Bagwell C E
Division of Pediatric Surgery, Medical College of Virginia, Richmond, USA.
Surg Annu. 1995;27:133-63.
Whereas all of these surgical modifications and new approaches are somewhat preliminary and have yet to achieve widespread clinical application, they illustrate an awareness of shortcomings in the present operative management of reflux as well as a gradual disenchantment with complications seen in many children, especially the neurologically impaired. However, the final analysis of surgical treatment for these children should not be viewed in an overly pessimistic light. Strategies for management of gastroesophageal reflux remain multifaceted, and operative intervention has a laudable role in the relief of symptoms for many afflicted children. However, the child's presentation and symptomatology should be predominant in planning therapy, operative or otherwise. It is the goal of this review to point out several points in this respect: 1. The diagnosis of gastroesophageal reflux may be difficult to pinpoint. 2. Multiple tests for reflux may offer conflicting results. 3. Clinical presentations associated with reflux do respond to treatment, which may include operative intervention. 4. The risks of anti-reflux procedures are greater than have been previously recognized, especially in the chronically ill and neurologically impaired child. 5. New approaches offer some promise to lower the risks of complications inherent in operative treatment of pathologic gastroesophageal reflux. 6. The best management plan for surgical treatment of reflux in children is evolving with less of a conviction for "prophylactic" fundoplication procedures, especially in the neurologically impaired child, and there is a recognition that underlying motility disorders may require modification of the operative approach or even the decision to operate. It is only through an awareness of the significant benefits as well as the considerable risks of operative treatment that the contemporary surgeon can best serve the interests of a child with gastroesophageal reflux. It is hoped that these guidelines will be helpful in this regard.
尽管所有这些手术改良和新方法都还处于某种初步阶段，尚未实现广泛的临床应用，但它们表明了对目前反流手术治疗缺点的认识，以及对许多儿童尤其是神经功能受损儿童出现的并发症逐渐感到失望。然而，对于这些儿童手术治疗的最终分析不应以过于悲观的眼光来看待。胃食管反流的管理策略仍然是多方面的，手术干预在缓解许多患病儿童的症状方面有着值得称赞的作用。然而，在规划治疗方案（无论是手术还是其他方式）时，儿童的表现和症状应占主导地位。本综述的目的是指出这方面的几个要点：1. 胃食管反流的诊断可能难以精确确定。2. 多种反流检测可能会给出相互矛盾的结果。3. 与反流相关的临床表现确实对治疗有反应，治疗可能包括手术干预。4. 抗反流手术的风险比以前认识到的要大，尤其是在慢性病患儿和神经功能受损的儿童中。5. 新方法有望降低病理性胃食管反流手术治疗中固有的并发症风险。6. 儿童反流手术治疗的最佳管理方案正在不断演变，对于“预防性”胃底折叠术的信念有所减弱，尤其是在神经功能受损的儿童中，并且认识到潜在的动力障碍可能需要改变手术方法甚至决定是否进行手术。只有通过认识到手术治疗的显著益处以及相当大的风险，当代外科医生才能最好地为胃食管反流患儿的利益服务。希望这些指南在这方面会有所帮助。
