贲门失弛缓症-课件

贲门失弛缓症贲门失弛缓症ACHALASIA1贲门失弛缓症ACHALASIA1Anatomy-esophagusn n-Muscular tube-Conduit from the pharynx-Muscular tube-Conduit from the pharynx to the stomachto the stomachn n-Length is defined anatomically,from cricoid -Length is defined anatomically,from cricoid cartilage to the gastric orificecartilage to the gastric orificen n-Distance from the incisor 40-45 cm(actual-Distance from the incisor 40-45 cm(actual length:M 22-28cm F 2cm shorter)length:M 22-28cm F 2cm shorter)n n-Passes behind aortic arch and left main-Passes behind aortic arch and left main bronchus.bronchus.n n-Enters abdomen through esophageal hiatus-Enters abdomen through esophageal hiatus 2-4 cm below the diaphragm 2-4 cm below the diaphragm2Anatomy-esophagus-Muscular n nCourse of the esophagusCourse of the esophagusn n-Neck and upper esophagus:-Neck and upper esophagus:left of midline left of midlinen n-Mid-esophagus:right of-Mid-esophagus:right of midline midlinen n -Lower esophagus:left of-Lower esophagus:left of midline midlinen nThree area of normalThree area of normal constrictions:constrictions:n n-Cricopharangeal-Cricopharangealn n-Behind the aortic arch-Behind the aortic archn n -LES(thickening of the-LES(thickening of the Circular muscles 4cm)Circular muscles 4cm)3 Course of the esophagus3n n-Fixed in position at two places:-Fixed in position at two places:n n.Upper:firmly attached to the cricoid cartilage.Upper:firmly attached to the cricoid cartilagen n.Lower:Phreno-esophageal ligament to the .Lower:Phreno-esophageal ligament to the esophagus whichesophagus whichn nprovides an air-tight seal between the thoracic provides an air-tight seal between the thoracic and abdominal cavity.and abdominal cavity.n n(lack of fixation throughout its length allows(lack of fixation throughout its length allows both transverse and longitudinal mobility)both transverse and longitudinal mobility)4-Fixed in position at two plaVascular supplyn nARTERIAL SUPPLYARTERIAL SUPPLYn nUpper superior and inferior thyroidUpper superior and inferior thyroid artery arteryn nMiddle Bronchial arteries andMiddle Bronchial arteries and esophageal branches directly from aorta esophageal branches directly from aortan n Lower L inferior phrenic and gastricLower L inferior phrenic and gastricn nVENOUS SUPPLYVENOUS SUPPLYn nUpper esophageal venous plexusUpper esophageal venous plexus to azygos vein to azygos veinn nLower esophageal branches ofLower esophageal branches of the coronary vein,a tributary of the the coronary vein,a tributary of the portal vein portal vein5Vascular supplyARTERIAL SUPPLStructuren n-Consists of 3 layers:muscularis externa,submucosa,mucosa6Structure-Consists of 3 layeAchalasia-historical noten nFirst described more than 300yrs agon n Referred to as cardiospasmn n Thomas Willis(1621-1675)n n Described a pt starving and unable to swallowDescribed a pt starving and unable to swallown n Conclusion was due to lower esophageal Conclusion was due to lower esophageal narrowingnarrowingn n Constructed the first dilator-made of whale Constructed the first dilator-made of whale bonebone and sponge and spongen n First successful treatment of achalasiaFirst successful treatment of achalasia7Achalasia-historical noteFirstAchalasia-historical noten n1914:Ernst Heller1914:Ernst Hellern n(1877-1964)-First(1877-1964)-First successful successful cardiomyotomy cardiomyotomyn nAnterior and posteriorAnterior and posterior myotomies myotomiesn n Extending 8cm or more Extending 8cm or more into esophagus and into esophagus and stomach stomach8Achalasia-historical note1914:Achalasia-historical noten n1918:De Brune Groenveldt and Zaaijer performed modified Heller myotomyn nanterior onlyn nOriginal technique was to excessive9Achalasia-historical note1918:Achalasian n-Uncommon(0.5-1 in 100,000)-Uncommon(0.5-1 in 100,000)n n-No sex predilection M=F-No sex predilection M=Fn n-Majority between ages 20-50s-Majority between ages 20-50sn n-Ineffective relaxation of the LES combined-Ineffective relaxation of the LES combined withwith loss of esophageal peristalsis impaired loss of esophageal peristalsis impaired esophageal emptying and gradual dilatationesophageal emptying and gradual dilatationn n-Decrease or loss of myenteric ganglion-Decrease or loss of myenteric ganglion cellscellsn n-Slight increase risk of esophageal-Slight increase risk of esophageal carcinomacarcinoman n(approx.10yrs earlier than the general(approx.10yrs earlier than the general population)population)10Achalasia10Achalasia-Presentationn n-Dysphagia-delayed and progressive presentation(mean 2 years)n n-Exacerabated by emotional stress or cold fluidn n-60-90%report spontaneous or forced regurgitation of undigested foodn n-10%will have pulmonary complicationn n-Chest pain(heartburn)-30-50%resolves with Myotomy11Achalasia-Presentation11Achalasia-Diagnosisn n-CXR:air fluid levels-CXR:air fluid levelsn n-Barium swallow:dilated esophagus with-Barium swallow:dilated esophagus with Birds beak deformity.(pseudoachalasia from Birds beak deformity.(pseudoachalasia from extrinsic mass mayextrinsic mass may mimic the classic achalasia appearance)mimic the classic achalasia appearance)n n-Manometry:-Manometry:gold standardgold standardn n.Elevated LES pressure(greater than.Elevated LES pressure(greater than 35mmHg)35mmHg)n n.Incomplete sphincter relaxation.Incomplete sphincter relaxationn n.Complete absence of peristalsis.Complete absence of peristalsisn n-Endoscopy:dilated esophagus with tightly-Endoscopy:dilated esophagus with tightly closed LESclosed LESn n gentle pressure will admit the scope with a gentle pressure will admit the scope with a poppop“.12Achalasia-Diagnosis12Achalasia13Achalasia13Achalasia14Achalasia14Achalasia-Treatmentn nPalliation of dysphagia is the key relieve functional obstruction of distal esophagusn n -pharmacotherapyn n -botulinum toxinn n -esophageal dilationn n -operative myotomy15Achalasia-TreatmentPalliatioAchalasia-algorithm16Achalasia-algorithm16Achalasia-Treatmentn nPharmacotherapy:(poorly absorbed and short lived,best reserved as adjunct to other therapies)n n -Nitratesn n -Ca+channel blockersn n -Anticholinergicsn n -Opiods17Achalasia-TreatmentPharmacotBotulinum Toxin Therapy18Botulinum Toxin Therapy18Achalasia-Treatmentn nBotox injection:n n-Bind to cholinergic nerves and irreversibly inhibit Acetyl Choline releasen n-60-85%of patient get relief but 50%get recurrent symptoms within 6 months.n n-Endoscopically injectedn n-For pt who are not candidates for other therapies19Achalasia-Treatment19Achalasia-Treatmentn nBotox injection cont.n n-Advantages:safety,ease of administration,-Advantages:safety,ease of administration,minimal side effects minimal side effectsn n-Disadvantages:expensive,need for-Disadvantages:expensive,need for multiplemultiple injections,and efficacy decreased with injections,and efficacy decreased with repeated injectionrepeated injectionn n-Cause obliteration of the dissection planes-Cause obliteration of the dissection planes between submucosa and muscular layer between submucosa and muscular layer which will make subsequent surgery more which will make subsequent surgery more difficult and increase risk of perforation.difficult and increase risk of perforation.20Achalasia-Treatment20Pneumatic Dilator21Pneumatic Dilator21Achalasia-Treatmentn nEsophageal dilation(under fluroscopy)n n -Standard nonoperative therapy -Standard nonoperative therapyn n -Break the muscle fibers -Break the muscle fibersn n -For pts with limited life expectancy -For pts with limited life expectancyn n -Can have repeated dilatation -Can have repeated dilatationn n -60-80%success rate,5yr recurrence rate -60-80%success rate,5yr recurrence rate 50%50%n n -Efficacy is decreased after second -Efficacy is decreased after second dilatationdilatationn n -Perforation rate 2%-Perforation rate 2%n n -PPI reduces the need for repeat dilatation -PPI reduces the need for repeat dilatation22Achalasia-TreatmentEsophageaEsophageal myotomy23Esophageal myotomy23Achalasia Surgical treatmentn n-Excellent results in 90-95%Excellent results in 90-95%n n-Gold standardGold standardn n-1914-Ernest Heller-double myotomy1914-Ernest Heller-double myotomyn n-Modified by Zaaijer-single myotomyModified by Zaaijer-single myotomyn n-WorldWorld s largest experiences largest experiencen n-Brazil,ChagasBrazil,Chagas disease-endemic disease-endemicn n-1 in 8 inhabitants,in which 5%develops achalasia1 in 8 inhabitants,in which 5%develops achalasian n-Traditionally trans-thoracic or trans-abdominal-Traditionally trans-thoracic or trans-abdominaln n-Now minimally invasive Laparoscopic/-Now minimally invasive Laparoscopic/n nThoracoscopicThoracoscopicn n-Robotic Heller myotomy-Robotic Heller myotomy24Achalasia Surgical treatmentAchalasia Surgical treatmentn nIndications:Indications:n n Younger than 40yrs old(group which PD is Younger than 40yrs old(group which PD is 50%effective)50%effective)n n High risk of perforationHigh risk of perforationn n Esophageal diverticulaEsophageal diverticulan n Previous surgery of GE junctionPrevious surgery of GE junctionn n Tortuous or dilated distal esophagusTortuous or dilated distal esophagusn n Recurrent symptoms despite Botox or PD Recurrent symptoms despite Botox or PD therapytherapyn n Personal choice of therapyPersonal choice of therapyn n Lower risk of perforationLower risk of perforationn n Better long term outcomeBetter long term outcomen n Decrease chance of re-interventionDecrease chance of re-intervention25Achalasia Surgical treatmentAchalasia Surgical treatmentn n Expose mucosal surfaceExpose mucosal surfacen n Length of myotomyLength of myotomyn n Cephalad:1-2 cm beyond the dilated Cephalad:1-2 cm beyond the dilated esophagusesophagusn n Caudal:1-2 cm into the gastric musculature orCaudal:1-2 cm into the gastric musculature or when transverse veins are encountered when transverse veins are encounteredn n Check for perforationCheck for perforationn n Meythlene blueMeythlene bluen n AirAir26Achalasia Surgical treatmentComplicationsn nIntra-opn nMucosa perforationn nPost-op:n nDysphagia-adhesion,inadequate myotomyn nGERD-long myotomy,nerve damagen nDelay perforation-inadequate myotomy27Complications Intra-op27Achalasia Surgical treatmentn nWhich esophageal technique should be used?n nAny role for anti-reflux procedure?28Achalasia Surgical treatment29293030概念概念n n贲门失弛缓症是一种食管动力学功能障碍性疾病。n n特点是下食管括约肌不能松弛，食管体缺乏正常的蠕动波，食管排空受阻造成食管腔内食物淤积而扩张n n根据本病在X线上的解剖学改变又被称为巨食管症或贲门痉挛。31概念贲门失弛缓症是一种食管动力学功能障碍性疾病。31病因病因n n本病病因不清。可能与基因遗传、自身免疫、病毒感染、社会心理因素有关。n n目前,对其发病机制普遍接受神经源性学说，即病人食管壁肌间神经丛内神经节细胞减少或缺如，而控制食管环型肌松弛的氮能神经和血管活性肠肽(VIP)免疫阳性神经纤维减少或消失，从而导致LES不能正常松弛。32病因本病病因不清。可能与基因遗传、自身免疫、病毒感染、社会心临床表现临床表现n n大多数患者起病缓慢，起病时症状不明显。突然起病者多大多数患者起病缓慢，起病时症状不明显。突然起病者多与情绪紧张有关。与情绪紧张有关。n n(一一)吞咽困难：是该病最突出的的表现。其程度常有差异。吞咽困难：是该病最突出的的表现。其程度常有差异。通常液体吞咽困难者占通常液体吞咽困难者占6060，固体吞咽困难者占，固体吞咽困难者占9898。很少有食管癌的从固体到很少有食管癌的从固体到流食到液体的规律性吞咽困难的发病过程。流食到液体的规律性吞咽困难的发病过程。n n(二二)食管反流：未消化食物的食管内潴留及反流是该病另食管反流：未消化食物的食管内潴留及反流是该病另一常见症状，占总数的一常见症状，占总数的6o6o9090。n n(三三)胸痛：胸痛：1 13 31 12 2的病人伴有胸痛。常在进食后突发，的病人伴有胸痛。常在进食后突发，并时常迫使病人停止进食。并时常迫使病人停止进食。n n(四四)其他症状：部分病人可出现烧心症状，多发生于疾病其他症状：部分病人可出现烧心症状，多发生于疾病早期和吞咽困难以前。重症、病程较长时，可出现明显的早期和吞咽困难以前。重症、病程较长时，可出现明显的体重减轻、营养不良、贫血等症状。体重减轻、营养不良、贫血等症状。33临床表现大多数患者起病缓慢，起病时症状不明显。突然起病者多与非手术治疗方法非手术治疗方法n n1 药物治疗n n药物治疗包括局部麻醉剂、钙离子拮抗剂、硝酸盐类药物、抗胆碱药物、镇静药物、胃肠动力药、中药治疗等。药物治疗作用轻微，而且作用时间短暂，因此，仅用于贲门失弛缓症的早期、老年高危病人或拒绝其他治疗的病人。34非手术治疗方法1 药物治疗34n n1 11 1钙离子拮抗剂钙离子拮抗剂 可干扰细胞膜的钙离子内流，解除平滑可干扰细胞膜的钙离子内流，解除平滑肌痉挛，可松弛肌痉挛，可松弛LESLES，有效解除吞咽困难及胸骨后疼痛。侯，有效解除吞咽困难及胸骨后疼痛。侯延丽等报道，硝苯毗啶舌下含服能降低延丽等报道，硝苯毗啶舌下含服能降低LESLES静静l l卜压、食管收卜压、食管收缩振幅和自发性收缩频率，同时也能改善食物在食管中的排缩振幅和自发性收缩频率，同时也能改善食物在食管中的排空，使吞咽困难改善。常用量为空，使吞咽困难改善。常用量为101020 nag20 nag，每日，每日3 3次。硫次。硫氮卓酮、异博定疗效不如硝苯吡啶，且不良反应日月显，尤氮卓酮、异博定疗效不如硝苯吡啶，且不良反应日月显，尤其对有心功能不全、房室传导阻滞和房颤、房扑的患者，应其对有心功能不全、房室传导阻滞和房颤、房扑的患者，应忌用。忌用。n n1 12 2 硝酸盐类硝酸盐或亚硝酸盐类药物在体内降解产生硝酸盐类硝酸盐或亚硝酸盐类药物在体内降解产生NONO，松弛，松弛I EsI Es，从而缓解，从而缓解ACAC患者临床症状患者临床症状_2 J_2 J。实验证明硝酸。实验证明硝酸甘油、甘油、硝酸异戊硝酸异戊酯应用后酯应用后l5 nfinl5 nfin起效，起效，LESLES可从可从6.12 6.12 kPa(46 mmHg)kPa(46 mmHg)下降到下降到2 20 kPa(15 mmHg)0 kPa(15 mmHg)，持续，持续90 min90 min。常用药物：硝酸甘油常用药物：硝酸甘油0 03 30 06 mg6 mg每日每日3 3次餐前次餐前15min15min舌下舌下含服，硝酸异山梨酯含服，硝酸异山梨酯5 510 mg10 mg餐前餐前101020 min20 min舌下含服每舌下含服每日日3 3次，疗程不宜过长，一般为次，疗程不宜过长，一般为2 2周，以防止产生耐药性。周，以防止产生耐药性。3511钙离子拮抗剂 可干扰细胞膜的钙离子内流，解除平滑肌痉挛n n13 局部麻醉剂2普鲁卡因60 mL于餐前1520 min口服，有助于LES松弛，可能与该药抑制兴奋活动过程，而使LES松弛有关。n n14 抗胆碱能药物解痉灵1020 nag次，肌注或静推，可阻断M 胆碱能受体，使乙酰胆碱不能与受体结合而松弛平滑肌，改善食管排李，可扶疗效。其他药物山莨菪碱、阿托品等疗效不大，不良反应可见口干、尿潴留、心悸。应用较少。3613 局部麻醉剂2普鲁卡因60 mL于餐前1520 mn n1 16 6 胃肠动力药物胃肠动力药物ACAC患者晚期常继发食管运动患者晚期常继发食管运动明显减弱，排宅延迟，故可采用胃肠动力药物胃明显减弱，排宅延迟，故可采用胃肠动力药物胃复安复安5 510 nag10 nag每日每日4 4次口服，或多潘立酮次口服，或多潘立酮l0l020 20 nagnag每日每日 4 4次口服，增加次口服，增加LESPLESP和食管下端的蠕动，和食管下端的蠕动，缩短食管与酸性反流物的接触时间。缩短食管与酸性反流物的接触时间。n n1 17 7 注射肉毒杆菌毒素注射肉毒杆菌毒素(BT)BT(BT)BT能阻断神经肌肉能阻断神经肌肉接头处突触前膜乙酰胆碱的释放而使肌肉松弛麻接头处突触前膜乙酰胆碱的释放而使肌肉松弛麻痹。以缓解痹。以缓解ACAC患者临床症状。据报道内镜下行患者临床症状。据报道内镜下行LESLES内注射内注射A A型型BTBT初治有效率为初治有效率为82825 5 。本方。本方法不良反应轻微、操作简便、痛苦小、安全可靠。法不良反应轻微、操作简便、痛苦小、安全可靠。对无法手术、无法行气囊扩张的患者更为适宜。对无法手术、无法行气囊扩张的患者更为适宜。3716 胃肠动力药物AC患者晚期常继发食管运动明显减弱，排宅n n2 扩张治疗n n扩张治疗包括球囊扩张、支架治疗等。禁忌证包括病人不能合作、合并严重心肺疾患或其他严重疾病、严重器官衰竭无法耐受治疗、局部水肿严重、狭窄严重致导丝无法通过等。382 扩张治疗38手术治疗手术治疗n n开放式食管下括约肌开放式食管下括约肌(Heller(Heller肌肌)切开术切开术n n开放式开放式HellerHeller肌切开手术分为经腹和经胸肌切开手术分为经腹和经胸2 2种，手术的目的种，手术的目的是彻底切开食管下括约肌，以消除吞咽困难症状。目前，是彻底切开食管下括约肌，以消除吞咽困难症状。目前，常用的是改良常用的是改良HellerHeller手术。手术适应证包括临床诊断的贲手术。手术适应证包括临床诊断的贲门失弛缓症，无黏膜病变，无手术禁忌证均可手术治疗。门失弛缓症，无黏膜病变，无手术禁忌证均可手术治疗。n n手术要点是经胸或经腹暴露扩张、狭窄的病段食管，根据手术要点是经胸或经腹暴露扩张、狭窄的病段食管，根据狭窄长度，沿食管纵轴垂直切开食管侧肌层约狭窄长度，沿食管纵轴垂直切开食管侧肌层约6 cm6 cm，胃底，胃底侧侧 1 13 cm3 cm，完全切断狭窄环，并在黏膜外剥离被切开的，完全切断狭窄环，并在黏膜外剥离被切开的肌层，使其达到食管周径的肌层，使其达到食管周径的1 12 2。蒋俭等。蒋俭等 报道开放手术报道开放手术术后症状改善率为术后症状改善率为96969 9。早期并发症主要为食管穿孔，。早期并发症主要为食管穿孔，晚期主要为胃食管反流，发生率晚期主要为胃食管反流，发生率5050 以上。以上。39手术治疗开放式食管下括约肌(Heller肌)切开术394040腔镜下食管下括约肌腔镜下食管下括约肌(Heller肌肌)切开切开术术n n19911991年年ShimiShimi等等 率先施行腹腔镜率先施行腹腔镜HellerHeller肌切开术，肌切开术，n n19921992年年PellegriniPellegrini等等 首次施行胸腔镜首次施行胸腔镜HellerHeller肌切开术。肌切开术。n nPattiPatti等等 回顾了近十年来贲门失弛缓症治疗的变化趋势，总回顾了近十年来贲门失弛缓症治疗的变化趋势，总结出腔镜下结出腔镜下HellerHeller肌切开术手术具有传统手术的有效性，肌切开术手术具有传统手术的有效性，手术操作简便、创伤小、缩短术后住院手术操作简便、创伤小、缩短术后住院1313和康复时间，降和康复时间，降低术后死亡率，并发症和开放手术相当，腔镜下低术后死亡率，并发症和开放手术相当，腔镜下HellerHeller肌肌切开手术已经成为手术治疗首选。切开手术已经成为手术治疗首选。RobeRobe等等 报道报道3636例腹例腹腔镜腔镜HellerHeller肌切开术，手术优良率肌切开术，手术优良率94944 4，术中黏膜穿，术中黏膜穿孔发生率孔发生率8 83 3，术后胃食管反流发生率仅为，术后胃食管反流发生率仅为8 83 3。刘隆等刘隆等 报道报道2525例腹腔镜例腹腔镜HellerHellerDorDor手术，术后手术，术后9292 的患的患者吞咽功能恢复良好。者吞咽功能恢复良好。41腔镜下食管下括约肌(Heller肌)切开术41机器人辅助微创手术机器人辅助微创手术n n随着手术机器人达芬奇、宙斯的出现，机器人腹随着手术机器人达芬奇、宙斯的出现，机器人腹腔镜手术很快应用到外科各个领域。腔镜手术很快应用到外科各个领域。20002000年年7 7月月MelvinMelvin等等报道首例机器人辅助腹腔镜食管报道首例机器人辅助腹腔镜食管HellerHeller肌切开术。他们认为机器人腹腔镜手术具有三维肌切开术。他们认为机器人腹腔镜手术具有三维图像对病变的识别更容易、清楚，机械臂比人臂图像对病变的识别更容易、清楚，机械臂比人臂更稳定，准确性更高的优点。更稳定，准确性更高的优点。20052005年年HorganHorgan等等 报道机器人辅助腹腔镜食管贲门括约肌切开术比报道机器人辅助腹腔镜食管贲门括约肌切开术比普通腹腔镜食管贲门肌切开手术更安全。但机器普通腹腔镜食管贲门肌切开手术更安全。但机器人腹腔镜食管贲门括约肌切开术需要昂贵的仪器，人腹腔镜食管贲门括约肌切开术需要昂贵的仪器，且手术前安置机器的时间比较长，手术总时间长。且手术前安置机器的时间比较长，手术总时间长。42机器人辅助微创手术随着手术机器人达芬奇、宙斯的出现，机器人腹目前存在的争论目前存在的争论n n目前，存在的争论主要为是否需要联合抗反流手术，抗反流手术的方式和既往治疗对手术效果的影响等。n n抗反流手术基本有三类：全胃底折叠术、部分胃底折叠术和贲门固定术。43目前存在的争论43是否需要联合抗反流手术是否需要联合抗反流手术n nHellerHeller肌切开术是否联合抗反流手术是目前争论的主要问肌切开术是否联合抗反流手术是目前争论的主要问题。反对常规使用抗反流手术的人认为单纯题。反对常规使用抗反流手术的人认为单纯HellerHeller肌切开肌切开术后反流并不高，术后出现胃食管反流可以用药物很好控术后反流并不高，术后出现胃食管反流可以用药物很好控制，并且抗反流手术可能造成术后持续的吞咽困难或复发。制，并且抗反流手术可能造成术后持续的吞咽困难或复发。DempseyDempsey等等 对比对比2929例例HellerHeller肌切开联合肌切开联合DorDor折叠术和折叠术和2222例例单纯单纯HellerHeller肌切开，肌切开，2 2组病人在症状的改善、术后吞咽困难组病人在症状的改善、术后吞咽困难及烧心的症状评分均一样，提示及烧心的症状评分均一样，提示DorDor前折叠对手术疗效无前折叠对手术疗效无明显影响。认为需要联合抗反流手术的学者认为明显影响。认为需要联合抗反流手术的学者认为HellerHeller肌肌层切开破坏食管下段肌层原本的生理功能，会导致术后严层切开破坏食管下段肌层原本的生理功能，会导致术后严重的反流，而胃食管反流是引起贲门失弛缓症手术晚期失重的反流，而胃食管反流是引起贲门失弛缓症手术晚期失败的主要原因。败的主要原因。MahhanerMahhaner等等 州报道单纯州报道单纯HellerHeller肌切开术肌切开术后后2020年胃食管反流的发生率可达到年胃食管反流的发生率可达到7878。抗反流手术可。抗反流手术可有效降低手术后胃食管反流率，有效降低手术后胃食管反流率，RichardsRichards等等 在一项随机对在一项随机对照试验中比较了照试验中比较了HellerHellerDorDor手术与单纯手术与单纯HellerHeller手术疗效，手术疗效，发现前者术后病理性胃食管反流仅为发现前者术后病理性胃食管反流仅为9 9，1 1(2(222)22)，而，而单纯单纯HellerHeller肌切开手术术后病理性胃食管反流为肌切开手术术后病理性胃食管反流为47476 6(10(1021)21)。44是否需要联合抗反流手术Heller肌切开术是否联合抗反流手抗反流的方式抗反流的方式n n1 1、DorDor前折叠前折叠(前壁前壁180180胃底折叠胃底折叠)n nDorDor前折叠手术不用解剖食管后组织，对胃食管膜前折叠手术不用解剖食管后组织，对胃食管膜的破坏比较小，且前折叠将胃底覆盖在膨出的食的破坏比较小，且前折叠将胃底覆盖在膨出的食管黏膜上，可以预防手术食管黏膜破口所致的食管黏膜上，可以预防手术食管黏膜破口所致的食管瘘。管瘘。MineoMineo等等 在一组在一组8181例开放例开放HellerHellerDorDor手术手术中观察到术后病理性反流率仅为中观察到术后病理性反流率仅为7 77 7。DorDor前前折叠并不增加术后吞咽困难比例，如折叠并不增加术后吞咽困难比例，如HaroldHarold等等 报报道道HellerHellerDorDor手术后手术后9696 的病人吞咽功能良好。的病人吞咽功能良好。常用于配合常用于配合HellerHeller手术。手术。45抗反流的方式45n n2 2、ToupetToupet后折叠后折叠(食管左、后、右壁食管左、后、右壁270270胃底折胃底折叠术叠术)n nToupetToupet后折叠手术在食管后方将黏膜外肌分开缝后折叠手术在食管后方将黏膜外肌分开缝合，保持黏膜外肌持续分开，有效降低手术后病合，保持黏膜外肌持续分开，有效降低手术后病理性反流率，抗反流效果与理性反流率，抗反流效果与DorDor手术相当甚至更佳手术相当甚至更佳。ArainArain等等 比较了比较了4141例例HellerHellerDorDor和和2323例例HellerHellerToupetToupet手术疗效，认为在术后症状评分、手术疗效，认为在术后症状评分、吞咽困难的改善、病人对手术效果的评价以及质吞咽困难的改善、病人对手术效果的评价以及质子泵抑制剂的应用方面无明显差异，但后折叠手子泵抑制剂的应用方面无明显差异，但后折叠手术操作较前折叠困难，手术时间更长。术操作较前折叠困难，手术时间更长。462、Toupet后折叠(食管左、后、右壁270胃底折叠术n n3 3、NissenNissen全折叠全折叠（全胃底折叠（全胃底折叠360360）n nNissenNissen全折叠可有效缓解全折叠可有效缓解HellerHeller肌切开病人术后胃肌切开病人术后胃食管反流。食管反流。FalkenbackFalkenback等等 报道在附加报道在附加NissenNissen全折全折叠的叠的HellerHeller肌切开病人术后肌切开病人术后24 h24 h反流比单纯反流比单纯HellerHeller肌切开病人低很多。但由于贲门失弛缓病人食管肌切开病人低很多。但由于贲门失弛缓病人食管蠕动功能欠佳，蠕动功能欠佳，NissenNissen全折叠手术在食管运动过全折叠手术在食管运动过程中形成障碍而导致术后吞咽困难缓解率偏低，程中形成障碍而导致术后吞咽困难缓解率偏低，因此，有作者认为认为因此，有作者认为认为NissenNissen全折叠手术对贲门全折叠手术对贲门失弛缓症病人不适合失弛缓症病人不适合。473、Nissen全折叠（全胃底折叠360）47n n鉴于传统Nissen手术有较多的机械性并发症如包饶部分滑脱、缝合裂开、胃胀气、嗳气困难或呕吐以及难于掌握等，Donahue将折叠缝合改为2.0cm或更短，且包饶较松弛称为短松Nissen手术（short floppy Nissen手术），这种手术应用较广。48鉴于传统Nissen手术有较多的机械性并发症如包饶部分滑脱、n n4、Hill手术（经腹后固定术）n n将食管裂孔疝加以缝合后，将食管胃连接部缝合固定于弓状韧带上。手术难度大，术中需要测压指导缝合，采用者较少。494、Hill手术（经腹后固定术）49