Farrell T M, Archer S B, Galloway K D, Branum G D, Smith C D, Hunter J G
Emory University School of Medicine, Atlanta, Georgia, USA.
Am Surg. 2000 Mar;66(3):229-36; discussion 236-7.
Toupet (270 degrees) fundoplication is commonly recommended for patients with gastroesophageal reflux (GER) and esophageal dysmotility. However, Toupet fundoplication may be less effective at protecting against reflux than Nissen (360 degrees) fundoplication. We therefore compared the effectiveness and durability of both types of fundoplication as a function of preoperative esophageal motility. From January 1992 through January 1998, 669 patients with GER underwent laparoscopic fundoplication (78 Toupet, 591 Nissen). Patients scored heartburn, regurgitation, and dysphagia preoperatively, and at 6 weeks and 1 year postoperatively, using a 0 ("none") to 3 ("severe") scale. We compared symptom scores (Wilcoxon rank sum test) and redo fundoplication rates (Fisher exact test) in Toupet and Nissen patients. We also performed subgroup analyses on 81 patients with impaired esophageal motility (mean peristaltic amplitude, <30 mm Hg or peristalsis <70% of wet swallows) and 588 patients with normal esophageal motility. Toupet and Nissen patients reported similar preoperative heartburn, regurgitation, and dysphagia. At 6 weeks after operation, heartburn and regurgitation were similarly improved in both groups, but dysphagia was more prevalent among Nissen patients. After 1 year, heartburn and regurgitation were re-emerging in Toupet patients, and dysphagia was again similar between groups. Patients with impaired motility who have Nissen fundoplication are no more likely to suffer persistent dysphagia than their counterparts who have Toupet fundoplication. In addition, patients with normal motility are more likely to develop symptom recurrence after Toupet fundoplication than Nissen fundoplication, with no distinction in dysphagia rates. We conclude that since Toupet patients suffer more heartburn recurrence than Nissen patients, with similar dysphagia, selective use of Toupet fundoplication requires further study.
对于胃食管反流（GER）和食管动力障碍患者，通常推荐采用Toupet（270度）胃底折叠术。然而，与nissen（360度）胃底折叠术相比，Toupet胃底折叠术在预防反流方面可能效果较差。因此，我们比较了这两种胃底折叠术的有效性和持久性与术前食管动力的关系。从1992年1月至1998年1月，669例GER患者接受了腹腔镜胃底折叠术（78例Toupet术式，591例nissen术式）。患者在术前、术后6周和1年时，使用0（“无”）至3（“严重”）的量表对烧心、反流和吞咽困难进行评分。我们比较了Toupet术式和nissen术式患者的症状评分（Wilcoxon秩和检验）和再次胃底折叠术的发生率（Fisher精确检验）。我们还对81例食管动力受损（平均蠕动幅度<30 mmHg或蠕动次数<湿吞咽次数的70%）和588例食管动力正常的患者进行了亚组分析。Toupet术式和nissen术式患者术前的烧心、反流和吞咽困难情况相似。术后6周时，两组的烧心和反流情况均得到类似改善，但nissen术式患者的吞咽困难更为普遍。1年后，Toupet术式患者的烧心和反流情况再次出现，两组之间的吞咽困难情况再次相似。接受nissen胃底折叠术的动力受损患者比接受Toupet胃底折叠术的患者更不容易出现持续性吞咽困难。此外，食管动力正常的患者在接受Toupet胃底折叠术后比接受nissen胃底折叠术后更容易出现症状复发，吞咽困难发生率无差异。我们得出结论，由于Toupet术式患者比nissen术式患者更容易出现烧心复发，且吞咽困难情况相似，因此选择性使用Toupet胃底折叠术需要进一步研究。
