Watson D I, Jamieson G G, Bessell J R, Devitt P G
Flinders University Department of Surgery, Flinders Medical Center, Bedford Park, South Australia, Australia.
Dis Esophagus. 2006;19(2):94-8. doi: 10.1111/j.1442-2050.2006.00547.x.
A minority of patients with severe gastroesophageal reflux who present to surgeons for antireflux surgery have absent esophageal peristalsis when investigated before surgery with esophageal manometry. Some of these patients also have systemic sclerodema. While conventional wisdom suggests that these patients are at risk of a poor outcome if they proceed to fundoplication, some will have severe reflux symptoms, which are poorly controlled by medical therapy, and surgery will therefore offer the only chance of 'cure'. We performed this study to determine the outcome of laparoscopic fundoplication in the subset of patients with gastroesophageal reflux and an aperistaltic esophagus. From 1991 to 2003, the operative and follow-up details for all 1443 patients who underwent a laparoscopic fundoplication in our Departments have been prospectively collected on a database. These patients were then followed yearly using a standardized symptom assessment questionnaire. A subset of patients whose preoperative esophageal manometry demonstrated complete absence of esophageal body peristalsis and absent lower esophageal sphincter tone (aperistaltic esophagus) were identified from this database, and their outcome following laparoscopic fundoplication was determined. Twenty-six patients with an aperistaltic esophagus who underwent a laparoscopic fundoplication were identified. Six of these had a systemic connective tissue disease (scleroderma), and 20 had an aperistaltic esophagus without a systemic disorder. A Nissen fundoplication was performed in four patients, and an anterior partial fundoplication in 22. Follow-up extended up to 12 years (median, 6). A good overall symptomatic outcome was achieved in 88% at 1 year, 83% at 2 years and 93% at 5-12 years follow-up. Reflux symptoms were well controlled by surgery alone in 79% at 1 year, and 79% at 5-12 years. At 2 years, 87% were eating a normal diet. Two patients underwent further surgery - one at 1 week postoperatively for a tight esophageal hiatus, and one at 1 year for recurrent reflux. Patients with troublesome reflux and an aperistaltic esophagus can be effectively treated by laparoscopic fundoplication. An acceptable outcome will be achieved in the majority of patients.
少数因严重胃食管反流而寻求外科医生进行抗反流手术的患者，在术前接受食管测压检查时显示食管无蠕动。其中一些患者还患有系统性硬化症。传统观点认为，如果这些患者进行胃底折叠术，预后可能不佳，但有些患者会有严重的反流症状，药物治疗难以控制，因此手术是唯一的“治愈”机会。我们开展这项研究以确定腹腔镜胃底折叠术对胃食管反流且食管无蠕动患者亚组的治疗效果。1991年至2003年，我们科室所有1443例行腹腔镜胃底折叠术患者的手术及随访详情均已前瞻性地录入数据库。然后每年使用标准化症状评估问卷对这些患者进行随访。从该数据库中识别出术前食管测压显示食管体部完全无蠕动且食管下括约肌张力缺失（无蠕动食管）的患者亚组，并确定他们接受腹腔镜胃底折叠术后的治疗效果。确定了26例接受腹腔镜胃底折叠术的无蠕动食管患者。其中6例患有系统性结缔组织病（硬皮病），20例有无蠕动食管但无系统性疾病。4例患者行nissen胃底折叠术，22例行前部分胃底折叠术。随访时间长达12年（中位时间为6年）。随访1年时，88%的患者总体症状改善良好；2年时为83%；5 - 12年时为93%。仅手术治疗就能有效控制反流症状，1年时为79%，5 - 12年时为79%。2年时，87%的患者饮食正常。2例患者接受了再次手术，1例术后1周因食管裂孔狭窄接受手术，1例术后1年因反流复发接受手术。有严重反流且食管无蠕动的患者可通过腹腔镜胃底折叠术得到有效治疗。大多数患者将取得可接受的治疗效果。
