Patti M G, Feo C V, Diener U, Tamburini A, Arcerito M, Safadi B, Way L W
Department of Surgery, University of California, San Francisco, 533 Parnassus Avenue, Room U-122, San Francisco, CA 94143-0788, USA.
Surg Endosc. 1999 Sep;13(9):843-7. doi: 10.1007/s004649901117.
It has been said that a Heller myotomy cannot improve dysphagia in achalasia when the esophagus is markedly dilated or sigmoid shaped. Those who hold this belief recommend esophagectomy as the primary treatment in such cases. This study aimed to compare the results of laparoscopic Heller myotomy combined with Dor fundoplication in 66 patients with and without esophageal dilatation, all of whom had achalasia.
On the basis of the maximal diameter of the esophageal lumen and the shape of the esophagus, the patients were placed into four groups: group A (esophageal diameter <4.0 cm; 26 patients), group B (diameter 4.0-6.0 cm; 21 patients), group C1 (diameter >6.0 cm and straight esophageal axis; 12 patients), and group C2 (diameter >6.0 cm and sigmoid-shaped esophagus; 7 patients). All patients underwent a laparoscopic Heller myotomy and Dor fundoplication.
The duration of the operation and the length of hospital stay were similar among the four groups. Excellent or good results were obtained in 88% of group A, 100% of group B, 83% of group C1, and 100% of group C2. No patient in this consecutive series ultimately required an esophagectomy.
In patients with achalasia who have esophageal dilation, a laparoscopic Heller myotomy and Dor fundoplication (a) took no longer and was no more difficult, (b) was associated with no more postoperative complications, and (c) gave just as good relief of dysphagia. We conclude that esophageal dilation by itself should rarely serve as an indication for esophagectomy rather than myotomy as the initial surgical treatment.
据说当食管明显扩张或呈乙状结肠形时，贲门肌层切开术无法改善贲门失弛缓症患者的吞咽困难。秉持这种观点的人建议在这类病例中将食管切除术作为主要治疗方法。本研究旨在比较66例贲门失弛缓症患者行腹腔镜贲门肌层切开术联合Dor胃底折叠术的结果，这些患者中有食管扩张的，也有未扩张的。
根据食管腔的最大直径和食管形状，将患者分为四组：A组（食管直径<4.0 cm；26例患者）、B组（直径4.0 - 6.0 cm；21例患者）、C1组（直径>6.0 cm且食管轴呈直线；12例患者）和C2组（直径>6.0 cm且食管呈乙状结肠形；7例患者）。所有患者均接受了腹腔镜贲门肌层切开术和Dor胃底折叠术。
四组患者的手术时间和住院时间相似。A组88%、B组100%、C1组83%、C2组100%的患者获得了优或良的结果。在这一连续系列病例中，没有患者最终需要行食管切除术。
对于有食管扩张的贲门失弛缓症患者，腹腔镜贲门肌层切开术和Dor胃底折叠术（a）耗时不长且难度不大，（b）术后并发症并未增多，（c）缓解吞咽困难的效果同样良好。我们得出结论，食管扩张本身很少应作为食管切除术而非肌层切开术作为初始手术治疗的指征。
