状控制。
Gastroesophageal reflux disease (GERD) is a spectrum of disease that includes nonerosive reflux disease (NERD), erosive reflux disease (ERD), and Barrett's esophagus (BE). Treatment outcomes for patients with different stages have differed in many studies. In particular, acid suppressant medication therapy is reported to be less effective for treating patients with NERD and Barrett's esophagus. The aims of this study were to investigate (1) the role of mechanical factors including hiatal hernia and lower esophageal sphincter (LES) competence in the spectrum of GERD and (2) outcomes of Nissen fundoplication.From the records of patients who had undergone laparoscopic Nissen fundoplication after an abnormal pH study, we identified 50 symptomatic consecutive patients with each of the GERD stages: (1) NERD, (2) mild ERD, defined as esophagitis that was healed with acid suppression therapy, (3) severe ERD, defined as esophagitis that persisted despite medical therapy, and (4) BE. Exclusion criteria were normal distal esophageal acid exposure, esophageal pH monitoring performed elsewhere, antireflux surgery less than 1 year previously or previous fundoplication, and a named esophageal motility disorder or distal esophageal low amplitude hypomotility. Patients who could not be contacted for the study were also excluded. All patients completed a detailed preoperative questionnaire; underwent preoperative upper gastrointestinal endoscopy, stationary manometry, and distal esophageal pH monitoring; and were interviewed at least 1 year after operation.One hundred sixty patients meeting the entry criteria were studied. The mean follow-up period was 36.7 months. The only significant preoperative symptom difference was that patients with BE had more moderately severe or severe dysphagia compared to patients with NERD. Patients with severe ERD or BE had a significantly higher prevalence of hiatal hernia, lower LES pressures, and more esophageal acid exposure. Hiatal hernia and hypotensive LES were present in most patients with severe ERD or BE but in only a minority of patients with NERD or mild ERD. Surgical therapy resulted in similarly excellent symptom outcomes for patients in all GERD categories.Compared to mild ERD and NERD, severe ERD and BE are associated with significantly greater loss of the mechanical antireflux barrier as reflected in the presence of hiatal hernia and LES measurements. Restoration of the antireflux barrier and hernia reduction by laparoscopic Nissen fundoplication provides similarly excellent symptom control in all patients.