腹腔镜Nissen胃底折叠联合His角重建术治疗胃食管反流病的短期疗效

doi:10.3877/cma.j.issn.1674-392X.2022.05.005

中华疝和腹壁外科杂志(电子版) ›› 2022, Vol. 16 ›› Issue (05) : 510 -515. doi: 10.3877/cma.j.issn.1674-392X.2022.05.005

临床论著

腹腔镜Nissen胃底折叠联合His角重建术治疗胃食管反流病的短期疗效

杜兴¹, 罗颖¹, 高颖¹, 董庆申², 刘殿刚¹^,^†(

), 汪忠镐³, 郑煜琳¹

^1. 100053　北京，首都医科大学宣武医院普通外科
^2. 100053　北京市仁和医院普通外科
^3. 100053　北京，首都医科大学宣武医院血管外科

收稿日期:2022-03-02 出版日期:2022-10-18
通信作者: 刘殿刚
基金资助:
首都卫生发展科研专项项目(首发2020-2-2035)

Short-term efficacy of laparoscopic Nissen fundoplication combined with the reconstruction of His angle in the treatment of gastroesophageal reflux disease

Xing Du¹, Ying Luo¹, Ying Gao¹, Qingshen Dong², Diangang Liu¹^,^†(), Zhonggao Wang³, Yulin Zheng¹

^1. Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
^2. Department of General Surgery, Beijing Renhe Hospital, Beijing 100053, China
^3. Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China

Received:2022-03-02 Published:2022-10-18
Corresponding author: Diangang Liu

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引用本文：

杜兴, 罗颖, 高颖, 董庆申, 刘殿刚, 汪忠镐, 郑煜琳. 腹腔镜Nissen胃底折叠联合His角重建术治疗胃食管反流病的短期疗效[J/OL]. 中华疝和腹壁外科杂志(电子版), 2022, 16(05): 510-515.

Xing Du, Ying Luo, Ying Gao, Qingshen Dong, Diangang Liu, Zhonggao Wang, Yulin Zheng. Short-term efficacy of laparoscopic Nissen fundoplication combined with the reconstruction of His angle in the treatment of gastroesophageal reflux disease[J/OL]. Chinese Journal of Hernia and Abdominal Wall Surgery(Electronic Edition), 2022, 16(05): 510-515.

目的

探讨腹腔镜Nissen胃底折叠术联合His角重建治疗胃食管反流病（GERD）的效果。

方法

回顾性分析2018年10月至2021年2月于首都医科大学宣武医院普通外科接受Nissen胃底折叠（360°）+His角重建术和单纯Nissen胃底折叠术GERD患者的临床资料，观察比较两种术式抗反流效果的差异、患者对手术治疗满意度等情况。

结果

本研究共纳入GERD患者98例，其中Nissen+His角重建组为52例，Nissen组为46例。术后6个月时，2组患者GERD相关症状（食管症状：反流、胃灼热、胸背痛及剑突下顶胀感。食管外症状：咳嗽、喘息、咽部异物感）评分均显著低于治疗前（P<0.05）。术后症状评分中，Nissen+His角重建组反流、胃灼热症状评分低于Nissen组，差异有统计学意义（反流：Z=－2.466，P=0.014；胃灼热：Z=－2.674，P=0.007）；2组其他症状评分差异均无统计学意义（P>0.05）。2组术后功能性并发症（包括吞咽困难、腹胀、难以嗳气、排气增多及慢性腹部疼痛）发生率相似，经保守治疗均获得明显缓解。Nissen+His角重建组患者对手术治疗满意度为94.2%（49/52），Nissen组患者满意度为91.3%（42/46），2组患者手术满意度差异无统计学意义（P=0.866）。

结论

Nissen胃底折叠+His角重建术与Nissen胃底折叠术均有较好的抗反流疗效，手术并发症少、轻微，患者满意度高。与Nissen组相比，Nissen+His角重建组控制反流、胃灼热症状更佳，该结果需要前瞻性、大样本、长期随访结果予以证实。

关键词: 胃食管反流病, 胃底折叠术, 腹腔镜

Objective

To investigate the efficacy of Nissen fundoplication combined with the reconstruction of His angle for gastroesophageal reflux disease (GERD).

Methods

The clinical data of GERD patients who received Nissen fundoplication combined with His angle reconstruction or Nissen fundoplication alone in the department of general surgery of Xuanwu Hospital of Capital Medical University from October 2018 to February 2021 were retrospectively analyzed. The differences of the anti-reflux effects and the satisfaction of the two procedures were observed and compared.

Results

98 GERD patients were included in this study, including 52 patients in the Nissen+His angle reconstruction group and 46 patients in the Nissen group. 6 months after operation, GERD related symptoms (esophageal symptoms: reflux, heart burn, chest and back pain, and distension in the lower of xiphoid; extraesophageal symptoms: cough, wheezing, foreign body sensation of pharynx) scores were significantly lower than those before treatment (all P<0.05). In postoperative symptoms scores, score of the reflux and heart burn symptom of the Nissen+His angle reconstruction group were lower than that of Nissen group, the difference was statistically significant (reflux: Z=-2.466, P=0.014; heart burn: Z=-2.674, P=0.007). There was no statistical difference in the scores of other symptom between the two groups (all P>0.05). Postoperative functional complications (including dysphagia, abdominal distention, difficult belching, increased exhaust and chronic abdominal pain) were similar in both groups, and were significantly relieved after conservative treatment. The satisfaction of the group of Nissen+His angle reconstruction and the group of Nissen was 94.2% (49/52) and 91.3% (42/46), respectively, and no significant difference was observed (P=0.866).

Conclusion

Both Nissen+His angle reconstruction and Nissen fundoplication alone had good anti-reflux efficacy, with few and mild surgical complications and high patient satisfaction. Compared to Nissen group, Nissen+His angle reconstruction group had better control of reflux and heart burn symptoms, which required prospective, large-sample, and long-term follow-up results to confirm.

Key words: Gastroesophageal reflux disease, Fundoplication, Laparoscopes

图1 腹腔镜Nissen +His角重建操作要点注：1A缝合两侧膈肌脚，缩小食管裂孔；1B、1C分别为His角重建时折叠瓣、膈肌部位进针位置；1D Nissen折叠联合His角重建完成效果

表1 2组患者基本特征

组别	例数	性别[例(%)]		年龄(岁, ±s)	体质量指数(kg/m², ±s)	反流性食管炎[例(%)]	24h MII-pH监测M(P25,P75)				HRM M(P25,P75)
组别	例数	男	女	年龄(岁, ±s)	体质量指数(kg/m², ±s)	反流性食管炎[例(%)]	Demeester积分	AET(%)	BET(%)	反流总次数	LES(mmHg)		UES(mmHg)
Nissen+His角重建组	52	21(40.4)	31(59.6)	52.37±16.88	24.7±5.4	37(71.1)	25.3(14.6,38.9)	9.7(5.1,2.8)	2.4(1.0,4.3)	79(55.1,84)	6.9(3.4,11.9)		47.1(27.1,72.5)
Nissen组	46	19(41.3)	27(58.7)	54.35±14.06	26.7±4.3	28(60.9)	23.3(14.1,37.7)	8.2(3.6,1.0)	2.2(0.8,3.2)	74(52.8,77.3)	7.8(5.2,11.7)		48.3(27.5,73.1)
P		0.926		0.532	0.413	0.282	0.253	0.287	0.054	0.234	0.265	0.576

表1 2组患者基本特征

组别	例数	性别[例(%)]		年龄(岁, ±s)	体质量指数(kg/m², ±s)	反流性食管炎[例(%)]	24h MII-pH监测M(P25,P75)				HRM M(P25,P75)
组别	例数	男	女	年龄(岁, ±s)	体质量指数(kg/m², ±s)	反流性食管炎[例(%)]	Demeester积分	AET(%)	BET(%)	反流总次数	LES(mmHg)		UES(mmHg)
Nissen+His角重建组	52	21(40.4)	31(59.6)	52.37±16.88	24.7±5.4	37(71.1)	25.3(14.6,38.9)	9.7(5.1,2.8)	2.4(1.0,4.3)	79(55.1,84)	6.9(3.4,11.9)		47.1(27.1,72.5)
Nissen组	46	19(41.3)	27(58.7)	54.35±14.06	26.7±4.3	28(60.9)	23.3(14.1,37.7)	8.2(3.6,1.0)	2.2(0.8,3.2)	74(52.8,77.3)	7.8(5.2,11.7)		48.3(27.5,73.1)
P		0.926		0.532	0.413	0.282	0.253	0.287	0.054	0.234	0.265	0.576

表2 2组患者术前症状评分[M（P25，P75）]

组别	例数	食管症状				食管外症状
组别	例数	反流	胃灼热	胃灼热	剑突下顶胀感	咳嗽	喘息	咽部异物感
Nissen+His角重建组	52	7(6,8)	7(5,8)	4(0,6)	3(0,6)	2(0,5)	4(0,5)	4.5(0,6)
Nissen组	46	7(5,7)	7(5,8)	1(0,5)	0(0,5)	2(0,4.3)	3(0,5)	3(0,5)
Z		-1.151	-0.134	-1.334	-1.637	-0.615	-0.853	-1.115
P		0.25	0.894	0.182	0.102	0.539	0.394	0.265

表2 2组患者术前症状评分[M（P25，P75）]

组别	例数	食管症状				食管外症状
组别	例数	反流	胃灼热	胃灼热	剑突下顶胀感	咳嗽	喘息	咽部异物感
Nissen+His角重建组	52	7(6,8)	7(5,8)	4(0,6)	3(0,6)	2(0,5)	4(0,5)	4.5(0,6)
Nissen组	46	7(5,7)	7(5,8)	1(0,5)	0(0,5)	2(0,4.3)	3(0,5)	3(0,5)
Z		-1.151	-0.134	-1.334	-1.637	-0.615	-0.853	-1.115
P		0.25	0.894	0.182	0.102	0.539	0.394	0.265

表3 2组患者抗反流手术前后症状评分[M（P25，P75）]

组别			术前	术后	Z	P
Nissen+His角重建组
	食管症状
		反流	7(6,8)	0(0,2)	-6.317	<0.001
		胃灼热	7(5,8)	0(0,2)	-6.244	<0.001
		胸背痛	4(0,6)	0(0,2)	-4.989	<0.001
		剑突下顶胀感	3(0,6)	0(0,1.5)	-4.802	<0.001
	食管外症状
		咳嗽	2(0,5)	0(0,2)	-4.672	<0.001
		喘息	4(0,5)	0(0,2)	-4.920	<0.001
		咽部异物感	4.5(0,6)	0(0,2)	-5.131	<0.001
Nissen组
	食管症状
		反流	7(5,7)	2(0,3)	-5.813	<0.001
		胃灼热	7(5,8)	2(0,2)	-5.866	<0.001
		胸背痛	1(0,5)	0(0,0)	-4.220	<0.001
		剑突下顶胀感	0(0,5)	0(0,0)	-4.031	<0.001
	食管外症状
		咳嗽	2(0,4.3)	0(0,2)	-4.223	<0.001
		喘息	3(0,5)	0(0,2)	-4.405	<0.001
		咽部异物感	5(3,6)	2(0,2.3)	-5.363	<0.001

表3 2组患者抗反流手术前后症状评分[M（P25，P75）]

组别			术前	术后	Z	P
Nissen+His角重建组
	食管症状
		反流	7(6,8)	0(0,2)	-6.317	<0.001
		胃灼热	7(5,8)	0(0,2)	-6.244	<0.001
		胸背痛	4(0,6)	0(0,2)	-4.989	<0.001
		剑突下顶胀感	3(0,6)	0(0,1.5)	-4.802	<0.001
	食管外症状
		咳嗽	2(0,5)	0(0,2)	-4.672	<0.001
		喘息	4(0,5)	0(0,2)	-4.920	<0.001
		咽部异物感	4.5(0,6)	0(0,2)	-5.131	<0.001
Nissen组
	食管症状
		反流	7(5,7)	2(0,3)	-5.813	<0.001
		胃灼热	7(5,8)	2(0,2)	-5.866	<0.001
		胸背痛	1(0,5)	0(0,0)	-4.220	<0.001
		剑突下顶胀感	0(0,5)	0(0,0)	-4.031	<0.001
	食管外症状
		咳嗽	2(0,4.3)	0(0,2)	-4.223	<0.001
		喘息	3(0,5)	0(0,2)	-4.405	<0.001
		咽部异物感	5(3,6)	2(0,2.3)	-5.363	<0.001

表4 2组患者术后症状比较[M(P25, P75)]

组别	例数	食管症状				食管外症状
组别	例数	反流	胃灼热	胸背痛	剑突下顶胀感	咳嗽	喘息	咽部异物感
Nissen+His角重建组	52	0(0,2)	0(0,2)	0(0,2)	0(0,0)	0(0,2)	0(0,2.5)	0(0,2)
Nissen组	46	2(0,3)	1(0,2)	0(0,2)	0(0,0)	0(0,2)	0(0,2)	0(0,2.5)
Z		-2.466	-2.674	-1.319	-1.287	-0.279	-1.027	-1.002
P		0.014	0.007	0.187	0.198	0.78	0.305	0.317

表4 2组患者术后症状比较[M(P25, P75)]

组别	例数	食管症状				食管外症状
组别	例数	反流	胃灼热	胸背痛	剑突下顶胀感	咳嗽	喘息	咽部异物感
Nissen+His角重建组	52	0(0,2)	0(0,2)	0(0,2)	0(0,0)	0(0,2)	0(0,2.5)	0(0,2)
Nissen组	46	2(0,3)	1(0,2)	0(0,2)	0(0,0)	0(0,2)	0(0,2)	0(0,2.5)
Z		-2.466	-2.674	-1.319	-1.287	-0.279	-1.027	-1.002
P		0.014	0.007	0.187	0.198	0.78	0.305	0.317

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Short-term efficacy of laparoscopic Nissen fundoplication combined with the reconstruction of His angle in the treatment of gastroesophageal reflux disease

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Short-term efficacy of laparoscopic Nissen fundoplication combined with the reconstruction of His angle in the treatment of gastroesophageal reflux disease