DeMeester Steven R, Sillin Lelan F, Lin Harrison W, Gurski Richard R
Department of Cardiothoracic Surgery, The University of Southern California, Keck School of Medicine, Los Angeles, CA, USA.
J Am Coll Surg. 2003 Oct;197(4):558-64. doi: 10.1016/S1072-7515(03)00481-2.
New laparoscopic techniques allow both mediastinal mobilization and performance of a Collis gastroplasty when necessary, and the utility of a transthoracic approach is questioned. The aim of this study was to compare the increase in esophageal length achievable with laparoscopic and transthoracic esophageal mobilization in pigs, and to assess the impact of vagal trunk division on esophageal length.
Baseline esophageal length was obtained in 20 farm pigs by measuring the distance between a stitch placed in the esophagus to a K-wire placed in a vertebral body. Subsequently, laparoscopic and then transthoracic mediastinal mobilization of the esophagus were performed in 15 pigs and the length gain after each procedure recorded. In 7 of 15 animals, the vagal nerve trunks were divided after esophageal mobilization and the increase in esophageal length measured. In five animals, vagal trunk division was performed without earlier esophageal mobilization.
Esophageal length gain after laparoscopic mobilization (median 4 mm) was significantly less than that after transthoracic mobilization (median 12 mm, p < 0.0001). Unilateral vagal nerve transection resulted in a median 2.5 mm of esophageal length gain compared with a median of 6.25 mm with division of both vagal trunks. Maximal esophageal lengthening (median 18.5 mm) occurred with a combination of esophageal mobilization and bilateral vagal trunk division.
Esophageal length gain after transthoracic mobilization in normal pigs is significant, and would likely be even greater in patients with gastroesophageal reflux disease with concomitant mediastinal inflammation. Transthoracic mobilization alone likely will allow successful reduction of the gastroesophageal junction below the diaphragm in many patients who might otherwise require a Collis gastroplasty.
新的腹腔镜技术既能实现纵隔游离，又能在必要时进行科利斯胃成形术，经胸入路的实用性受到质疑。本研究的目的是比较猪腹腔镜和经胸食管游离所能达到的食管长度增加情况，并评估迷走神经干切断对食管长度的影响。
通过测量置于食管的缝线与置于椎体的克氏针之间的距离，在20头农场猪中获得基线食管长度。随后，对15头猪进行腹腔镜下然后经胸纵隔食管游离，并记录每次手术后的长度增加情况。在15只动物中的7只中，食管游离后切断迷走神经干并测量食管长度的增加。在5只动物中，未先进行食管游离就进行迷走神经干切断。
腹腔镜游离后食管长度增加（中位数4mm）明显小于经胸游离后（中位数12mm，p<0.0001）。单侧迷走神经横断导致食管长度增加中位数为2.5mm，而双侧迷走神经干切断时中位数为6.25mm。食管游离与双侧迷走神经干切断相结合时出现最大食管延长（中位数18.5mm）。
正常猪经胸游离后食管长度增加显著，在伴有纵隔炎症的胃食管反流病患者中可能更大。单独经胸游离可能会使许多原本可能需要科利斯胃成形术的患者成功将胃食管交界处降至膈肌以下。
