Minimally Invasive and Bariatric Surgical Services, Providence Saint Joseph Medical Center, PSJHS, Burbank, CA, USA.
Surg Endosc. 2020 Jun;34(6):2460-2464. doi: 10.1007/s00464-019-07040-1. Epub 2019 Jul 30.
Numerous techniques have been historically proposed in the management of gastroesophageal reflux and paraesophageal hernias (PEH). A follow-up study (Quilici et al. in Surg Endosc 23(11):2620-2623, 2009) to a novel laparoscopic approach introduced in 2009 and performed in 49 patients is presented.
All procedures were performed via laparoscopy. Thirty-two patients underwent a Nissen Fundoplication, eleven a reduction of the PEH with a Nissen fundoplication, two without a fundoplication, and four with a Collis-Nissen fundoplication. In all patients, the left hepatic lobe was freed, repositioned, and anchored under and inferior to the gastroesophageal junction, propping the gastroesophageal junction anteriorly. This maneuver entirely covers and closes the diaphragmatic defect.
At the time of laparoscopy, several patients were found not to be suitable candidates for this procedure (morphology of the left hepatic lobe). Forty-nine procedures were completed. One patient was re-explored on POD 2 for a tight hiatus post-Collis fundoplication. Post-operatively, all other patients did well without notable, unusual complaints. The average length of stay was 2.2 days. Although not statistically significant, 43 patients had no recurrence of symptoms with the longest follow-up at 10 years, two patients were lost to follow-up, one patient had a recurrence of the PEH and three patients stated they were experiencing some form of gastroesophageal reflux requiring medical management.
In selected patients, patients with an "at-risk" crural closure during a laparoscopic anti-reflux procedure or PEH can safely be managed via a laparoscopic anti-reflux procedure with the hepatic shoulder technique. This technique has shown good early post-operative results and could be used as an alternative to a laparoscopic mesh-reinforced fundoplication in difficult crural closures or in the management of large paraesophageal hernias.
在胃食管反流和食管裂孔疝（PEH）的治疗中，历史上提出了许多技术。本文报道了 2009 年引入并在 49 例患者中实施的一种新型腹腔镜方法的后续研究（Quilici 等人，Surg Endosc 23(11):2620-2623, 2009）。
所有手术均通过腹腔镜进行。32 例患者行 Nissen 胃底折叠术，11 例患者行 PEH 复位加 Nissen 胃底折叠术，2 例无胃底折叠术，4 例行 Collis-Nissen 胃底折叠术。在所有患者中，游离、复位左肝叶，并将其固定在胃食管交界处下方和下方，将胃食管交界处向前支撑。这一操作完全覆盖并封闭了膈肌缺损。
在腹腔镜检查时，发现一些患者不适合进行该手术（左肝叶形态）。完成了 49 例手术。1 例 Collis 胃底折叠术后因食管裂孔过紧，第 2 天再次探查。术后，所有其他患者均恢复良好，无明显异常。平均住院时间为 2.2 天。虽然无统计学意义，但 43 例患者在最长 10 年的随访中无症状复发，2 例失访，1 例 PEH 复发，3 例患者表示存在某种形式的胃食管反流，需要药物治疗。
在选择合适的患者中，对于腹腔镜抗反流手术或 PEH 中存在“高危”裂孔闭合的患者，可通过腹腔镜抗反流手术联合肝肩技术安全治疗。该技术显示出良好的术后早期结果，可作为腹腔镜网片增强胃底折叠术在困难裂孔闭合或治疗大食管裂孔疝时的替代方法。
