Gómez Cárdenas Xavier, Flores Armenta Jesús Humberto, Elizalde Di Martino Alexandro, Guarneros Zárate Joaquín Eugenio, Cervera Servín Andrés, Ochoa Gómez Ramón, Quijano Orvañanos Fernando
Departamento de Cirugía General, Centro Médico ABC, México, D.F.
Rev Gastroenterol Mex. 2005 Oct-Dec;70(4):402-10.
Laparoscopic fundoplication for the surgical treatment of gastroesophageal reflux disease is widely accepted all over the world.
To compare clinical results of patients operated with the Nissen, Nissen-Rossetti and Toupet techniques, in Centro Medico ABC, for the treatment of pathologic gastroesophageal reflux, and to determine if there is a difference when dividing the short gastric vessels with complete mobilization of the gastric fundus.
We carried out a retrospective, longitudinal, comparative and observational study of 241 laparoscopic fundoplications performed in Centro Medico ABC, between January 2000 and May 2001. The following variables were analyzed: age, sex, smoking, habits, drinking habits, time of evolution of gastroesophageal reflux, typical and atypical clinical manifestations, medical treatment received, preoperative dysphagia, hiatal hernia, degree of esophagitis, Barrett's esophagus, esophageal motility disorders, preoperative and postoperative pressure of the inferior esophageal sphincter, 24-hour pH monitoring, type of fundoplication, division of short gastric vessels, complete mobilization of the gastric fundus, closure of the pillars, diameter of probang, fundoplication fixed to the right pillar, suture applied, transoperative endoscopy, days of hospitalization, time before applying orally, morbidity and mortality. For the clinical follow-up, patients were contacted via telephone, assessing the following variables: dysphagia for liquids, dysphagia for solids, heartburn, postprandial fullness, gastric bubble, ability to belch, flatulence, diarrhea, medical treatment post-fundoplication, esophageal dilatation, reoperation, satisfaction with procedure divided into 5 levels: excellent, satisfied, moderately satisfied, poorly satisfied, unsatisfied and, for each group, the modified Visick scale was included. These variables were analyzed and compared between Nissen, Nissen-Rossetti and Toupet fundoplication, attempting to identify a significant statistical difference. Qualitative analysis; Chi-square at p < 0.05.
241 patients underwent laparoscopic fundoplication surgery in Centro Medico ABC between January 2000 and May 2001. 27.4% (n = 66) corresponded to Nissen fundoplication, 31.5% (n = 76) to Nissen-Rossetti and 41.1% (n = 99) to Toupet. Males predominated at 65.6% (n = 158). Average age was 42 years ranging from 18 to 76 years old. We were able to contact and interview 231 patients via telephone, which corresponded to 95.8%. The average follow-up time was 12 months, ranging from 6 to 18 months in which the control of gastroesophageal reflux was higher for the Nissen group at 98.5%, Nissen-Rossetti 93% and Toupet 73% with statistical significance p < 0.001. In the Toupet group 27% (n = 26) had recurrent heartburn and 11% (n = 8) had persistent dysphagia in the Nissen-Rossetti group p < 0.001. Six patients underwent reoperation, five (7%) of the Nissen-Rossetti group due to severe dysphagia and one (1%) of the Toupet group due to the dismantling of the fundoplication and recurrence of symptoms p < 0.001. The clinical condition during follow-up was superior for the Nissen group (Visick I-II in 98.5% p < 0.001). Morbidity was 2.4%, with no operative mortality.
Our results are comparable to the ones published in the world literature. In our hands, a Nissen fundoplication with complete mobilization of the fundus yielded the best results, a Nissen-Rossetti operation had more disphagia and more reoperations and a partial fundoplication of Toupet, had a higher incidence of recurrent heartburn.
腹腔镜胃底折叠术用于胃食管反流病的外科治疗在全世界被广泛接受。
比较在ABC医疗中心采用nissen、nissen - rossetti和Toupet技术进行手术的患者治疗病理性胃食管反流的临床结果，并确定在完全游离胃底时切断胃短血管是否存在差异。
我们对2000年1月至2001年5月在ABC医疗中心进行的241例腹腔镜胃底折叠术进行了回顾性、纵向、比较性和观察性研究。分析了以下变量：年龄、性别、吸烟习惯、饮酒习惯、胃食管反流病程、典型和非典型临床表现、接受的药物治疗、术前吞咽困难、食管裂孔疝、食管炎程度、巴雷特食管、食管动力障碍、术前和术后食管下括约肌压力、24小时pH监测、胃底折叠术类型、胃短血管切断、胃底完全游离、支柱闭合、探条直径、固定于右支柱的胃底折叠术、应用的缝合、术中内镜检查、住院天数、口服前时间、发病率和死亡率。为进行临床随访，通过电话联系患者，评估以下变量：液体吞咽困难、固体吞咽困难、烧心、餐后饱胀、胃泡、嗳气能力、腹胀、腹泻、胃底折叠术后药物治疗、食管扩张、再次手术、对手术的满意度分为5个等级：优秀、满意、中等满意、不满意、非常不满意，并且每组都纳入了改良的Visick量表。对这些变量在nissen、nissen - rossetti和Toupet胃底折叠术之间进行分析和比较，试图确定显著的统计学差异。定性分析；p < 0.05时的卡方检验。
2000年1月至2001年5月，241例患者在ABC医疗中心接受了腹腔镜胃底折叠术。27.4%（n = 66）为nissen胃底折叠术，31.5%（n = 76）为nissen - rossetti胃底折叠术，41.1%（n = 99）为Toupet胃底折叠术。男性占主导，为65.6%（n = 158）。平均年龄为42岁，范围在18至76岁之间。我们能够通过电话联系并采访231例患者，占95.8%。平均随访时间为个月，范围在6至18个月，其中nissen组胃食管反流控制率为98.5%，nissen - rossetti组为93%，Toupet组为73%，具有统计学意义p < 0.001。在Toupet组中，27%（n = 26）有复发性烧心，在nissen - rossetti组中11%（n = 8）有持续性吞咽困难，p < 0.001。6例患者接受了再次手术，nissen - rossetti组5例（7%）因严重吞咽困难，Toupet组1例（1%）因胃底折叠术松解和症状复发，p < 0.001。随访期间nissen组的临床状况更佳（98.5%为Visick I - II级，p < 0.001）。发病率为2.4%，无手术死亡。
我们的结果与世界文献中发表的结果相当。在我们的研究中，完全游离胃底的nissen胃底折叠术效果最佳，nissen - rossetti手术有更多吞咽困难和更多再次手术，而Toupet部分胃底折叠术复发性烧心的发生率更高。
