Danielson P D, Emmens R W
University of Rochester, NY, USA.
J Pediatr Surg. 1999 Jan;34(1):84-6; discussion 87. doi: 10.1016/s0022-3468(99)90234-8.
Fundoplication has been used successfully to treat gastroesophageal reflux in the pediatric population; however, the results are poorer in those children with neurological impairment. We propose an alternative approach to the needs of these special patients and report the use of esophagogastric disconnection to control reflux in children with profound neurological impairment.
Between 1991 and 1997, 27 esohagogastric disconnections were performed. All patients were severely neurologically impaired with symptomatic gastroesophageal reflux confirmed by an upper gastrointestinal radiographic study. There were 16 boys and 11 girls with ages ranging from 6 months to 40 years. Three had undergone previous fundoplications that failed, whereas the remaining underwent esophagogastric disconnection as a primary antireflux procedure. Follow-up ranged from 1 month to 6.3 years (average, 2.8 years). The operative approach used a midline incision. The gastroesophageal junction was divided, and the gastric side was closed. A 30- to 40-cm jejunal limb was prepared for Roux-en-Y reconstruction and brought up to the esophagus in a retrocolic manner. Esophagojejunal and jejunojejunal anastomoses were then performed. A Stamm tube gastrostomy was placed, and the appendix was removed. A pyloroplasty and tube jejunostomy were performed when felt to be clinically indicated.
Gastroesophageal reflux symptoms resolved, and bolus feedings were tolerated by all patients. Oral feedings were tolerated except in those children limited by their swallowing abilities. Early postoperative complications occurred in eight patients (30%) with two (7%) requiring reoperation (esophageal leak and enterocolitis). Late reoperation was necessary in four patients (15%) for small bowel obstruction, paraesophagcal hernia, gastrostomy revision, and enterocolitis. There were no perioperative deaths, but three patients (11%) died of late surgical complications (two of small bowel obstructions, and one of improper reinsertion of a gastrostomy tube). Three other children died of unrelated causes.
Esophagogastric disconnection effectively eliminates gastroesophageal reflux while allowing both bolus tube feedings and oral supplementation. This operation provides an alternative method of controlling gastroesophageal reflux in children with profound neurological impairment.
胃底折叠术已成功用于治疗儿童胃食管反流；然而，对于那些有神经功能障碍的儿童，治疗效果较差。我们针对这些特殊患者的需求提出了一种替代方法，并报告了采用食管胃离断术来控制重度神经功能障碍儿童的反流情况。
1991年至1997年间，实施了27例食管胃离断术。所有患者均有严重的神经功能障碍，经上消化道造影检查确诊有症状性胃食管反流。其中男16例，女11例，年龄从6个月至40岁。3例曾接受过失败的胃底折叠术，其余患者则将食管胃离断术作为主要的抗反流手术。随访时间为1个月至6.3年（平均2.8年）。手术采用正中切口。将食管胃交界处切断，关闭胃侧。准备一段30至40厘米的空肠袢用于Roux-en-Y重建，并经结肠后上提至食管处。然后进行食管空肠和空肠空肠吻合。放置 Stamm 管胃造口术，并切除阑尾。如有临床指征，则进行幽门成形术和空肠造瘘术。
胃食管反流症状消失，所有患者均能耐受推注式管饲喂养。除了那些因吞咽能力受限的儿童外，其他儿童均能耐受经口喂养。8例患者（30%）出现早期术后并发症，其中2例（7%）需要再次手术（食管漏和小肠结肠炎）。4例患者（15%）因小肠梗阻、食管旁疝、胃造口术修复和小肠结肠炎而需要晚期再次手术。围手术期无死亡病例，但3例患者（11%）死于晚期手术并发症（2例死于小肠梗阻，1例死于胃造口管重新插入不当）。另外3名儿童死于无关原因。
食管胃离断术能有效消除胃食管反流，同时允许推注式管饲喂养和经口补充营养。该手术为控制重度神经功能障碍儿童的胃食管反流提供了一种替代方法。
