Johnson D G, Reid B S, Meyers R L, Fry M A, Nortmann C A, Jackson W D, Marty T L
Division of Pediatric Surgery, Primary Children's Medical Center and University of Utah School of Medicine, Salt Lake City 84113, USA.
J Pediatr Surg. 1998 Apr;33(4):573-9. doi: 10.1016/s0022-3468(98)90319-0.
Gastric emptying scintiscans are currently used to select reflux patients for added pyloroplasty at the time of fundoplication. The accuracy of this scan selection approach has been assumed. If preoperative scintiscans do not reliably predict postfundoplication gastric emptying, however, the decision to add pyloroplasty to the fundoplication operation may be inappropriate and even harmful.
The authors studied 27 children prospectively before and after gastric fundoplication. Gastric emptying at 60 minutes was measured by double isotopic labeling of liquid (111In) and solid (99mTc) phases of a test meal specifically designed for label fixation. The authors' question involved the accuracy of preoperative gastric scintiscans in predicting postfundoplication delay of gastric emptying (DGE). An evaluation of pyloroplasty as an effective treatment for DGE was not part of the study design. Pyloroplasty was performed as a secondary operation in three of the study children, however, because they persisted with unrelieved symptoms of retching, fullness, and abdominal discomfort. Scintiscan-documented postfundoplication delay in gastric emptying was present in all three patients at 18, 58, and 12 weeks, respectively. Additional scintiscans were performed in these patients after pyloroplasty.
Gastric emptying of solids at 60 minutes did not show a significant change after a gastric fundoplication operation, although the trend was in the direction of a decrease (paired t test, P= .13). Liquid emptying at 60 minutes, however, was significantly increased (paired t test, P = .01). The variation in values between patients was wide, and the correlation between pre- and postoperative study results in the same patient was poor (r2 = 0.337 for solids and r2 = 0.116 for liquids). Most unexpectedly, scintiscans after postfundoplication pyloroplasty in the three patients with persistent symptoms showed no improvement in delayed gastric emptying on repeat scintiscan 42 to 117 weeks later.
The data suggest that preoperative scintiscan evidence for postfundoplication DGE is probably accurate for solid emptying but not for liquids, at least as measured by the double isotope methodology of our study. Preoperative scintiscans that use a liquid phase label only may be highly misleading for the prediction of postfundoplication DGE. Furthermore, pyloroplasty may not be useful as treatment even when postfundoplication delay in gastric emptying can be accurately anticipated or confirmed. A fundamental motility disorder of the gastric body seems to be more important than muscular resistance at the gastric outlet as a cause for postfundoplication DGE, and the most effective treatment approach remains unclear.
目前，胃排空闪烁扫描用于选择在进行胃底折叠术时需加做幽门成形术的反流患者。这种扫描选择方法的准确性已被假定。然而，如果术前闪烁扫描不能可靠地预测胃底折叠术后的胃排空情况，那么在胃底折叠术时加做幽门成形术的决定可能是不恰当的，甚至是有害的。
作者对27名儿童在胃底折叠术前和术后进行了前瞻性研究。通过对专门设计用于标记固定的试验餐的液体（111铟）和固体（99m锝）相进行双同位素标记，测量60分钟时的胃排空情况。作者的问题涉及术前胃闪烁扫描预测胃底折叠术后胃排空延迟（DGE）的准确性。评估幽门成形术作为DGE的有效治疗方法并非本研究设计的一部分。然而，在三名研究儿童中进行了二次幽门成形术，因为他们持续存在干呕、饱胀和腹部不适等未缓解的症状。这三名患者在术后第18周、58周和12周的闪烁扫描均显示胃排空延迟。在这些患者进行幽门成形术后又进行了额外的闪烁扫描。
胃底折叠术后，60分钟时固体的胃排空虽有下降趋势，但无显著变化（配对t检验，P = 0.13）。然而，60分钟时液体排空显著增加（配对t检验，P = 0.01）。患者之间的值差异很大，同一患者术前和术后研究结果的相关性很差（固体r2 = 0.337，液体r2 = 0.116）。最出乎意料的是，三名有持续症状的患者在胃底折叠术后进行幽门成形术，在术后42至117周重复闪烁扫描时，胃排空延迟未见改善。
数据表明，至少按照我们研究的双同位素方法测量，术前闪烁扫描显示的胃底折叠术后DGE证据对于固体排空可能是准确的，但对于液体排空则不准确。仅使用液相标记的术前闪烁扫描对于预测胃底折叠术后DGE可能具有高度误导性。此外，即使能够准确预测或确认胃底折叠术后胃排空延迟，幽门成形术作为治疗方法可能也无用。胃体的基本动力障碍似乎比胃出口处的肌肉阻力更重要，是胃底折叠术后DGE的原因，最有效的治疗方法仍不明确。
