St Peter Shawn D, Poola Ashwini, Adibe Obinna, Juang David, Fraser Jason D, Aguayo Pablo, Holcomb G W
Center for Prospective Clinical Trials and Department of Surgery, The Children's Mercy Hospital, Kansas City, MO.
Center for Prospective Clinical Trials and Department of Surgery, The Children's Mercy Hospital, Kansas City, MO.
J Pediatr Surg. 2017 Oct 8. doi: 10.1016/j.jpedsurg.2017.10.008.
Historically, fundoplication has been performed with extensive dissection of the esophageal attachments to the diaphragm. Previously, we conducted a randomized trial demonstrating that minimal esophageal dissection and mobilization reduce the rate of wrap herniation and the need for reoperation. In that study, four esophagocrural (EC) sutures were placed in both groups to help obliterate the space between the esophagus and diaphragmatic crura. In this current study, we evaluate the need for these EC sutures.
Children less than age 7 undergoing laparoscopic fundoplication were randomized to receive four EC sutures or none. Exclusion criteria included an existing hiatal hernia. The primary outcome was transmigration of the fundoplication wrap through the esophageal hiatus into the mediastinum. A contrast study was performed around 1year postoperatively. Telephone follow-up was performed at a minimum of 1.5years.
120 patients were enrolled from 2/2010 to 2/2014, and 13 did not survive. One patient was excluded because a hiatal hernia was found at laparoscopy, leaving 52 patients with EC sutures (S) and 54 without EC sutures (NS). Operative time was 20min longer in the S group (P<0.01). Contrast studies were obtained in 62% of S and 68% of NS patients, and there were no wrap herniations in either group. There was one reoperation for wrap loosening in the NS group, none in the S group. Final telephone and clinic follow up was at a median of 4years (IQR 3-4.7). Reflux symptoms and medications were not different at one month, one year, and final follow-up.
When minimal phrenoesophageal dissection is performed, EC sutures offer no advantages and increase operating time.
Level II.
从历史上看，胃底折叠术一直伴随着对食管与膈肌附着处的广泛解剖。此前，我们进行了一项随机试验，结果表明，最小限度的食管解剖和游离可降低包绕疝形成率及再次手术的必要性。在该研究中，两组均放置了4针食管裂孔（EC）缝线，以帮助消除食管与膈肌脚之间的间隙。在本项研究中，我们评估了这些EC缝线的必要性。
将年龄小于7岁接受腹腔镜胃底折叠术的儿童随机分为接受4针EC缝线组或不接受EC缝线组。排除标准包括存在食管裂孔疝。主要结局是胃底折叠包绕物通过食管裂孔迁移至纵隔。术后约1年进行造影检查。至少随访1.5年，通过电话进行随访。
2010年2月至2014年2月共纳入120例患者，13例死亡。1例患者因腹腔镜检查发现食管裂孔疝被排除，最终52例患者接受了EC缝线（S组），54例未接受EC缝线（NS组）。S组手术时间长20分钟（P<0.01）。62%的S组患者和68%的NS组患者进行了造影检查，两组均未出现包绕疝。NS组有1例因包绕松弛进行再次手术，S组无再次手术病例。最终电话及门诊随访时间中位数为4年（四分位间距3 - 4.7年）。1个月、1年及最终随访时反流症状及用药情况无差异。
当进行最小限度的膈食管解剖时，EC缝线并无优势，反而会增加手术时间。
二级。
