Ritter M P, Peters J H, DeMeester T R, Crookes P F, Mason R J, Green L, Tefera L, Bremner C G
Department of Surgery, University of Southern California School of Medicine, Los Angeles, California 90033-4612, USA.
J Gastrointest Surg. 1998 Nov-Dec;2(6):567-72. doi: 10.1016/s1091-255x(98)80058-9.
With the advent of laparoscopic surgery and the recognition that gastroesophageal reflux disease often requires lifelong medication, patients with normal resting sphincter characteristics are now being considered for surgery. The outcome of these patients after fundoplication is unknown and formed the basis of this study. The study population consisted of 123 patients undergoing laparoscopic Nissen fundoplication between 1992 and 1996. All patients had increased esophageal acid exposure on 24-hour esophageal pH monitoring. Patients were divided into those with a normal (n = 36) and those with a structurally defective (n = 87) lower esophageal sphincter (LES), based on LES resting pressure (normal >6 mm Hg), overall length (normal >2 cm), and abdominal length (normal >1 cm), and their outcomes were assessed. Each group was subsequently divided into patients presenting with a primary symptom that was "typical" (heartburn, regurgitation, or dysphagia) or "atypical" (gastric, respiratory, or chest pain) of gastro-esophageal reflux, and outcome was assessed. Median duration of follow-up was 18 months after surgery. Overall, laparoscopic fundoplication was successful in relieving symptoms of gastroesophageal reflux in 90% of patients. Patients with a typical primary symptom had an excellent outcome irrespective of the resting status of the LES (95% and 97%, respectively). Atypical primary symptoms were significantly more common in patients with a normal LES (29%) than in those with a structurally defective LES (10%; P <0.05), and these symptoms were less likely (50%) to be relieved by antireflux surgery. Laparoscopic antireflux surgery is highly successful and not dependent on the status of the resting LES in patients with increased esophageal acid exposure and primary symptoms "typical" of gastroesophageal reflux. Antireflux surgery should be applied cautiously in patients with atypical primary symptoms.
随着腹腔镜手术的出现以及人们认识到胃食管反流病常常需要终身药物治疗，目前静息时括约肌特征正常的患者也在考虑接受手术治疗。这些患者行胃底折叠术后的结局尚不清楚，这也是本研究的基础。研究对象包括1992年至1996年间接受腹腔镜尼氏胃底折叠术的123例患者。所有患者24小时食管pH监测均显示食管酸暴露增加。根据食管下括约肌（LES）静息压力（正常>6 mmHg）、总长度（正常>2 cm）和腹段长度（正常>1 cm），将患者分为LES正常组（n = 36）和结构缺陷组（n = 87），并评估其结局。随后，每组又根据胃食管反流的主要症状是“典型的”（烧心、反流或吞咽困难）还是“非典型的”（胃部、呼吸或胸痛）进行分组，并评估结局。术后随访的中位时间为18个月。总体而言，腹腔镜胃底折叠术在90%的患者中成功缓解了胃食管反流症状。有典型主要症状的患者无论LES的静息状态如何，结局都很好（分别为95%和97%）。LES正常的患者出现非典型主要症状的比例（29%）显著高于结构缺陷的LES患者（10%；P<0.05），而且抗反流手术缓解这些症状的可能性较小（50%）。对于食管酸暴露增加且有胃食管反流“典型”主要症状的患者，腹腔镜抗反流手术非常成功，且不依赖于LES的静息状态。对于有非典型主要症状的患者，应谨慎应用抗反流手术。
