Department of Surgery, Washington University School of Medicine, 660 S Euclid Ave., Box 8109, St. Louis, MO 63110, USA.
Surg Endosc. 2012 Jan;26(1):18-26. doi: 10.1007/s00464-011-1822-y. Epub 2011 Jul 26.
The type of fundoplication that should be performed in conjunction with Heller myotomy for esophageal achalasia is controversial. We prospectively compared anterior fundoplication (Dor) with partial posterior fundoplication (Toupet) in patients undergoing laparoscopic Heller myotomy.
A multicenter, prospective, randomized-controlled trial was initiated to compare Dor versus Toupet fundoplication after laparoscopic Heller myotomy. Outcome measures were symptomatic GERD scores (0-4, five-point Likert scale questionnaire) and 24-h pH testing at 6-12 months after surgery. Data are mean ± SD. Statistical analysis was by Mann-Whitney U test, Wilcoxon signed rank test, and Freidman's test.
Sixty of 85 originally enrolled and randomized patients who underwent 36 Dor and 24 Toupet fundoplications had follow-up data per protocol for analysis. Dor and Toupet groups were similar in age (46.8 vs. 51.7 years) and gender (52.8 vs. 62.5% male). pH studies at 6-12 months in 43 patients (72%: Dor n = 24 and Toupet n = 19) showed total DeMeester scores and % time pH < 4 were not significant between the two groups. Abnormal acid reflux was present in 10 of 24 Dor group patients (41.7%) and in 4 of 19 Toupet patients (21.0%) (p = 0.152). Dysphagia and regurgitation symptom scores improved significantly in both groups compared to preoperative scores. No significant differences in any esophageal symptoms were noted between the two groups preoperatively or at follow-up. SF-36 quality-of-life measures changed significantly from pre- to postoperative for five of ten domains in the Dor group and seven of ten in the Toupet patients (not significant between groups).
Laparoscopic Heller myotomy provides significant improvement in dysphagia and regurgitation symptoms in achalasia patients regardless of the type of partial fundoplication. Although a higher percentage of patients in the Dor group had abnormal 24-h pH test results compared to those of patients who underwent Toupet, the differences were not statistically significant.
在食管失弛缓症行 Heller 肌切开术时，应行哪种胃底折叠术存在争议。我们前瞻性地比较了腹腔镜 Heller 肌切开术联合前胃底折叠术（Dor）与部分后胃底折叠术（Toupet）。
启动一项多中心、前瞻性、随机对照试验，比较腹腔镜 Heller 肌切开术后 Dor 与 Toupet 胃底折叠术。术后 6-12 个月的主要结局是症状性 GERD 评分（0-4 分，五分制 Likert 量表问卷）和 24 小时 pH 检测。数据为均数 ± 标准差。采用 Mann-Whitney U 检验、Wilcoxon 符号秩检验和 Friedman 检验进行统计学分析。
85 例最初入组并随机分组的患者中，有 60 例完成 Dor 术式（36 例）和 Toupet 术式（24 例），并按方案进行了 6-12 个月的随访分析。Dor 组和 Toupet 组在年龄（46.8 岁比 51.7 岁）和性别（52.8%比 62.5%男性）方面相似。在 43 例（72%：Dor 组 n=24，Toupet 组 n=19）患者中进行了 6-12 个月的 pH 研究，两组的总 DeMeester 评分和 pH<4 的时间百分比均无显著差异。24 例 Dor 组患者中有 10 例（41.7%）和 19 例 Toupet 组患者中有 4 例（21.0%）存在异常酸反流（p=0.152）。与术前相比，两组患者的吞咽困难和反流症状评分均显著改善。两组患者术前或随访时的食管症状均无显著差异。Dor 组的十个领域中有五个领域和 Toupet 组的十个领域中有七个领域的 SF-36 生活质量测量在术后均有显著改善（两组间无显著差异）。
腹腔镜 Heller 肌切开术可显著改善贲门失弛缓症患者的吞咽困难和反流症状，无论行何种类型的部分胃底折叠术。与 Toupet 组相比，Dor 组有更高比例的患者 24 小时 pH 检测结果异常，但差异无统计学意义。
