Pitcher D E, Curet M J, Martin D T, Castillo R R, Gerstenberger P D, Vogt D, Zucker K A
University of New Mexico School of Medicine, Albuquerque.
Am J Surg. 1994 Dec;168(6):547-53; discussion 553-4. doi: 10.1016/s0002-9610(05)80120-5.
Nissen fundoplication has been shown to be superior to medical treatment in the management of severe or complicated gastroesophageal reflux disease (GERD). Rapid advances in minimally invasive surgical technique and recognition of the advantages of reduced incision-related morbidity have fostered application of laparoscopic techniques to antireflux surgery. A prospective evaluation of 70 patients undergoing laparoscopic Nissen fundoplication for severe GERD was undertaken.
Rigid selection criteria for laparoscopic Nissen fundoplication included severe or refractory disease with documentation of abnormal esophageal acid exposure by 24-hour pH probe monitoring, documentation of a mechanically defective lower esophageal sphincter by esophageal manometry, and absence of severe esophageal and/or gastric motility disorders.
Sixty-eight of 70 patients were completed laparoscopically with an intraoperative morbidity rate of 9%. Major postoperative complications occurred in 3 patients (4%) and included deep venous thrombosis (n = 1), delayed gastric leak (n = 1), and trocar site hernia (n = 1). The average hospital stay was 3.0 days, and the average time to return to normal activity was 7.0 days. All patients experienced relief of symptoms of reflux with mean follow-up of 7.7 months. Transient, mild dysphagia was experienced by 37% of patients, and persistent, severe dysphagia by 7%. The mean increase in lower esophageal sphincter pressure was 16.2 mm Hg. The total and intra-abdominal sphincter lengths increased an average of 1.5 and 1.4 cm, respectively.
These preliminary data suggest that laparoscopic Nissen fundoplication can be performed by experienced laparoscopic surgeons with excellent symptomatic and physiologic results and a morbidity rate comparable to conventional open antireflux procedures. Rigid patient selection criteria will help identify the patients most likely to benefit from reconstruction of a mechanically defective lower esophageal sphincter. Adherence to established operative principles for Nissen fundoplication will reduce the incidence of significant postfundoplication symptoms.
在严重或复杂性胃食管反流病（GERD）的治疗中，nissen胃底折叠术已被证明优于药物治疗。微创外科技术的迅速发展以及对减少切口相关发病率优势的认识，推动了腹腔镜技术在抗反流手术中的应用。对70例因严重GERD接受腹腔镜nissen胃底折叠术的患者进行了前瞻性评估。
腹腔镜nissen胃底折叠术的严格选择标准包括：严重或难治性疾病，通过24小时pH探头监测记录食管酸暴露异常；通过食管测压记录食管下括约肌机械功能缺陷；无严重食管和/或胃动力障碍。
70例患者中有68例成功完成腹腔镜手术，术中发病率为9%。3例患者（4%）出现主要术后并发症，包括深静脉血栓形成（n = 1）、延迟性胃漏（n = 1）和套管针部位疝（n = 1）。平均住院时间为3.0天，平均恢复正常活动时间为7.0天。所有患者反流症状均得到缓解，平均随访7.7个月。37%的患者出现短暂、轻度吞咽困难，7%的患者出现持续性、严重吞咽困难。食管下括约肌压力平均增加16.2 mmHg。总括约肌长度和腹内括约肌长度分别平均增加1.5 cm和1.4 cm。
这些初步数据表明，经验丰富的腹腔镜外科医生可进行腹腔镜nissen胃底折叠术，其症状和生理效果良好，发病率与传统开放性抗反流手术相当。严格的患者选择标准将有助于确定最有可能从重建机械功能缺陷的食管下括约肌中获益的患者。遵循既定的nissen胃底折叠术手术原则将降低胃底折叠术后严重症状的发生率。
