Wu J S, Dunnegan D L, Luttmann D R, Soper N J
Department of Surgery and Institute for Minimally Invasive Surgery, Washington University School of Medicine, One Barnes Hospital Plaza, St. Louis, MO 63110, USA.
Surg Endosc. 1996 Dec;10(12):1164-69; discussion 1169-70. doi: 10.1007/s004649900271.
During laparoscopic Nissen fundoplication (LNF), it is unclear whether the short gastric vessels (SGV) should be divided, the crura reapproximated, or the wrap sutured to the crus.
Since first performing LNF, we have consistently utilized a <2.5-cm wrap performed over a >50 Fr dilator. Other technical details have varied, and these are reviewed in terms of early clinical outcome. Of 105 consecutive patients undergoing LNF, two were converted to open operation (2%). In the remaining 103 patients with >/=3-month follow-up (mean 17 months), the initial 46 (group 1; 45%, mean age +/- SEM = 47 +/- 2 years) had selective division of the SGV, crural closure, and wrap fixation. In this group, 32 patients (70%) underwent SGV division, 30 patients (65%) had crural closure (10 anteriorly/20 posteriorly), and 14 patients (30%) had the wrap sutured to the crus. During the subsequent 57 LNFs (group 2; 55%, 47 +/- 2 years), all patients underwent SGV division, posterior crural closure, and suture of the wrap to the crus.
Clinical outcome at >/=3 months was compared between the two groups. The frequencies of mild reflux symptoms, meteorism, and persistent dysphagia were similar in the two groups. However, the incidences of slippage of the wrap into the chest and the need for secondary intervention (esophageal dilatation and/or laparoscopic reoperation) decreased significantly from 15% and 13% of patients in group 1, respectively, to no occurrences in group II. Chi-square analyses revealed that combinations of these technical variables were significantly related to the improved outcome in group II.
Based on these data demonstrating improved clinical outcome, we recommend routine division of the SGV, posterior closure of the crura, and fixation of the wrap to the crus during LNF.
在腹腔镜下尼氏胃底折叠术（LNF）中，尚不清楚是否应切断胃短血管（SGV）、重新缝合脚或胃底折叠处缝合至脚。
自首次开展LNF以来，我们一直采用在大于50F扩张器上进行小于2.5cm的胃底折叠术。其他技术细节有所不同，现根据早期临床结果进行回顾。在连续接受LNF的105例患者中，2例转为开放手术（2%）。在其余103例随访时间大于或等于3个月（平均17个月）的患者中，最初的46例（第1组；45%，平均年龄±标准误=47±2岁）进行了SGV的选择性切断、脚闭合和胃底折叠处固定。在该组中，32例患者（70%）进行了SGV切断，30例患者（65%）进行了脚闭合（10例在前/20例在后），14例患者（30%）将胃底折叠处缝合至脚。在随后的57例LNF中（第2组；55%，47±2岁），所有患者均进行了SGV切断、脚后闭合以及胃底折叠处缝合至脚。
比较两组在大于或等于3个月时的临床结果。两组中轻度反流症状、腹胀和持续性吞咽困难的发生率相似。然而，胃底折叠处滑入胸腔的发生率以及二次干预（食管扩张和/或腹腔镜再次手术）的需求从第1组患者的15%和13%分别显著降至第2组中的无发生。卡方分析显示，这些技术变量的组合与第2组中改善的结果显著相关。
基于这些显示临床结果改善的数据，我们建议在LNF期间常规切断SGV、脚后闭合以及胃底折叠处固定至脚。
