Wright A S, Williams C W, Pellegrini C A, Oelschlager B K
Department of Surgery, University of Washington Hospital, 1959 NE Pacific Street, Mailbox 356410, Seattle, WA 98195-6410, USA.
Surg Endosc. 2007 May;21(5):713-8. doi: 10.1007/s00464-006-9165-9. Epub 2007 Mar 1.
The standard Heller myotomy (SM) for achalasia extends 1 to 2 cm on to the stomach. The authors perform an extended myotomy (EM) (>3 cm) with the goal of reducing postoperative dysphagia. This study examines the long-term efficacy and durability of EM compared with SM.
Patients with achalasia who underwent a laparoscopic Heller myotomy were identified from a prospective database that includes symptom evaluation and results of esophageal functional studies. From September 1994 to August 1998, the authors performed SM with Dor fundoplication, and from September 1998 through 2003, they performed EM with Toupet fundoplication. In 2001, they performed a telephone survey of all available patients. This was repeated in 2005 for the EM group. The survey included scales of symptom frequency (0 [never], 1 [once per month], 2 [once per week], 3 [once per day], 4 [more than once per day]) and severity (0 [no symptoms] to 10 [symptoms equal to preoperative state]) as well as the need to undergo postoperative intervention for dysphagia.
For this study, 52 patients underwent SM with Dor fundoplication (median follow-up period, 46 +/- 24 months), and 63 patients underwent EM with Toupet fundoplication (median follow-up period, 45 +/- 17 months. Postoperative dysphagia severity was significantly better in the EM group (4.8 +/- 2.3 vs 3.1 +/- 2.6; p < 0.005). There was no significant difference in postoperative heartburn frequency, esophageal acid exposure, or lower esophageal sphincter pressure. In the SM group, 9 patients (17%) required reintervention for dysphagia: 14 endoscopic interventions for 5 patients (10%) and reoperation for 4 patients. Three patients (5%) in the EM group required reintervention for dysphagia: one endoscopic intervention each and no reoperations (p < 0.05). A total of 30 patients in the EM group were contacted in both 2001 (median follow-up period, 19 +/- 11 months) and 2005 (median follow-up period, 63 +/- 10 months). There was no significant change over time in dysphagia severity (2.6 +/- 1.9 vs 3.7 +/- 2.0; p = 0.19).
For the treatment of achalasia, EM with Toupet fundoplication provides excellent durable dysphagia relief that is superior to SM with Dor fundoplication.
治疗贲门失弛缓症的标准赫勒肌切开术（SM）向胃内延伸1至2厘米。作者进行了一种扩大肌切开术（EM，>3厘米），目的是减少术后吞咽困难。本研究比较了EM与SM的长期疗效和持久性。
从一个前瞻性数据库中识别出接受腹腔镜赫勒肌切开术的贲门失弛缓症患者，该数据库包括症状评估和食管功能研究结果。1994年9月至1998年8月，作者进行了带Dor胃底折叠术的SM，1998年9月至2003年，他们进行了带Toupet胃底折叠术的EM。2001年，他们对所有可联系到的患者进行了电话调查。2005年对EM组重复进行了此项调查。调查包括症状频率量表（0[从不]，1[每月一次]，2[每周一次]，3[每天一次]，4[每天多次]）和严重程度量表（0[无症状]至10[症状与术前状态相同]）以及因吞咽困难而需要进行术后干预的情况。
本研究中，52例患者接受了带Dor胃底折叠术的SM（中位随访期，46±24个月），63例患者接受了带Toupet胃底折叠术的EM（中位随访期，45±17个月）。EM组术后吞咽困难严重程度明显更好（4.8±2.3对3.1±2.6；p<0.005）。术后烧心频率、食管酸暴露或食管下括约肌压力无显著差异。在SM组中，9例患者（17%）因吞咽困难需要再次干预：5例患者（10%）进行了14次内镜干预，4例患者进行了再次手术。EM组中有3例患者（5%）因吞咽困难需要再次干预：各进行了1次内镜干预，无再次手术（p<0.05）。2001年（中位随访期，19±11个月）和2005年（中位随访期，63±10个月）共联系了EM组的30例患者。吞咽困难严重程度随时间无显著变化（2.6±1.9对3.7±2.0；p = 0.19）。
对于贲门失弛缓症的治疗，带Toupet胃底折叠术的EM能提供持久且出色的吞咽困难缓解效果，优于带Dor胃底折叠术的SM。
