Perdikis G, Hinder R A, Filipi C J, Walenz T, McBride P J, Smith S L, Katada N, Klingler P J
Department of Surgery, Mayo Clinic, Jacksonville, Fla, USA.
Arch Surg. 1997 Jun;132(6):586-9; discussion 590-1. doi: 10.1001/archsurg.1997.01430300028005.
Paraesophageal hernias require surgery to avoid potentially serious complications.
To evaluate paraesophageal hernia repair using the laparoscopic approach.
Case series.
University hospital and foregut testing laboratory.
Sixty-five consecutive patients (mean age, 63.6 years; range, 26-90 years). Preoperative evaluation included barium esophagogram, endoscopy, esophageal manometry, and 24-hour pH monitoring.
Operative complications, postoperative morbidity, follow-up symptoms (53 patients; mean, 18 months; range, 2-54 months) and barium esophagogram (46 patients).
Fifty-six patients (86%) had a type III hernia and 9 (14%) had a type II hernia. Twenty (65%) of 31 patients who underwent pH monitoring had a positive 24-hour pH score, and 24 (56%) of 43 patients who underwent manometry had an incompetent lower esophageal sphincter. Four patients had a gastric volvulus and 21 patients had more than 50% of their stomach in the chest. All patients underwent hernia reduction, crural repair, and fundoplication (64 Nissen procedures and 1 Toupet procedure). The average duration of surgery was 2 hours. There were 2 conversions: gastric perforation and a difficult dissection because of a large fibrotic sac. Other complications, all managed intraoperatively, were 2 gastric perforations and bleeding in 6 patients. Average length of hospital stay was 2 days (range, 1-23 days). Early re-operation was required in 3 patients: slipped Nissen; small-bowel obstruction due to trocar-site hernia; and organo-axial rotation with gastroduodenal obstruction. Four patients required esophageal dilatation after surgery. Forty-nine of 53 patients available for long-term follow-up were satisfied with the results of surgery. Time to full recovery was 3 weeks (range, 1 week to 2 months). Seven of 46 patients experienced small type I hernias observed on routine follow-up esophagograms.
Most paraesophageal hernias are type III. A concomitant antireflux procedure is recommended. Paraesophageal hernias can be managed successfully by the laparoscopic route with good outcome.
食管旁疝需要手术治疗以避免潜在的严重并发症。
评估使用腹腔镜方法修复食管旁疝。
病例系列。
大学医院和前肠检测实验室。
65例连续患者（平均年龄63.6岁；范围26 - 90岁）。术前评估包括钡剂食管造影、内镜检查、食管测压和24小时pH监测。
手术并发症、术后发病率、随访症状（53例患者；平均18个月；范围2 - 54个月）和钡剂食管造影（46例患者）。
56例患者（86%）为Ⅲ型疝，9例患者（14%）为Ⅱ型疝。31例行pH监测的患者中有20例（65%）24小时pH评分呈阳性，43例行测压的患者中有24例（56%）食管下括约肌功能不全。4例患者发生胃扭转，21例患者超过50%的胃位于胸腔内。所有患者均接受了疝复位、膈肌脚修补和胃底折叠术（64例nissen手术和1例Toupet手术）。平均手术时间为2小时。有2例中转手术：胃穿孔和因巨大纤维化囊导致的困难解剖。其他并发症均在术中处理，包括2例胃穿孔和6例患者出血。平均住院时间为2天（范围1 - 23天）。3例患者需要早期再次手术：nissen滑脱；套管针部位疝导致的小肠梗阻；以及器官轴旋转伴胃十二指肠梗阻。4例患者术后需要食管扩张。53例可进行长期随访的患者中有49例对手术结果满意。完全恢复时间为3周（范围1周 - 2个月）。46例患者中有7例在常规随访食管造影中发现小型Ⅰ型疝。
大多数食管旁疝为Ⅲ型。建议同时进行抗反流手术。食管旁疝可通过腹腔镜途径成功治疗，效果良好。
