Wykypiel H, Hugl B, Gadenstaetter M, Bonatti H, Bodner J, Wetscher G J
Department of General and Transplant Surgery, Medical University, Anichstrasse 35, A-6020, Innsbruck, Austria.
Surg Endosc. 2008 Aug;22(8):1845-51. doi: 10.1007/s00464-007-9719-5. Epub 2007 Dec 11.
Impaired esophageal clearance is important in the pathogenesis of gastroesophageal reflux disease (GERD). It is unknown whether esophageal clearance improves following antireflux surgery. The aim of this study was to investigate the effect of laparoscopic Nissen fundoplication (NF), laparoscopic partial posterior (Toupet) fundoplication (PPF) or medical therapy on esophageal clearance.
This was a prospective nonrandomized crossover study. Sixty patients were evaluated with endoscopy, esophageal manometry, radionuclide scanning of esophageal emptying, and assessment of symptoms prior to surgery or medical therapy and 6 months after treatment. In 20 GERD patients with normal esophageal peristalsis an NF was performed, in 20 patients with impaired esophageal peristalsis a PPF was chosen, and 20 patients received proton-pump inhibitor (PPI) treatment.
On endoscopy, esophagitis had resolved in all patients after surgery; two patients with medical therapy still had esophagitis. On manometry, a significant improvement of lower esophageal sphincter competence was seen in both surgical groups. LES relaxation was complete after PPF, but incomplete after NF. Esophageal peristalsis did not improve after medical therapy, was significantly improved after PPF, but had worsened after NF. On scintigraphic esophageal emptying for solid meals, there was no improvement after medical therapy but a significant improvement after PPF. A significant deterioration of esophageal emptying was observed after NF. There was a strong correlation between scintigraphic and manometric evaluation of peristalsis preoperatively (r(s) = -0.87, p < 0.05) and postoperatively (r(s) = -0.82, p < 0.05). There was no change in dysphagia after medical therapy and after NF but a significant improvement after PPF. Globus sensation was significantly improved after PPF but did not change after medical therapy or NF. Postprandial bloating and inability to belch were significantly more common after NF than after PPF.
Laparoscopic partial posterior (Toupet) fundoplication can restore a preoperatively defective esophageal bolus propagation on scintigraphy with the same antireflux effect as the laparoscopic Nissen fundoplication, but with lower side-effects.
食管清除功能受损在胃食管反流病（GERD）的发病机制中起重要作用。抗反流手术后食管清除功能是否改善尚不清楚。本研究的目的是探讨腹腔镜尼氏胃底折叠术（NF）、腹腔镜部分后位（图佩特）胃底折叠术（PPF）或药物治疗对食管清除功能的影响。
这是一项前瞻性非随机交叉研究。60例患者在手术或药物治疗前以及治疗后6个月接受了内镜检查、食管测压、食管排空的放射性核素扫描以及症状评估。在20例食管蠕动正常的GERD患者中进行了NF手术，在20例食管蠕动受损的患者中选择了PPF手术，20例患者接受质子泵抑制剂（PPI）治疗。
内镜检查显示，所有手术患者术后食管炎均已消退；2例接受药物治疗的患者仍有食管炎。测压显示，两个手术组的食管下括约肌功能均有显著改善。PPF术后LES松弛完全，但NF术后不完全。药物治疗后食管蠕动未改善，PPF术后显著改善，但NF术后恶化。对于固体餐的放射性核素食管排空检查，药物治疗后无改善，但PPF术后有显著改善。NF术后观察到食管排空显著恶化。术前蠕动的放射性核素和测压评估之间（r(s)=-0.87，p<0.05）以及术后（r(s)=-0.82，p<0.05）有很强的相关性。药物治疗和NF术后吞咽困难无变化，但PPF术后有显著改善。PPF术后球部感觉显著改善，但药物治疗或NF术后无变化。餐后腹胀和不能嗳气在NF术后比PPF术后明显更常见。
腹腔镜部分后位（图佩特）胃底折叠术可在闪烁扫描中恢复术前有缺陷的食管团块推进，其抗反流效果与腹腔镜尼氏胃底折叠术相同，但副作用较小。
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