Dallemagne B, Weerts J M, Jeahes C, Markiewicz S
Departement de Chirurgie de l'Appareil Digestif, Les Cliniques Saint Joseph, Liege, Belgium.
Hepatogastroenterology. 1998 Sep-Oct;45(23):1338-43.
BACKGROUND/AIMS: Laparoscopic surgery for treatment of gastroesophageal reflux disease was first described 5 years ago. The more widespread technique is the Nissen fundoplication with its different modifications. The early results suggest that this operation is equivalent in efficacy to the open antireflux operations.
Over a 5 year period, 622 patients underwent laparoscopic fundoplication for gastroesophageal reflux disease. Five hundred and fifty patients underwent Nissen fundoplication. Preoperative, operative and postoperative data were prospectively reviewed. One hundred twenty seven patients were evaluated 1 to 4 years after the operation.
Laparoscopic Nissen fundoplication with standard gastric mobilisation and without division of the SGV was performed during the first three years of the laparoscopic approach. Since early 1994, we applied division of the SGV with complete mobilisation of the upper part of the gastric fundus in all the patients. The mean operative time was 86 minutes (range 30-180 minutes). Conversion to open surgery was necessary in 5 patients (0.9%). There was neither incidence of splenic trauma nor esophageal perforation. There was no mortality. Morbidity was 2.3%. Mean hospital stay was 3.1 days (range 1-13 days). Postoperative dysphagia was observed in all the patients and resolved after 2 to 6 weeks in all but 12 patients (2.1%) who were submitted to endoscopic dilatation with success in 9 patients. At a median follow-up period of 2 years (16-44 months), 127 consecutive patients from the initial experience (series 1991-1992) volunteerd for mid term follow-up evaluation. We obtained Visick I and II grading in 92% of the patients. Reoperation for failure has been necessary in 6 patients (1.0%).
The long term results of laparoscopic Nissen fundoplication are not yet available. The incidence of poor long term outcome or recurrence of symptoms cannot be assessed. At present, we feel that, in experienced hands, the laparoscopic operation is as good as the open procedure if all the surgical principles of antireflux surgery are respected. One of our complications is related to the choice of the operative technique and that highlights the absolute necessity of strict preoperative assessment and selection of the patient but also selection of the type of operation, tailored to the patient.
背景/目的：腹腔镜手术治疗胃食管反流病于5年前首次被描述。应用最为广泛的技术是不同改良方式的nissen胃底折叠术。早期结果表明，该手术在疗效上与开放性抗反流手术相当。
在5年期间，622例患者接受了腹腔镜胃底折叠术治疗胃食管反流病。550例患者接受了nissen胃底折叠术。对术前、术中及术后数据进行了前瞻性回顾。127例患者在术后1至4年接受了评估。
在腹腔镜手术开展的前3年，实施了标准胃游离且未离断胃短血管（SGV）的腹腔镜nissen胃底折叠术。自1994年初起，我们对所有患者均采用离断SGV并完全游离胃底上部的方法。平均手术时间为86分钟（范围30 - 180分钟）。5例患者（0.9%）需要转为开放手术。未发生脾损伤及食管穿孔。无死亡病例。发病率为2.3%。平均住院时间为3.1天（范围1 - 13天）。所有患者均出现术后吞咽困难，除12例患者（2.1%）外，其余患者均在2至6周后缓解，这12例患者接受了内镜扩张，9例成功。在中位随访期2年（16 - 44个月）时，最初经验中的127例连续患者（1991 - 1992系列）自愿接受中期随访评估。92%的患者获得了Visick I和II级评分。6例患者（1.0%）因手术失败需要再次手术。
腹腔镜nissen胃底折叠术的长期结果尚无定论。长期预后不良或症状复发的发生率无法评估。目前，我们认为，在经验丰富的医生手中，如果遵循抗反流手术的所有外科原则，腹腔镜手术与开放手术效果相当。我们的并发症之一与手术技术的选择有关，这突出了严格术前评估和患者选择的绝对必要性，同时也强调了根据患者情况选择手术方式的必要性。
