Little A G, Soriano A, Ferguson M K, Winans C S, Skinner D B
Department of Surgery, University of Chicago, IL.
Ann Thorac Surg. 1988 May;45(5):489-94. doi: 10.1016/s0003-4975(10)64520-1.
To address the controversy regarding the choice of operation for achalasia, the cases of 57 patients having operation, 38 for the first time (Group 1) and 19 with a previous procedure (Group 2), were reviewed. Surgical emphasis was on hiatal dissection to maximize exposure and use of the Belsey fundoplication to achieve cardiac competence without obstruction. Operative mortality was 1 (1.8%) of 57 patients. In group 1, 21 of the 38 had prior pneumatic dilations. All were treated with esophagomyotomy and a Belsey fundoplication. Clinical results are excellent or good in 30 (88%) of the 34 patients for whom follow-up is available, and are similar in patients with and without prior dilation. Lower esophageal sphincter (LES) pressure decreased from 22.3 to 7.7 mm Hg (p less than 0.001), and pH testing shows no reflux in any of 13 patients. In Group 2, previous operations were esophagomyotomy in 13, esophagomyotomy plus a Nissen fundoplication in 3, and a Nissen fundoplication only in 3. The initial operation failed because of inadequate myotomy in 6 patients, an obstructive Nissen fundoplication in 6, and reflux esophagitis in 7. In these 7 patients, acid reflux testing documented reflux due to cardiac incompetence and delayed clearance. Reoperations included takedown of a Nissen fundoplication in 6, esophagomyotomy and Belsey procedure in 15, Belsey procedure in 1, and resection plus colon interposition in 2. Clinical results are excellent or good in 12 (75%) of the patients with follow-up. These conclusions can be drawn. (1) Esophagomyotomy and Belsey fundoplication lowers LES pressure and provides good results with low risk, even after pneumatic dilation.(ABSTRACT TRUNCATED AT 250 WORDS)
为解决贲门失弛缓症手术方式选择上的争议，我们回顾了57例接受手术的患者病例，其中38例为首次手术（第1组），19例曾接受过手术（第2组）。手术重点在于食管裂孔解剖以最大化暴露，并采用贝尔西胃底折叠术来实现贲门功能正常且无梗阻。57例患者的手术死亡率为1例（1.8%）。在第1组中，38例患者中有21例曾接受过气囊扩张。所有患者均接受了食管肌层切开术和贝尔西胃底折叠术。在有随访资料的34例患者中，30例（88%）的临床结果为优或良，有或无先前扩张的患者结果相似。食管下括约肌（LES）压力从22.3毫米汞柱降至7.7毫米汞柱（p<0.001），pH测试显示13例患者中无一例有反流。在第2组中，先前的手术包括13例食管肌层切开术、3例食管肌层切开术加nissen胃底折叠术、3例仅行nissen胃底折叠术。6例患者因肌层切开不充分导致初次手术失败，6例因nissen胃底折叠术梗阻，7例因反流性食管炎。在这7例患者中，酸反流测试证实反流是由于贲门功能不全和清除延迟所致。再次手术包括6例拆除nissen胃底折叠术、15例食管肌层切开术和贝尔西手术、1例贝尔西手术、2例切除加结肠间置术。在有随访的患者中，12例（75%）的临床结果为优或良。可得出以下结论。（1）食管肌层切开术和贝尔西胃底折叠术可降低LES压力，即使在气囊扩张后也能以低风险取得良好效果。（摘要截短至250字）
