Tamhankar Anand P, Almogy Gideon, Arain Mustafa A, Portale Giuseppe, Hagen Jeffrey A, Peters Jeffrey H, Crookes Peter F, Sillin Lelan F, DeMeester Steven R, Bremner Cedric G, DeMeester Tom R
Department of Surgery, University of Southern California, Los Angeles, California 90033, USA.
J Gastrointest Surg. 2003 Dec;7(8):990-6; discussion 996. doi: 10.1016/j.gassur.2003.09.003.
Hypertensive lower esophageal sphincter (LES) is an uncommon manometric abnormality found in patients with dysphagia and chest pain, and is sometimes associated with gastroesophageal reflux disease (GERD). Preventing reflux by performing a fundoplication raises concerns about inducing or increasing dysphagia. The role of myotomy in isolated hypertensive LES is also unclear. The aim of this study was to determine the outcome of surgical therapy for isolated hypertensive LES and for hypertensive LES associated with GERD. Sixteen patients (5 males and 11 females), ranging in age from 39 to 89 years, with hypertensive LES (>26 mm Hg; i.e., >95th percentile of our control population) who had surgical therapy between 1996 and 1999 were reviewed. Patients with a diagnosis of achalasia and diffuse esophageal spasm were excluded. All patients had dysphagia or chest pain. Eight of 16 patients had symptoms of GERD, four had a type III hiatal hernia, and four had isolated hypertensive LES pain. Patients with hypertensive LES and GERD or type III hiatal hernia had a Nissen fundoplication, and those with isolated hypertensive LES had a myotomy of the LES with partial fundoplication. Outcome was assessed as follows: excellent if the patient was asymptomatic; good if symptoms were present but no treatment was required; fair if symptoms were present and required treatment; and poor if symptoms were unimproved or worsened. All patients were contacted by telephone for symptom assessment at a median of 3.6 years (range 3 to 6.1 years) after surgery. Patients with hypertensive LES and GERD or type III hiatal hernia had significantly lower LES pressure than those with isolated hypertensive LES (29.9 vs. 47.4 mm Hg; P=0.013). Dysphagia and chest pain were relieved in all patients at long-term follow up. Outcome was excellent in 10 of 16, good in 3 of 16, and fair in 3 of 16. All patients but one were satisfied with their outcome. Patients with hypertensive LES are a heterogeneous group in regard to symptoms and etiology. Treatment of patients with hypertensive LES should be individualized. A Nissen fundoplication for hypertensive LES with GERD or type III hiatal hernia relieves dysphagia and chest pain suggesting reflux as an etiology. A myotomy with partial fundoplication for isolated hypertensive LES relieves dysphagia and chest pain suggesting a primary sphincter dysfunction.
高血压性食管下括约肌（LES）是在吞咽困难和胸痛患者中发现的一种罕见的测压异常，有时与胃食管反流病（GERD）相关。通过进行胃底折叠术预防反流引发了对诱发或加重吞咽困难的担忧。肌切开术在孤立性高血压性LES中的作用也不明确。本研究的目的是确定手术治疗孤立性高血压性LES以及与GERD相关的高血压性LES的结果。回顾了1996年至1999年间接受手术治疗的16例患者（5例男性和11例女性），年龄在39至89岁之间，患有高血压性LES（>26 mmHg；即高于我们对照人群的第95百分位数）。排除诊断为贲门失弛缓症和弥漫性食管痉挛的患者。所有患者均有吞咽困难或胸痛。16例患者中有8例有GERD症状，4例有III型食管裂孔疝，4例有孤立性高血压性LES疼痛。患有高血压性LES和GERD或III型食管裂孔疝的患者接受了nissen胃底折叠术，而患有孤立性高血压性LES的患者接受了LES肌切开术并部分胃底折叠术。结果评估如下：如果患者无症状则为优秀；如果有症状但无需治疗则为良好；如果有症状且需要治疗则为中等；如果症状未改善或恶化则为差。术后中位3.6年（范围3至6.1年）通过电话联系所有患者进行症状评估。患有高血压性LES和GERD或III型食管裂孔疝的患者的LES压力明显低于患有孤立性高血压性LES的患者（29.9对47.4 mmHg；P = 0.013）。所有患者在长期随访中吞咽困难和胸痛均得到缓解。16例中有10例结果优秀，16例中有3例良好，16例中有3例中等。除1例患者外，所有患者对其结果均满意。高血压性LES患者在症状和病因方面是一个异质性群体。高血压性LES患者的治疗应个体化。对于患有GERD或III型食管裂孔疝的高血压性LES患者，nissen胃底折叠术可缓解吞咽困难和胸痛，提示反流是病因。对于孤立性高血压性LES，肌切开术并部分胃底折叠术可缓解吞咽困难和胸痛，提示原发性括约肌功能障碍。
