Brindley G V, Hightower N C
Surg Clin North Am. 1979 Oct;59(5):841-51. doi: 10.1016/s0039-6109(16)41931-6.
Most investigators agree that the most important goal in correcting gastroesophageal reflux is restoring or developing a competent lower esophageal sphincter. Although the sphincter can be incompetent in its normal intra-abdominal position and rarely a patient may have a competent sphincter in the thorax, generally the sphincter is much more effective in the positive pressure abdominal position. The choice of operative technique will depend upon the abnormal conditions present and the general condition of the patient. The thoracic approach is elected if there is associated intrathoracic disease warranting surgical correction, such as diffuse spasm of the esophagus, achalasia, epiphrenic diverticulum, or a pulmonary lesion requiring biopsy and possible resection. Very obese patients, patients with recurrent hernias, and patients with shortened esophagus are better managed by the thoracic approach. Patients with an essentially normal esophagus are treated with a Mark IV Belsey procedure. If shortening of the esophagus is present, a combination Collis-Nissen technique with fixation below the diaphragm is preferable. The abdominal approach is indicated when there is another intraabdominal disease known or suspected warranting surgical correction. This approach is also useful for the thin or poor risk patient. Usually, through an abdominal incision, we elect to use a modified Nissen fundoplication, with fixation of the fundoplication to the median arcuate ligament or the right crus of the diaphragm. The crural sling is returned to normal dimensions with interrupted sutures. Reflux in the absence of an hiatal hernia initially is treated medically. If symptoms are significant and intractable, a competent lower esophageal sphincter is restored, or developed by the modified Nissen procedure just described. Most reflux strictures at the esophagogastric junction are reversible by dilatation and restoration of a competent sphincter. Firm, fixed, fibrous strictures occasionally cannot be safely dilated. These may be managed by a Thal procedure to correct the stricture and a Nissen fundoplication to prevent recurrent reflux.
大多数研究者一致认为，纠正胃食管反流的最重要目标是恢复或形成一个功能正常的食管下括约肌。尽管该括约肌在其正常的腹内位置可能功能不全，并且极少有患者在胸腔内有功能正常的括约肌，但一般来说，在腹内正压位置时该括约肌的功能要有效得多。手术技术的选择将取决于所存在的异常情况以及患者的一般状况。如果存在需要手术矫正的相关胸内疾病，如食管弥漫性痉挛、贲门失弛缓症、膈上憩室或需要活检及可能切除的肺部病变，则选择经胸入路。非常肥胖的患者、复发性疝患者以及食管缩短的患者采用经胸入路治疗效果更好。食管基本正常的患者采用马克IV型贝尔西手术治疗。如果存在食管缩短，采用科利斯-尼森联合技术并在膈肌下方固定更为可取。当已知或怀疑存在另一种需要手术矫正的腹内疾病时，采用经腹入路。这种入路对体型瘦或手术风险高的患者也很有用。通常，通过腹部切口，我们选择采用改良的尼森胃底折叠术，将胃底折叠固定于正中弓状韧带或膈肌右脚。用间断缝合使膈脚吊带恢复到正常尺寸。无裂孔疝的反流最初采用药物治疗。如果症状严重且难以治疗，则通过上述改良的尼森手术恢复或形成一个功能正常的食管下括约肌。大多数食管胃交界处的反流性狭窄通过扩张和恢复功能正常的括约肌是可逆的。坚硬、固定的纤维性狭窄偶尔无法安全扩张。这些情况可通过塔尔手术矫正狭窄，并采用尼森胃底折叠术预防反流复发。
