Bell Reginald C W, Kurian Ashwin A, Freeman Katherine D
Swedish Medical Center, Englewood, CO, USA,
Surg Endosc. 2015 Jul;29(7):1746-52. doi: 10.1007/s00464-014-3897-8. Epub 2014 Nov 8.
Transoral incisionless fundoplication (TIF) treats gastroesophageal reflux disease (GERD) by creating a full-thickness esophagogastric plication using transmural fasteners. If unsuccessful, revision laparoscopic anti-reflux surgery (rLARS) may be performed. This study evaluated operative findings and clinical outcomes of rLARS in 28 patients with prior primary TIF.
Intraoperative findings, complications, and symptomatic outcomes with GERD health-related quality of life (GERD-HRQL) were evaluated prospectively in patients having rLARS after TIF. Results are median with interquartile range (IQR).
Between 03/2009 and 08/2013, 28 patients underwent rLARS at 14 (13-50) months post-TIF for recurrent symptoms after initial improvement. Pre-rLARS endoscopies found hiatal hernia (9) and wrap disruption (12). All revisions were completed laparoscopically in 88 (70-90) min. Eight patients underwent partial fundoplication, the rest Nissen. No intraoperative or postoperative complications occurred. Operative findings included: No axial hernia in 65%; Dense adhesions in 14%; Fasteners incorporating the lateral crus in 95%; Traction diverticuli from esophagus to crura in 21%. Residual plication was noted anteriorly in 75%, posteriorly in 0%. Operative approaches: (1) Areas where the TIF fundoplication remained were left intact. This necessitated rolling the fundoplication over the fused area to prevent an endoscopic appearance of 'fold'. (2) Fasteners were cut and left to migrate into the lumen, rather than being pulled out. (3) In 8 patients with fusion of the lateral crus to TIF fundoplication and no axial hernia, revision fundoplication was performed without mediastinal mobilization but with posterior hernia repair. One patient required subsequent surgery for small paraesophageal hernia, one for refractory gas-bloat after rLARS. Dysphagia in 2 patients resolved with dilation. GERD-HRQL improved from a median of 20 (8-27) pre-TIF and 10 (1-20) pre-rLARS to 3 (0-4) at 28 months (12-40) post-rLARS (p = 0.020 for pre-rLARS to post-rLARS).
rLARS after TIF can be performed safely with excellent clinical outcomes.
经口无切口胃底折叠术（TIF）通过使用透壁紧固件创建全层食管胃折叠来治疗胃食管反流病（GERD）。如果不成功，可进行翻修腹腔镜抗反流手术（rLARS）。本研究评估了28例先前接受过原发性TIF的患者行rLARS的手术发现和临床结果。
对TIF术后行rLARS的患者前瞻性评估术中发现、并发症以及GERD健康相关生活质量（GERD-HRQL）的症状性结果。结果以中位数和四分位数间距（IQR）表示。
在2009年3月至2013年8月期间，28例患者在TIF术后14（13 - 50）个月因初始改善后复发症状而接受rLARS。rLARS术前内镜检查发现食管裂孔疝（9例）和胃底折叠破坏（12例）。所有翻修手术均在腹腔镜下88（70 - 90）分钟内完成。8例患者行部分胃底折叠术，其余行nissen胃底折叠术。未发生术中或术后并发症。手术发现包括：65%无轴向疝；14%有致密粘连；95%的紧固件包含外侧脚；21%有从食管到脚的牵引憩室。75%在前方可见残余折叠，后方为0%。手术方法：（1）TIF胃底折叠术保留的区域保持完整。这需要将胃底折叠术翻转到融合区域上方以防止内镜下出现“褶皱”外观。（2）切断紧固件并任其移入管腔，而非拔出。（3）8例外侧脚与TIF胃底折叠术融合且无轴向疝的患者，行翻修胃底折叠术时未进行纵隔松解，但进行了后方疝修补。1例患者随后因小的食管旁疝需要再次手术，1例因rLARS后难治性气体膨胀需要再次手术。2例患者的吞咽困难经扩张后缓解。GERD-HRQL从TIF术前中位数20（8 - 27）和rLARS术前10（1 - 20）改善至rLARS术后28个月（12 - 40）时的3（0 - 4）（rLARS术前与术后比较，p = 0.020）。
TIF术后行rLARS可安全进行，临床效果良好。
