Merchant Aziz M, Cook Michael W, Srinivasan Jahnavi, Davis S Scott, Sweeney John F, Lin Edward
Department of Surgery, Emory Endosurgery Unit, Emory University, Atlanta, Georgia 30322, USA.
Am Surg. 2009 Jul;75(7):620-5.
Treatment options for morbidly obese patients with complications from large paraesophageal hernias (PEH) are limited. Simple repair of the PEH has a high recurrence rate and may be associated with poor gastric function. We compared a series of patients who underwent repair of large PEH plus gastrostomy tube gastropexy (PEH-GT) with PEH plus sleeve gastrectomy (PEH-SG). Retrospective review of patients undergoing PEH-SG and patients with PEH-GT was performed. We assessed symptoms of delayed gastric emptying and reflux postoperatively. In selected patients, gastric-emptying studies and upper gastrointestinal contrast studies were also obtained. All patients with large PEH were repaired laparoscopically with sac resection, primary crural closure using pledgeted sutures, and biologic patch onlay. SG for patients undergoing concomitant weight loss surgery (PEH-SG) was performed with linear endoscopic staplers and staple line reinforcement. Patients undergoing PEH repair alone had a gastrostomy tube gastropexy (PEH-GT). Patients had intraoperative endoscopic evaluation and postoperative contrast swallow studies. In a 12-month period, five patients underwent laparoscopic PEH-SG; two of five had previous antireflux surgery and one of five with a previous diagnosis of delayed gastric emptying. Postoperatively, two patients undergoing PEH-SG had readmission for dehydration and odynophagia. Six-month follow-up body mass index was 32 kg/m2 for the PEH-SG group with no hernia recurrence and complete resolution of gastroesophageal reflux disorder symptoms. Six patients underwent PEH-GT, one for acute incarceration and anemia and four with previous antireflux surgery. Follow up at 8 months demonstrated one recurrence, four of six had severe delayed gastric emptying and reflux, three of six had additional hospitalization for poor oral intake, and three of six underwent reoperation for delayed gastric emptying. There were no perforations, leaks, or deaths in either group. Combined laparoscopic PEH-SG is a clinically reasonable option for patients with morbid obesity with minimal additional risks and decreased incidence of delayed gastric emptying, reflux, and reoperation.
患有巨大食管旁疝（PEH）并发症的病态肥胖患者的治疗选择有限。单纯修复PEH复发率高，且可能与胃功能不良有关。我们比较了一系列接受巨大PEH修复术加胃造瘘管胃固定术（PEH-GT）的患者与接受PEH加袖状胃切除术（PEH-SG）的患者。对接受PEH-SG的患者和接受PEH-GT的患者进行了回顾性研究。我们评估了术后胃排空延迟和反流的症状。在选定的患者中，还进行了胃排空研究和上消化道造影研究。所有巨大PEH患者均通过腹腔镜进行修复，包括疝囊切除、使用带垫片缝线进行初次膈肌脚闭合以及生物补片覆盖。对于接受同期减重手术的患者（PEH-SG），使用线性内镜吻合器进行袖状胃切除术并加强吻合线。仅接受PEH修复的患者进行胃造瘘管胃固定术（PEH-GT）。患者接受术中内镜评估和术后造影剂吞咽研究。在12个月期间，5例患者接受了腹腔镜PEH-SG；5例中有2例曾接受过抗反流手术，5例中有1例先前诊断为胃排空延迟。术后，2例接受PEH-SG的患者因脱水和吞咽痛再次入院。PEH-SG组6个月随访时体重指数为32 kg/m²，无疝复发，胃食管反流病症状完全缓解。6例患者接受了PEH-GT，1例因急性嵌顿和贫血，4例曾接受过抗反流手术。8个月随访显示1例复发，6例中有4例有严重的胃排空延迟和反流，6例中有3例因口服摄入不良再次住院，6例中有3例因胃排空延迟接受再次手术。两组均无穿孔、渗漏或死亡病例。联合腹腔镜PEH-SG对于病态肥胖患者是一种临床合理的选择，额外风险最小，胃排空延迟、反流和再次手术的发生率降低。
