Service de chirurgie digestive, CHU de Bordeaux, hôpital Haut-Lévèque, 33604 Pessac cedex, France.
J Visc Surg. 2013 Dec;150(6):395-402. doi: 10.1016/j.jviscsurg.2013.07.002. Epub 2013 Sep 21.
Para-esophageal hernias are relatively rare and typically occur in elderly patients. The various presenting symptoms are non-specific and often occur in combination. These include symptoms of gastro-esophageal reflux (GERD) in 26 to 70% of cases, microcytic anemia in 17 to 47%, and respiratory symptoms in 9 to 59%. Respiratory symptoms are not completely resolved by surgical intervention. Acute complications such as gastric volvulus with incarceration or strangulation are rare (estimated incidence of 1.2% per patient per year) but gastric ischemia leading to perforation is the main cause of mortality. Only patients with symptomatic hernias should undergo surgery. Prophylactic repair to prevent acute incarceration should only be undertaken in patients younger than 75 in good condition; surgical indications must be discussed individually beyond this age. The laparoscopic approach is now generally accepted. Resection of the hernia sac is associated with a lower incidence of recurrence. Repair of the hiatus can be reinforced with prosthetic material (either synthetic or biologic), but the benefit of prosthetic repair has not been clearly shown. Results of prosthetic reinforcement vary in different studies; it has been variably associated with four times fewer recurrences or with no measurable difference. A Collis type gastroplasty may be useful to lengthen a foreshortened esophagus, but no objective criteria have been defined to support this approach. The anatomic recurrence rate can be as high as 60% at 12years. But most recurrences are asymptomatic and do not affect the quality of life index. It therefore seems more appropriate to evaluate functional results and quality of life measures rather than to gauge success by a strict evaluation of anatomic hernia reduction.
食管裂孔疝较为罕见，通常发生于老年患者。各种表现症状不具有特异性，通常合并出现。这些症状包括胃食管反流病（GERD），发生率为 26%至 70%；小细胞性贫血，发生率为 17%至 47%；以及呼吸道症状，发生率为 9%至 59%。手术干预并不能完全解决呼吸道症状。急性并发症如胃扭转伴嵌顿或绞窄较为罕见（估计每年每位患者的发生率为 1.2%），但胃缺血导致穿孔是导致死亡的主要原因。只有有症状的裂孔疝患者才需要手术治疗。预防性修复以预防急性嵌顿应仅在身体状况良好的 75 岁以下患者中进行；在此年龄以上，必须单独讨论手术适应证。目前腹腔镜方法已被普遍接受。疝囊切除与较低的复发率相关。膈裂孔的修复可以用假体材料（合成或生物）加强，但假体修复的益处尚未明确。不同研究中假体强化的结果存在差异；它与复发减少四倍或无明显差异相关。Collis 型胃底折叠术可能有助于延长缩短的食管，但尚无明确的客观标准支持这种方法。解剖学复发率在 12 年内可高达 60%。但大多数复发是无症状的，不会影响生活质量指数。因此，评估功能性结果和生活质量指标似乎比通过严格评估解剖学疝修复来评估手术成功更为合适。
