Demeester T R, Johnson L F, Kent A H
Ann Surg. 1974 Oct;180(4):511-25. doi: 10.1097/00000658-197410000-00016.
A prospective randomized study was done on 45 patients to evaluate the effectiveness of the Hill, Nissen or Belsey anti-reflux procedure. All patients had symptoms of GE reflux unresponsive to medical therapy, a + standard acid reflux test (SART), and esophagitis (38/45) or + Burnstein test (7/45). Esophageal symptomatic, radiographic, manometric and pH (SART and 24-hr monitoring) evaluation was done pre- and 154 days (ave.) postsurgery. All procedures improved the symptoms of pyrosis. The best improvement was seen after the Nissen repair. All procedures increased the distal esophageal sphincter (DES) pressures over preoperative levels. The Nissen and Belsey increased it more than the Hill. Sphincter length and dynamics remained unchanged. The Nissen procedure placed more of the manometric sphincter below the respiratory inversion point in the positive pressure environment of the abdomen. The esophageal length was increased by the Nissen and Hill repairs. This was thought to account for the high incidence of temporary postsurgery dysphagia following the Nissen and Hill repairs and the lower incidence following the Belsey repair. Reflux was most effectively prevented by the Nissen repair, as shown by the SART and the 24-hr esophageal pH monitoring, a sensitive measurement of frequency and duration of reflux. The average length of hospital stay was 20 days for Belsey and 12 days for both Nissen and Hill procedure. Postsurgery complications were more common following the thoracic than the abdominal approach. Ability to vomit postrepair was greatest with the Hill and least with the Belsey and Nissen repair. All procedures temporarily increased amount of flatus. It is concluded that the Nissen repair best controls reflux and its symptoms by providing the greatest increase in DES pressure and placing more of the sphincter in the positive abdominal environment. This is accomplished with the lowest morbidity but at the expense of temporary postoperative dysphagia and a 50% chance of being unable to vomit after the repair.
对45例患者进行了一项前瞻性随机研究，以评估希尔（Hill）、尼森（Nissen）或贝尔西（Belsey）抗反流手术的有效性。所有患者均有胃食管反流症状，对药物治疗无反应，标准酸反流试验（SART）呈阳性，且患有食管炎（38/45）或伯恩斯坦试验（Burnstein test）呈阳性（7/45）。在手术前和术后平均154天进行食管症状、影像学、测压和pH值（SART和24小时监测）评估。所有手术均改善了烧心症状。尼森修复术后改善效果最佳。所有手术均使食管下括约肌（DES）压力高于术前水平。尼森和贝尔西手术使压力升高的幅度大于希尔手术。括约肌长度和动力学保持不变。在腹部的正压环境中，尼森手术使更多的测压括约肌位于呼吸反转点以下。尼森和希尔修复术使食管长度增加。这被认为是尼森和希尔修复术后暂时性吞咽困难发生率高以及贝尔西修复术后发生率低的原因。如SART和24小时食管pH值监测所示，尼森修复术最有效地预防了反流，后者是对反流频率和持续时间的敏感测量。贝尔西手术的平均住院时间为20天，尼森和希尔手术均为12天。胸段手术比腹段手术术后并发症更常见。修复术后呕吐能力以希尔手术最强，贝尔西和尼森手术最弱。所有手术均使肠胀气暂时增加。结论是，尼森修复术通过最大程度地增加DES压力并使更多的括约肌处于腹部正压环境中，从而最佳地控制反流及其症状。这是以最低的发病率实现的，但代价是术后暂时性吞咽困难以及修复术后有50%的几率无法呕吐。
