Raiss M, Hrora A, Menfaa M, Al Baroudi S, Ahallat M, Hosni K, Halhal A, Tounsi A
Clinique chirurgicale C, hôpital Ibn Sina, Rabat, Maroc.
Ann Chir. 2002 Dec;127(10):771-5. doi: 10.1016/s0003-3944(02)00876-3.
Surgical treatment of achalasia of lower oesophageal sphincter is Heller's myotomy, usually associated with a fundoplication due to an high risk of postoperative gastro-oesophageal reflux. The value of this fundoplication is discussed. The aim of this study was to evaluate retrospectively the results of Heller's myotomy without fundoplication but performed according to a precise technique preventing postoperative reflux.
Between 1975 and 1999, 123 patients underwent Heller's myotomy without systematic fundoplication. Diagnosis of achalasia was performed clinically and confirmed by investigations: baryum meal, fibroscopy and manometry. Myotomy was performed through an abdominal approach in 117 (95%) patients. Dissection preserved fixity of abdominal oesophagus in all cases, particularly its posterior meso. Myotomy was performed on abdominal oesophagus but not below the cardia. Posterior fundoplication was associated in 2 patients.
One patient (0,8%) died from massive aspiration. Morbidity (1,6%) consisted in one peritonitis and one postoperative occlusion. At follow-up (mean = 5 years; range: 1-20), functional results were satisfying (excellent and good) in 112 (92%) patients. Seven patients (6%) developed postoperative reflux, including one who need surgical treatment. Dysphagia persisted in 3 patients (2%) who had to be reoperated.
Results of this series show that systematic fundoplication is not necessary in Heller's myotomy for achalasia of lower oesophageal sphincter.
食管下括约肌失弛缓症的外科治疗方法是赫勒肌切开术，由于术后发生胃食管反流的风险较高，通常会联合抗反流手术。本文讨论了这种抗反流手术的价值。本研究旨在回顾性评估未行抗反流手术但采用精确技术预防术后反流的赫勒肌切开术的效果。
1975年至1999年间，123例患者接受了未常规行抗反流手术的赫勒肌切开术。失弛缓症的诊断通过临床检查并经钡餐、纤维内镜检查和测压等进一步确认。117例（95%）患者通过腹部入路进行肌切开术。所有病例均保留了腹段食管的固定性，尤其是其后系膜。肌切开术在腹段食管进行，但不低于贲门水平。2例患者联合了后方抗反流手术。
1例患者（0.8%）因大量误吸死亡。并发症发生率为1.6%，包括1例腹膜炎和1例术后梗阻。随访（平均5年；范围1 - 20年）时，112例（92%）患者的功能结果良好（优和良）。7例患者（6%）出现术后反流，其中1例需要手术治疗。3例患者（2%）吞咽困难持续存在，需再次手术。
本系列研究结果表明，对于食管下括约肌失弛缓症的赫勒肌切开术，常规行抗反流手术并非必要。
