Sciaudone G, Perniceni T, Chiche R, Levard H, Gayet B
Département médicochirurgical de pathologie digestive, institut mutualiste montsouris, université Paris VI, 42, boulevard Jourdan, 75014 Paris, France.
Ann Chir. 2000 Nov;125(9):838-43. doi: 10.1016/s0003-3944(00)00009-2.
The immediate postoperative course of laparoscopic partial posterior fundoplication can be complicated by severe dysphagia or paraesophageal hernia. The aim of this study was to describe the technical causes of these complications.
Four patients, operated for gastroesophageal reflux disease by laparoscopic partial posterior fundoplication, developed severe dysphagia (n = 2) or paraesophageal hernia (n = 2) during the immediate postoperative period. A barium swallow examination visualized the complication in both cases of dysphagia and in 1 case of paraesophageal hernia. The correct diagnosis was established by CT scan in the other case of paraesophageal hernia. Reoperations were performed by laparoscopy, 3 days (n = 2) or 6 days (n = 2) postoperatively.
Dysphagia was due to compression of the esophagus against the hiatus by the fundoplication. A new and looser fundoplication was easily performed. Dysphagia was no longer present postoperatively. The two patients were symptom-free after 6 and 12 months of follow-up, respectively. In the cases of paraesophageal hernia, the bottoms of the crura were torn. In the patient reoperated 3 days postoperatively, the procedure was easily performed, the postoperative course was uneventful and the patient was symptom-free after a follow-up of 20 months. In the patient reoperated 6 days postoperatively, the upper part of the stomach had moved into the left pleural cavity, the procedure was difficult due to inflammation and thickening of the gastric wall, and the postoperative course was uneventful, but reflux recurred 18 months later.
When severe dysphagia or paraesophageal hernia occurs during the immediate postoperative course of laparoscopic partial posterior fundoplication, reoperation, possibly by laparoscopy, identifies and cures the technical defects. Based on our experience, we suggest that surgical cure of paraesophageal hernia is easier when performed during the immediate postoperative period.
腹腔镜部分后壁胃底折叠术术后早期可能并发严重吞咽困难或食管旁疝。本研究旨在描述这些并发症的技术原因。
4例因胃食管反流病接受腹腔镜部分后壁胃底折叠术的患者，在术后早期出现严重吞咽困难（2例）或食管旁疝（2例）。吞咽困难的2例及食管旁疝的1例经吞钡检查显示有并发症。另一例食管旁疝经CT扫描确诊。术后3天（2例）或6天（2例）通过腹腔镜进行再次手术。
吞咽困难是由于胃底折叠术使食管在裂孔处受压所致。轻松实施了新的、更宽松的胃底折叠术。术后吞咽困难不再存在。两名患者分别在随访6个月和12个月后无症状。在食管旁疝的病例中，膈脚底部撕裂。术后3天接受再次手术的患者，手术操作轻松，术后过程顺利，随访20个月后患者无症状。术后6天接受再次手术的患者，胃上部移入左胸腔，由于胃壁炎症和增厚，手术困难，术后过程顺利，但18个月后反流复发。
当腹腔镜部分后壁胃底折叠术术后早期出现严重吞咽困难或食管旁疝时，再次手术（可能通过腹腔镜）可识别并纠正技术缺陷。根据我们的经验，我们建议在术后早期进行食管旁疝的手术治疗更容易。
