Dalla Vecchia L K, Grosfeld J L, West K W, Rescorla F J, Scherer L R, Engum S A
Department of Surgery, Indiana University School of Medicine and the James Whitcomb Riley Hospital for Children, Indianapolis 46202, USA.
Ann Surg. 1997 Sep;226(3):315-21; discussion 321-3. doi: 10.1097/00000658-199709000-00011.
The authors evaluate reoperation for recurrent gastroesophageal reflux (GER) after a failed Nissen fundoplication.
Nissen fundoplication is an accepted treatment for GER refractory to medical therapy. Wrap failure and recurrence of GER are noted in 8% to 12%.
Medical records of 130 children undergoing a second antireflux operation for recurrent GER from January 1985 to June 1996 retrospectively were reviewed.
One hundred one patients (78%) were neurologically impaired (NI), 74 (57%) had chronic pulmonary disease, and 8 had esophageal atresia. Recurrent symptoms included vomiting (78%), growth failure (62%), choking-coughing-gagging (38%), and pneumonia (25%). Gastroesophageal reflux was confirmed by barium swallow, gastric scintigraphy, and endoscopy. Operative findings showed wrap breakdown (42%), wrap-hiatal hernia (30%), or both (21%). A second Nissen fundoplication was performed in 128 children. Complications included bowel obstruction (18), wound infection (10), pneumonia (6) and tight wrap (9). There were two postoperative (<30 days) deaths (1.5%). Of 124 patients observed long term, 89 (72%) remain symptom free. Eight were converted to tube feedings. Twenty-seven required a third fundoplication, and 19 (70%) were successful outcome. Two with repetitive wrap failure due to gastric atony underwent gastric resection and esophagojejunostomy.
Nissen fundoplication was successful in 91% of patients. In 9% with wrap failure, a second Nissen fundoplication was successful in 72%. Reoperation is justified in properly selectedpatients. Conversion to jejunostomy feedings is suggested for neurologically impaired after two wrap failures and a partial wrap in those with esophageal atresia and severe esophageal dysmotility. Repeated wrap failure due to gastric atony requires gastric resection and esophagojejunostomy.
作者评估在nissen胃底折叠术失败后针对复发性胃食管反流（GER）进行再次手术的情况。
nissen胃底折叠术是药物治疗无效的GER的一种公认治疗方法。胃底折叠失败和GER复发的发生率为8%至12%。
回顾性分析1985年1月至1996年6月期间130例因复发性GER接受二次抗反流手术的儿童的病历。
101例患者（78%）存在神经功能障碍（NI），74例（57%）患有慢性肺部疾病，8例有食管闭锁。复发症状包括呕吐（78%）、生长发育迟缓（62%）、呛咳-咳嗽-作呕（38%）和肺炎（25%）。通过钡餐、胃闪烁显像和内镜检查确诊为胃食管反流。手术发现胃底折叠破裂（42%）、胃底折叠-食管裂孔疝（30%）或两者皆有（21%）。128例儿童接受了第二次nissen胃底折叠术。并发症包括肠梗阻（18例）、伤口感染（10例）、肺炎（6例）和胃底折叠过紧（9例）。术后有2例（<30天）死亡（1.5%）。在124例长期观察的患者中，89例（72%）症状消失。8例改为管饲。27例需要进行第三次胃底折叠术，其中19例（70%）手术成功。2例因胃无力导致反复胃底折叠失败，接受了胃切除术和食管空肠吻合术。
nissen胃底折叠术在91%的患者中成功。在9%胃底折叠失败的患者中，第二次nissen胃底折叠术72%成功。对经过适当选择的患者进行再次手术是合理的。对于两次胃底折叠失败且存在神经功能障碍的患者，以及食管闭锁和严重食管动力障碍患者中胃底折叠部分失败的情况，建议改为空肠造瘘喂养。因胃无力导致反复胃底折叠失败需要进行胃切除术和食管空肠吻合术。
