Fuller C B, Hagen J A, DeMeester T R, Peters J H, Ritter M, Bremmer C G
University of Southern California School of Medicine Department of Surgery, Los Angeles, USA.
J Thorac Cardiovasc Surg. 1996 Mar;111(3):655-61. doi: 10.1016/s0022-5223(96)70319-7.
The role of fundoplication in patients with pure type II paraesophageal hiatal hernia remains controversial. Conventional thinking suggests that because the lower esophageal sphincter is located within the abdomen, it is competent, and fundoplication is unnecessary. Few studies have used objective evaluation to guide the addition of an antireflux procedure.
Fifteen consecutive patients with type II paraesophageal hernia were treated between May 1991 and July 1994. All had radiographic criteria of pure type II hernias. Preoperative evaluation included upper intestinal endoscopy, esophageal manometry, and 24-hour ambulatory pH monitoring. The lower esophageal sphincter was considered incompetent if any of the following criteria were present: a resting pressure less than 7 mm Hg, an overall sphincter length less than 2 cm, or an intraabdominal length less than 1 cm. Primary symptoms responsible for surgery were related to the hernia in 73% of patients: dysphagia or postprandial abdominal pain in six patients, abdominal distension or vomiting in four patients, and bleeding in one patient. Symptoms typical of gastroesophageal reflux were present in four patients: heartburn and regurgitation in two each.
Objective evidence of gastroesophageal reflux was present in the majority of patients. Five patients (31%) had evidence of esophageal injury: esophagitis in three patients, stricture in one, and esophageal ulcer in one. In 11 of 15 patients (69%), pathologic esophageal acid exposure was detected by 24-hour pH monitoring. Twelve patients (75%) had a defective lower esophageal sphincter, usually the result of an inadequate intraabdominal length (8/12, 66%). Hernia reduction, crural closure, and Nissen fundoplication were performed in 14 patients (one patient awaits surgery). Symptomatic relief was excellent in all cases. No patient has had hernia recurrence at an average of 14 months' follow-up (range 2 to 39 months).
Objective evaluation reveals that gastroesophageal reflux accompanies type II paraesophageal hernia in a high proportion of patients, usually because of an incompetent lower esophageal sphincter. Appropriate treatment includes reduction of the hernia, crural closure, and fundoplication in most, if not all, patients.
贲门固定术在单纯II型食管旁裂孔疝患者中的作用仍存在争议。传统观点认为，由于食管下括约肌位于腹腔内，功能正常，因此不需要进行贲门固定术。很少有研究采用客观评估来指导抗反流手术的增加。
1991年5月至1994年7月期间，连续治疗了15例II型食管旁疝患者。所有患者均符合单纯II型疝的影像学标准。术前评估包括上消化道内镜检查、食管测压和24小时动态pH监测。如果出现以下任何一项标准，则认为食管下括约肌功能不全：静息压低于7 mmHg、括约肌总长度小于2 cm或腹腔内长度小于1 cm。73%的患者导致手术的主要症状与疝有关：6例患者出现吞咽困难或餐后腹痛，4例患者出现腹胀或呕吐，1例患者出现出血。4例患者出现典型的胃食管反流症状：2例患者出现烧心和反流。
大多数患者存在胃食管反流的客观证据。5例患者（31%）有食管损伤的证据：3例患者患有食管炎，1例患者患有狭窄，1例患者患有食管溃疡。15例患者中有11例（69%）通过24小时pH监测检测到病理性食管酸暴露。12例患者（75%）食管下括约肌功能不全，通常是由于腹腔内长度不足（8/12，66%）。14例患者（1例患者等待手术）进行了疝复位、膈肌脚闭合和nissen贲门固定术。所有病例症状缓解均良好。平均随访14个月（范围2至39个月），无患者出现疝复发。
客观评估显示，II型食管旁疝患者中很大一部分伴有胃食管反流，通常是由于食管下括约肌功能不全。在大多数（如果不是全部）患者中，适当的治疗包括疝复位、膈肌脚闭合和贲门固定术。
