经腹食管裂孔修补加Dor胃底折叠术治疗食管裂孔疝的远期疗效观察

发布时间：2018-10-05 07:29

【摘要】：目的：探讨经腹行食管裂孔修补加Dor部分胃底折叠术治疗食管裂孔疝的远期疗效。方法：对2007年10月至2011年9月天津市胸科医院胸外科41例食管裂孔疝患者行食管裂孔疝修补术及Dor胃底折叠术的资料进行统计分析。其中男性8例,女性33例。年龄34～81岁,30～50岁患者2例,50-70岁患者19例,70岁以上患者20例,平均年龄67岁。入院前病人均有不同程度的返酸,主要表现为返酸烧心者28例,表现为上腹疼痛不适者8例,表现为恶心呕吐者5例。病史3个月-30年。术前、术后短期、术后远期分别对患者进行综合评估,记录手术时间、术中出血量、术后住院时间、术后症状缓解情况,手术前后胃镜、食管测压、食管24小时pH测定,上消化道造影情况,术后生活质量评分及术后并发症情况。记录术前、术后3个月、术后1年的随访情况。通过自身配对t检验方法对配对指标进行统计学分析,观察经腹食管裂孔修补及Dor胃底折叠术治疗食管裂孔疝的远期疗效。结果：41例患者均手术顺利,手术时间60-180min,平均85miin;术中出血量20-80mL,平均35mL；术后住院时间7-30d,平均12d。术后烧心返酸等症状均明显缓解,无围手术期死亡病例。41例均得到随访,随访时间为1年至5年,平均3.4年,无术后复发病例。手术结果满意率95.12%。1例患者术后切口感染,经换药处理后痊愈。4例患者术后短期内进固体食物时有不同程度哽噎感,3例可耐受,1例患者行球囊扩张后好转,远期随访仍有2例述进固体食物时轻度哽咽感,但均可耐受。食管测酸测压结果显示经手术治疗后患者食管下端括约肌压力增加,有效地建立食管下段抗返流屏障抑制酸反流。伴有返流性食管炎的患者术前均有不同程度的食管炎症,术后复查胃镜,其食管粘膜随着时间的延长逐渐恢复,1年后复查全部恢复正常。对比术前与术后生活质量评分、食管测酸及测压结果,术后远期和术前比较,差异有统计学意义(P均0.05)；术后远期和术后短期比较差异无统计学意义(P均0.05)。结论：随着造影、内镜等检查技术的应用以及人们对疾病认识水平的提高,食管裂孔疝这一欧美常见疾病在我国的检出率正在逐年增加。腹腔镜技术在我国发展较快,很多家三甲医院均能进行此类手术,但仍处于探索阶段,较国外仍存在一定差距,且受医院本身硬件条件限制,部分医院无腹腔镜相关技术及设备。因此,经腹行食管裂孔修补加Dor胃底折叠术是一种较实用的选择,而且具有出血少,对患者心肺功能影响小,疗效确切,费用低等特点,具有临床推广价值。由于临床资料有限,只随访到术后5年内疗效,更远期疗效还需继续随访观察。
[Abstract]:Objective: to investigate the long-term effect of transabdominal repair of esophageal hiatus and Dor partial fundus folding in the treatment of hiatal hernia. Methods: the data of 41 cases of esophageal hiatal hernia repair and Dor fundus folding in thoracic surgery of Tianjin chest Hospital from October 2007 to September 2011 were analyzed statistically. There were 8 males and 33 females. Two patients aged from 50 to 50 years old, 19 patients over 70 years old and 20 patients over 70 years old, with an average age of 67 years. All the patients had different degrees of regurgitation before admission. The main manifestations were acid burning in 28 cases, upper abdominal pain and discomfort in 8 cases, nausea and vomiting in 5 cases. History 3 months-30 years. The patients were evaluated before and after operation, the time of operation, the amount of blood lost during operation, the time of hospitalization after operation, the relief of symptoms after operation, gastroscopy, esophageal manometry and 24 hour esophageal pH were recorded before and after operation. Upper gastrointestinal angiography, postoperative quality of life score and postoperative complications. The follow-up data were recorded before operation, 3 months after operation and 1 year after operation. The long-term efficacy of transabdominal esophageal hiatus repair and Dor fundus folding in the treatment of esophageal hiatal hernia was observed. Results all 41 cases were successfully operated, the operative time was 60-180 min (average 85miin), the amount of intraoperative bleeding was 20-80 mL (mean 35 mL), and the postoperative hospitalization time was 7-30 days (mean 12 days). All patients were followed up for 1 to 5 years with an average of 3.4 years. The satisfactory rate of operation was 95.12.1 cases of incision infection after operation. After dressing change, 4 cases were cured, 4 cases had different degree of choking and feeling of choking during the short period of time after operation, 3 cases could tolerate it, and 1 case had improved after balloon dilatation. At long-term follow-up, 2 patients with mild choking in solid food were tolerable. The results of esophageal acid manometry showed that the lower esophageal sphincter pressure increased after surgical treatment, which effectively established the lower esophageal anti-reflux barrier to inhibit acid reflux. The patients with reflux esophagitis had different degree of esophagitis before operation. After operation, the esophagus mucosa gradually recovered with the extension of time, and all of them returned to normal after one year. Compared with preoperative and postoperative quality of life scores, esophageal acid and pressure test results, postoperative long-term and preoperative differences were statistically significant (P 0.05), postoperative long-term and postoperative short-term differences were not statistically significant (P 0.05). Conclusion: with the application of radiography, endoscopic examination and the improvement of people's understanding of the disease, the detection rate of esophageal hiatal hernia, a common disease in Europe and America, is increasing year by year in China. The technique of laparoscopy is developing rapidly in our country. Many third Class A hospitals can perform this kind of operation, but it is still in the exploratory stage, and there is still a certain gap compared with foreign countries, and it is limited by the hardware condition of the hospital itself. Some hospitals do not have laparoscopy related technology and equipment. Therefore, transabdominal repair of esophageal fissure and Dor fundus folding is a practical choice with less bleeding, less influence on cardiopulmonary function, accurate curative effect and low cost. Due to limited clinical data, only 5 years after the follow-up, more long-term results need to continue to follow-up observation.
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R655.4

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