Del Genio A, Di Martino N, Maffettone V, Izzo G, Zampiello P, Mugione P
Facoltà di Medicina e Chirurgia, Seconda Università degli Studi di Napoli.
Ann Ital Chir. 1995 Sep-Oct;66(5):587-95.
After a wide revision of the Literature, the most frequent causes of failure in the surgical therapy of esophageal achalasia are described. Above all there is the uncorrect execution of the Heller's myotomy as for its upward and downward extension or its deepness. An uncorrect myotomy, in fact, might cause the persistence or relapse of pre-operative symptoms, such as dysphagia and regurgitation. A correct myotomy, according to the authors, should be always carried out with the aid of intraoperative manometry (IEM), which allows the documentation of the alterations caused by surgery in the area of the high pressure zone, which corresponds to the sphincter (LES). A correct myotomy must produce the complete annulment of such a pressure. This technique creates the conditions sufficient to the genesis of gastroesophageal reflux (GER), which is one of the most frequent causes of failure in the surgery of achalasia. In fact, it causes a reflux esophagitis which can quickly evolve into a stricture with the reappearance of dysphagia. It is essential, therefore, to combine always the Heller's procedure with an antireflux procedure, which can protect the esophagus from GER and at the same time does not produce a mechanical obstacle to deglutition. The Authors report their last experience based on 114 primary operations of Heller's myotomy + Nissen fundoplication, performed since 1985 to date. IEM has been always used both for controlling the completeness of the myotomy and for the "calibration" of the Nissen's. Two patients, which had undergone elsewhere a Heller's myotomy alone, have been operated of re-myotomy + Nissen fundoplication. One patient, also operated elsewhere of myotomy of the esophageal body for diffuse esophageal spasm (DES), complained of dysphagia and had manometrical evidence of LES dischalasia; this patient has been reoperated of Heller's myotomy + Nissen fundoplication; another patient suffering from a reflux stricture after a Heller's myotomy without antireflux procedure, has been treated with a Roux esophago-jejunostomy. A last patient operated by Heller's myotomy + Dor fundoplication presented alkaline esophagitis without dysphagia; the treatment consisted in a Roux gastro-jejunostomy + bilateral troncular vagotomy. These data bring to the conclusion that the best treatment of achalasia relapses is their prevention, only obtainable by a good primary therapeutic approach and the routine use of IEM. The IEM avoids incomplete myotomies and inadequate antireflux procedures related to the incompetence (reflux) or hypercompetence (dysphagia recurrence) of the fundoplication.
在对文献进行广泛综述后，描述了食管贲门失弛缓症手术治疗失败的最常见原因。首先是赫勒肌切开术在向上和向下延伸或深度方面执行不正确。事实上，不正确的肌切开术可能导致术前症状如吞咽困难和反流持续存在或复发。作者认为，正确的肌切开术应始终在术中测压（IEM）的辅助下进行，这有助于记录手术在高压区（对应于括约肌，即LES）引起的改变。正确的肌切开术必须使这种压力完全消除。这种技术为胃食管反流（GER）的发生创造了充分条件，而GER是贲门失弛缓症手术失败的最常见原因之一。实际上，它会导致反流性食管炎，可迅速发展为狭窄并再次出现吞咽困难。因此，必须始终将赫勒手术与抗反流手术相结合，这样既能保护食管免受GER影响，又不会对吞咽产生机械性障碍。作者报告了他们自1985年至今基于114例赫勒肌切开术 + nissen胃底折叠术的初次手术的最新经验。IEM一直用于控制肌切开术的完整性以及nissen手术的“校准”。两名在其他地方仅接受过赫勒肌切开术的患者接受了再次肌切开术 + nissen胃底折叠术。一名同样在其他地方因弥漫性食管痉挛（DES）接受食管体肌切开术的患者，抱怨吞咽困难且有LES功能不全的测压证据；该患者接受了再次赫勒肌切开术 + nissen胃底折叠术；另一名在未进行抗反流手术的赫勒肌切开术后出现反流性狭窄的患者，接受了Roux食管空肠吻合术治疗。最后一名接受赫勒肌切开术 + Dor胃底折叠术的患者出现了无吞咽困难的碱性食管炎；治疗方法是Roux胃空肠吻合术 + 双侧迷走神经干切断术。这些数据得出结论，贲门失弛缓症复发的最佳治疗方法是预防，只有通过良好的初次治疗方法和常规使用IEM才能实现。IEM可避免与胃底折叠术功能不全（反流）或功能亢进（吞咽困难复发）相关的不完全肌切开术和不充分的抗反流手术。
