University of Toronto, Toronto, ON, Canada.
Surg Endosc. 2013 Jun;27(6):1945-52. doi: 10.1007/s00464-012-2692-7. Epub 2013 Jan 10.
Laparoscopic antireflux surgery is highly effective in patients with uncomplicated gastroesophageal reflux disease (GERD). However, long-term failure rates in paraesophageal hernia (PEH) and Barrett's metaplasia (BE) are higher and warrant a more durable repair. Outcomes for the laparoscopic Nissen fundoplication (LNF) and Hill repair (LHR) are equivalent, but their anatomic components are different and may complement each other (Aye R Ann Thorac Surg, 2012). We designed and tested the feasibility and safety of an operation that combines the essential components of each repair.
A prospective, phase II pilot study was performed on patients with symptomatic giant PEH hernias and/or GERD with nondysplastic Barrett's metaplasia. Pre- and postoperative esophagogastroduodenoscopy (EGD), upper gastrointestinal study (UGI), 48-hour pH testing, manometry, and three quality-of-life metrics were obtained.
Twenty-four patients were enrolled in the study. Three patients did not complete the planned procedure, leaving 21 patients, including 12 with PEH, 7 with BE, and 2 with both. There were no 30-day or in-hospital mortalities. At a median follow-up of 13 (range 6.4-30.2) months, there were no reoperations or clinical recurrences. Two patients required postoperative dilation for dysphagia, with complete resolution. Mean DeMeester scores improved from 54.3 to 7.5 (p < 0.0036). Mean lower esophageal sphincter pressures (LESP) increased from 8.9 to 21.3 mmHg (p < 0.013). Mean short-term and long-term QOLRAD scores improved from 4.09 at baseline to 6.04 and 6.48 (p < 0.0001). Mean short-term and long-term GERD-HQRL scores improved from 22.9 to 7.5 and 6.9 (p < 0.03). Mean long-term Dysphagia Severity Score Index improved from 33.3 to 40.6 (p < 0.064).
The combination of a Nissen plus Hill hybrid reconstruction of the gastroesophageal junction (GEJ) is technically feasible, safe, and not associated with increased side effects. Short-term clinical results in PEH and BE suggest that this may be an effective repair, supporting the value of further study.
腹腔镜抗反流手术对未经复杂处理的胃食管反流病（GERD）患者非常有效。然而，食管裂孔疝（PEH）和 Barrett 化生（BE）的长期失败率较高，需要更持久的修复。腹腔镜 Nissen 胃底折叠术（LNF）和 Hill 修复术（LHR）的结果相当，但它们的解剖结构不同，可能相互补充（Aye R Ann Thorac Surg，2012）。我们设计并测试了一种联合两种修复术基本结构的手术的可行性和安全性。
对患有症状性巨大食管裂孔疝疝和/或伴有非异型性 Barrett 化生的 GERD 的患者进行前瞻性、二期试点研究。术前和术后进行食管胃十二指肠镜检查（EGD）、上消化道研究（UGI）、48 小时 pH 测试、测压和 3 项生活质量指标的检测。
本研究共纳入 24 例患者。3 例患者未完成计划手术，21 例患者（12 例有 PEH，7 例有 BE，2 例同时有 PEH 和 BE）完成了手术。无 30 天或住院死亡率。中位随访时间为 13 个月（范围 6.4-30.2 个月），无再次手术或临床复发。2 例患者术后因吞咽困难需要进行扩张治疗，完全缓解。DeMeester 评分均值从 54.3 改善至 7.5（p<0.0036）。食管下括约肌压力（LESP）均值从 8.9 增加至 21.3mmHg（p<0.013）。短期和长期 QOLRAD 评分均值从基线时的 4.09 分别改善至 6.04 和 6.48（p<0.0001）。短期和长期 GERD-HQRL 评分均值从 22.9 分别改善至 7.5 和 6.9（p<0.03）。短期和长期的吞咽困难严重程度评分指数均值从 33.3 分别改善至 40.6（p<0.064）。
胃食管交界处（GEJ）的 Nissen 加 Hill 杂交重建技术在技术上是可行的、安全的，且不会增加副作用。在 PEH 和 BE 中，短期临床结果表明，这可能是一种有效的修复方法，支持进一步研究的价值。
