O'Rourke Robert W, Khajanchee Yashodhan S, Urbach David R, Lee Nicole N, Lockhart Barbara, Hansen Paul D, Swanstrom Lee L
Department of Minimally Invasive Surgery, Legacy Health System, Portland, OR, USA.
Arch Surg. 2003 Jul;138(7):735-40. doi: 10.1001/archsurg.138.7.735.
The significance of short esophagus and its impact on failure after laparoscopic Nissen fundoplication are unknown. Although patients with severe esophageal shortening that requires Collis gastroplasty comprise a small percentage of patients undergoing fundoplication, we hypothesize that patients with moderate esophageal shortening requiring extended mediastinal dissection make up a larger subgroup and that extended laparoscopic mediastinal dissection is a good treatment strategy for such patients.
Retrospective comparative analysis in an academic and private practice-based tertiary referral center.
A total of 205 patients underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease or paraesophageal hernias over 4 years. Outcomes in patients requiring either a type I (<5 cm) or type II (>5 cm) mediastinal dissection were compared.
Laparoscopic Nissen fundoplication with or without extended mediastinal dissection and esophageal physiology testing.
Symptom assessments, operative reports, and outcomes were prospectively recorded on standardized data sheets. Postoperative symptom assessment and esophageal physiology testing were performed.
A total of 133 (65%) of the 205 patients underwent type I dissection, and 72 (35%) of the 205 patients underwent type II dissection. Failure occurred in 15 (11%) of 133 patients and 6 (10%) of 72 patients, respectively. The presence of a large hiatal or paraesophageal hernia predicted the need for type II dissection.
No difference was seen in failure rates between patients who required a type II dissection and those who did not. This finding suggests that aggressive application of laparoscopic transmediastinal dissection to obtain adequate esophageal length may reduce fundoplication failure in patients with esophageal shortening and provide a success rate similar to that of patients with normal esophageal length. More liberal application of Collis gastroplasty in these patients is not warranted.
短食管的意义及其对腹腔镜下尼森胃底折叠术失败的影响尚不清楚。虽然需要进行科利斯胃成形术的严重食管缩短患者在接受胃底折叠术的患者中占比很小，但我们推测，需要进行广泛纵隔解剖的中度食管缩短患者构成了一个更大的亚组，并且广泛的腹腔镜纵隔解剖是这类患者的良好治疗策略。
在一个基于学术和私人执业的三级转诊中心进行回顾性比较分析。
在4年期间，共有205例患者因胃食管反流病或食管旁疝接受了腹腔镜下尼森胃底折叠术。比较了需要进行I型（<5厘米）或II型（>5厘米）纵隔解剖的患者的结局。
进行有或没有广泛纵隔解剖的腹腔镜下尼森胃底折叠术以及食管生理测试。
前瞻性地在标准化数据表上记录症状评估、手术报告和结局。进行术后症状评估和食管生理测试。
205例患者中有133例（65%）进行了I型解剖，205例患者中有72例（35%）进行了II型解剖。133例患者中有15例（11%）、72例患者中有6例（10%）出现了手术失败。巨大裂孔或食管旁疝的存在预示着需要进行II型解剖。
需要进行II型解剖的患者与不需要进行II型解剖的患者之间的失败率没有差异。这一发现表明，积极应用腹腔镜经纵隔解剖以获得足够的食管长度，可能会降低食管缩短患者胃底折叠术的失败率，并提供与食管长度正常患者相似的成功率。在这些患者中没有必要更广泛地应用科利斯胃成形术。
