Department of Surgery, G Hatzikosta General Hospital, Hippocratus 3, Stavraki, GR-45332 Ioannina, Greece.
Surg Endosc. 2010 Jun;24(6):1303-9. doi: 10.1007/s00464-009-0764-0. Epub 2009 Dec 4.
Laparoscopic Nissen fundoplication (LNF) has become established as the procedure of choice in the surgical management of the majority of patients suffering from gastroesophageal reflux disease (GERD). Postoperative paraesophageal herniation has an incidence range up to 7% in the immediate postoperative period.
A prospective randomized trial was scheduled to study the role of posterior gastropexy, in combination with LNF, in prevention of paraesophageal herniation and improvement of postoperative results in surgical treatment of GERD.
Eighty-two patients with GERD were randomized to LNF combined with (group A, n = 40) or without (group B, n = 42) posterior gastropexy. Subjective evaluation using disease-specific and generic questionnaires and structured interviews, and objective evaluation by endoscopy, esophageal manometry, and 24-h pH monitoring, were performed before operation, at 2 and 12 months after surgery, and then every year. Crura approximation was performed by stitches if the diameter was less than 6 cm, or with a patch to reinforce the conventional crural closure or by tension-free technique to close the hiatus. Posterior gastropexy (group A) was performed with one stitch between the posterior wall of the wrap and the crura near the arcuate ligament.
Sixteen patients of group A and 15 patients of group B with concomitant abdominal diseases had simultaneous procedures [cholecystectomy 25, vagotomy 2, ventral hernia repair 1, gastric polypectomy 1, gastric fundus diverticulectomy 1, gastrointestinal stromal tumor (GIST) wedge resection 1]. In mean follow-up of 48 +/- 26 months (range 7-94 months), one patient of group B presented with paraesophageal herniation in the first postoperative month (reoperation), while recurrent gastroesophageal reflux (Visick III or IV), successfully treated by medication, was noted in three patients of group B and in one patient of group A. Only mild dysphagia, during the first two postoperative months, was noted in nine patients of group A and eight patients of group B. Six patients of each group with Barrett's esophagus had endoscopic improvement after the second postoperative month. Visick score in groups A/B was I in 26/11 (P < 0.0001), II in 13/27 (P = 0.037), III in 1/2 (not significant, NS), and IV in 0/2. Generally, Visick score was I or II in 39/38 in groups A/B (97.5%/90.5%, NS) and III or IV in 1/4 (2.5%/9.5%, P < 0.0001).
LNF combined with posterior gastropexy may prevent postoperative paraesophageal or sliding herniation in surgical treatment of GERD, providing better early and long-term postoperative results. (Registered Clinical Trial number: NCT00872755. www.clinicaltrials.gov .).
腹腔镜 Nissen 胃底折叠术（LNF）已成为大多数胃食管反流病（GERD）患者手术治疗的首选方法。术后食管旁疝的发生率在术后即刻高达 7%。
计划进行一项前瞻性随机试验，研究胃后固定术（LNF 联合胃后固定术，A 组，n=40）与 LNF 联合胃后固定术（LNF 联合胃后固定术，B 组，n=42）在预防食管旁疝和改善 GERD 手术治疗术后结果方面的作用。
82 例 GERD 患者随机分为 LNF 联合胃后固定术（A 组，n=40）或不联合胃后固定术（B 组，n=42）。术前、术后 2 个月和 12 个月以及每年进行疾病特异性和一般问卷调查、结构访谈以及内镜、食管测压和 24 小时 pH 监测的客观评估。如果直径小于 6 厘米，则通过缝线进行穹窿接近，或者使用补片加强常规穹窿闭合或使用无张力技术关闭裂孔。胃后固定术（A 组）在包裹的后壁和靠近弧形韧带的穹窿之间的后外侧壁之间用一根缝线进行（图 1）。
A 组中有 16 例和 B 组中有 15 例患者同时伴有腹部疾病，因此同时进行了手术[胆囊切除术 25 例、迷走神经切断术 2 例、腹疝修补术 1 例、胃息肉切除术 1 例、胃底憩室切除术 1 例、胃肠道间质瘤（GIST）楔形切除术 1 例]。在平均 48+/-26 个月（7-94 个月）的随访中，B 组中有 1 例患者在术后第一个月出现食管旁疝（再次手术），而 B 组中有 3 例和 A 组中有 1 例患者出现复发性胃食管反流（Visick III 或 IV），经药物治疗成功。A 组中有 9 例和 B 组中有 8 例患者在术后前 2 个月仅出现轻度吞咽困难。两组各有 6 例 Barrett 食管患者在术后第 2 个月后内镜下改善。A/B 组的 Visick 评分分别为 I 级 26/11（P<0.0001）、II 级 13/27（P=0.037）、III 级 1/2（无显著意义，NS）和 IV 级 0/2。总的来说，A/B 组中 Visick 评分分别为 I 或 II 级 39/38（97.5%/90.5%，NS）和 III 或 IV 级 1/4（2.5%/9.5%，P<0.0001）。
LNF 联合胃后固定术可预防 GERD 手术治疗后食管旁或滑动性疝，提供更好的早期和长期术后结果。（注册号：NCT00872755.www.clinicaltrials.gov.）。
