Elton C, Jordan D, Moore D, Goldspink G, Winslet M
Department of Surgery, Royal Free Hospital School of Medicine, London, UK.
Dis Esophagus. 1997 Oct;10(4):262-9. doi: 10.1093/dote/10.4.262.
Previous work has shown promising results for an intercostal myoneurovascular transposition in the prevention of gastroesophageal reflux following esophagectomy. A first study evaluated the intercostal transposition procedure and compared it with the Nissen fundoplication using a rabbit model of gastroesophageal reflux. Group A underwent partial cardiomyectomy to produce gastroesophageal reflux. Group B underwent cardiomyectomy, and intercostal transposition around the gastric cardia. Group C underwent Nissen fundoplication and cardiomyectomy. All animals had preoperative and 1-week and 4-week postoperative intraesophageal manometry and pH studies. At the 4-week interval, macroscopic and microscopic esophageal histopathology was assessed. The mean change in values from preoperative to 4 weeks postoperative were compared. Group B showed significantly lower reflux time (P < 0.001) and grade of esophagitis (P < 0.005), and significantly greater average lower esophageal sphincter basal pressure (P < 0.001) and abdominal length of sphincter (P < 0.01) when compared with Group A. There was no statistical significance between the results of Group B and Group C. A second study assessed whether reflux was prevented by an anatomical structure, or a muscle flap acting in a physiological manner. At autopsy, the ten rabbits from Group B underwent removal of the intercostal wrap, and the right 11th intercostal muscle as a control. There was a significant difference in the quantity of viable muscle tissue between muscle flaps and controls (P < 0.001), the muscle flaps having generally little viable muscle left 4 weeks after surgery. A further experiment to evaluate this result found that loss of muscle tissue was due to excessive stretch and not due to damage of the intercostal neurovascular bundle during mobilization. Two groups of animals underwent electromyographic studies. The first group underwent recordings of all intercostal muscles. The second group underwent intercostal transposition around the gastric cardia, and insertion of recording electrodes into the muscle flap. The electromyographic activity of the muscle flap was recorded at 0, 2, and 4 weeks after surgery. The second group demonstrated activity in the muscle flaps simultaneous with diaphragmatic contractions. This activity, although much reduced, was still present 4 weeks after surgery. These studies showed that the intercostal transposition and Nissen fundoplication procedures are equally effective in preventing experimental gastroesophageal reflux. The antireflux properties of the intercostal transposition were possibly the result of anatomical buttressing of the gastroesophageal junction, and not due to a fully viable contracting muscle flap.
先前的研究表明，肋间肌神经血管转位术在预防食管切除术后胃食管反流方面取得了令人鼓舞的成果。第一项研究评估了肋间转位术，并使用胃食管反流兔模型将其与nissen胃底折叠术进行比较。A组进行部分心肌切除术以产生胃食管反流。B组进行心肌切除术，并在胃贲门周围进行肋间转位。C组进行nissen胃底折叠术和心肌切除术。所有动物在术前、术后1周和4周进行食管内压力测定和pH值研究。在4周时，评估食管的宏观和微观组织病理学。比较术前至术后4周的数值平均变化。与A组相比，B组的反流时间显著缩短（P<0.001），食管炎分级显著降低（P<0.005），食管下括约肌基础压力平均值显著升高（P<0.001），括约肌腹段长度显著增加（P<0.01）。B组和C组的结果之间无统计学意义。第二项研究评估了反流是由解剖结构还是以生理方式起作用的肌瓣预防的。尸检时，对B组的10只兔子切除肋间包裹物，并切除右侧第11肋间肌作为对照。肌瓣和对照之间的存活肌肉组织数量存在显著差异（P<0.001），术后4周肌瓣通常几乎没有存活肌肉。进一步评估该结果的实验发现，肌肉组织的丧失是由于过度拉伸，而不是由于动员期间肋间神经血管束的损伤。两组动物进行了肌电图研究。第一组记录所有肋间肌。第二组在胃贲门周围进行肋间转位，并将记录电极插入肌瓣。在术后0、2和4周记录肌瓣的肌电图活动。第二组显示肌瓣活动与膈肌收缩同步。这种活动虽然大大减少，但在术后4周仍然存在。这些研究表明，肋间转位术和nissen胃底折叠术在预防实验性胃食管反流方面同样有效。肋间转位术的抗反流特性可能是胃食管交界处解剖支撑的结果，而不是由于完全存活的收缩肌瓣。
