The purpose of treating esophageal hiatal hernia is to prevent gastroesophageal reflux, promote esophageal emptying and reduce or reduce gastric acid secretion. Appropriate treatment should be selected according to the size of esophageal hiatus, pathological classification, whether it is complicated with gastroesophageal reflux and gastric volvulus, the priority of clinical symptoms, and whether there are symptoms. Asymptomatic patients generally do not need treatment. Most patients with symptoms can be relieved to varying degrees through medical treatment, and only a few patients need surgery.
1. Non-surgical treatment of infantile esophageal hiatal hernia and small esophageal hiatal hernia with mild symptoms can disappear or improve themselves during development, so conservative treatment can be the first choice.
(1) Diet adjustment: Infants can choose a sticky diet, pat their backs properly after meals, and let the gas in their stomachs be discharged; Adopt a low-fat and high-protein diet to increase the tension of lower esophageal sphincter and reduce reflux; Avoid irritating food, alcohol, cigarettes and coffee; Take a small amount of meals and make full use of the neutralization effect of saliva on gastric acid; Chew slowly and avoid full meals, especially before going to bed.
(2) Use gravity to prevent reflux: mostly use semi-sitting position, sitting position or upright position; It is not advisable to lie down immediately after meals and form the habit of taking a walk after meals; When sleeping, the height of the bedside mat is above 15 ~ 20 cm.
(3) Avoid factors that increase abdominal pressure, such as bending over, tightening the belt, constipation, vomiting and coughing. Fat people should lose weight.
(4) The application of gastric motility drugs, such as cisapride, domperidone and metoclopramide, can promote the peristalsis of stomach and esophagus, reduce reflux and promote the healing of esophagitis by increasing the tension of sphincter. Do not use anticholinergic drugs, so as not to reduce the pressure of lower esophageal sphincter, delay gastric emptying and promote gastroesophageal reflux.
(5) Treatment of esophagitis: Use H receptor antagonists or proton pump inhibitors (such as omeprazole, cimetidine, ranitidine, etc.) to treat mild and moderate esophagitis. ) It has good curative effect for 8 ~ 12 weeks in a row, and omeprazole (Losec) is better than cimetidine and ranitidine, which can make 80% ~ 85% patients with esophagitis recover or completely relieve symptoms. But it is ineffective for severe esophagitis. Antacids or drugs that neutralize gastric acid can be used appropriately.
(6) Monitoring: Barium meal fluoroscopy, esophagoscopy and 24-hour pH dynamic detection should be carried out regularly during non-surgical treatment. If non-surgical treatment is adopted, the pH value should be monitored for 24 hours.
2. Surgical treatment The purpose of the operation is to restore the lower esophagus and gastroesophageal junction to their normal position in the abdominal cavity and strengthen the lower esophageal sphincter. The main problems to be solved in the operation are: restoring the abdominal segment of esophagus to its normal position; Fixing esophagus and cardia; Blunt his angle; Repair and reduce the enlarged esophageal hiatus; Prevent backflow.
(1) Surgical indications: ① Congenital esophageal hiatal hernia with severe gastroesophageal reflux and frequent vomiting, resulting in insufficient nutrient intake, affecting growth and development, and ineffective after non-surgical treatment; ② Patients complicated with severe esophagitis, ulcer, hemorrhage or severe anemia, who were ineffective after medical treatment; ③ Severe esophageal stricture and ineffective dilatation; ④ Recurrent respiratory complications, such as laryngitis, pharyngitis and aspiration pneumonia; ⑤ Diaphragmatic hernia with gastric ulcer, gastrorrhagia and gastric perforation; ⑥ Paraesophageal hernia, mixed esophageal hiatus hernia or hernia sac is huge and incarcerated repeatedly, resulting in symptoms of cardiopulmonary compression; ⑦ Reflux esophagitis is malignant and cannot be excluded or covered by columnar epithelium; ⑧ In case of paraesophageal hernia incarceration, an emergency laparotomy will be performed if immediate gastric tube decompression is unsuccessful or symptoms are not improved.
(2) Traditional anti-reflux surgery: Traditional anti-reflux surgery mainly adopts open surgery or thoracotomy. Open surgery is mainly used for patients with extensive abdominal adhesion, and laparoscopic surgery is taboo. Commonly used anti-reflux operations include Nissen fundoplication, Belsey operation, Hill retrogastric fixation and so on. Nissen operation can be performed through abdomen or chest, mainly by wrapping the lower end of esophagus with the fundus of stomach for a week to prevent reflux. It is reported that the effective rate is 96%, which is considered as a better surgical method at present. Hill's operation is transabdominal posterior fixation, and the esophagogastric junction is narrow. The correct and effective rate is over 90%. Belsey fundoplication was performed by thoracotomy, and the recurrence rate reached 65438 05% in long-term follow-up. Some scholars think that its curative effect is not as good as Nissen fundoplication, and it is rarely used at present.
In addition, for many years, the method of encircling the abdominal esophagus with silicon prosthesis (Angelchik prosthesis) has been abandoned to narrow the lower esophagus slightly, increase the sphincter pressure and prevent hernia recurrence. Prosthesis displacement, esophageal compression and ulcer formation may occur.
① Thoracic approach surgery: the visual field is well exposed, but it is traumatic and has great influence on the heart and lungs. It is suitable for patients with obvious esophageal hiatus, severe adhesion, gastric volvulus and hernia into the right chest cavity, especially patients with short esophagus.
Methods: Through the 7th or 8th intercostal posterolateral incision in the left chest. After entering the chest cavity, the inferior pulmonary ligament was cut off to fully expose the mediastinum and pleura; Then cut the mediastinum and pleura to free the lower esophagus, open the hernia sac and remove the redundant cyst wall tissue; Fully expose the diaphragmatic feet on both sides, suture and fix 2 ~ 3 stitches behind the esophagus, and then fold and suture the gastric fundus to prevent reflux; Finally, the diaphragm and the edge of the esophagus were sutured to reconstruct the esophageal hiatus. The new hiatus can accommodate an adult's fingertip.
② Abdominal operation: This operation has the advantages of less trauma, quick recovery, simultaneous examination of abdominal organs to deal with digestive tract malformation, and convenient operation of pyloroplasty and fundoplication. It is suitable for young patients with esophageal hiatal hernia.
Methods: The median incision of left upper abdomen or transverse incision of left upper abdomen was adopted. After entering the abdomen, the left triangular ligament of the liver was cut off to fully expose the esophageal hiatus; Then cut off the loose diaphragmatic esophageal ligament, open the hernia sac, and free the esophagus, so that the cardia and gastric fundus herniated into the thoracic cavity can be restored to normal position, and the redundant hernia sac can be taken out; Suture the left and right diaphragm angles to repair esophageal hiatus, and finally perform gastric fundus folding and pyloroplasty according to the specific situation.
(3) Laparoscopic repair of esophageal hiatal hernia and fundoplication: There are more and more reports on laparoscopic surgery for this disease, which is welcomed by clinic because of its advantages of less surgical injury and quick recovery after operation. Laparoscopic esophageal hiatal hernia repair and gastric fundus folding anti-reflux surgery are common laparoscopic operations in the United States and Europe except laparoscopic cholecystectomy, but those with a history of upper abdominal surgery should be regarded as relative contraindications.
① Laparoscopic repair of esophageal hiatal hernia:
A contraindications for laparoscopic surgery: those who can't tolerate general anesthesia or surgery, including those with severe center of gravity, pulmonary dysfunction and recent myocardial infarction or coagulation dysfunction that are difficult to correct; History of upper abdominal surgery (relative contraindication).
B. preoperative preparation: a. determine the situation of gastroesophageal reflux and its complications, such as esophagography, gastroscopy, esophageal manometry, 24-hour esophageal pH monitoring, etc. B. First of all, make a correct assessment of cardiopulmonary function, such as electrocardiogram examination and chest X-ray, and check cardiopulmonary function. C. Treating other diseases, such as treating lung infection, correcting cardiac, pulmonary and renal insufficiency and anemia, etc. Surgery should be performed after cardiopulmonary function is improved. D Most patients with esophageal hiatal hernia are malnourished and weak, so nutritional support should be strengthened before operation. Because esophageal or gastric perforation may occur during esophageal hiatal hernia operation, antibiotics should be used preventively before operation. F. Eat liquid diet and enema before operation. G. insert gastric tube and catheter before operation.
In recent years, western countries attach great importance to the prevention of deep venous thrombosis, such as giving low molecular weight heparin before operation and using intermittent pressurized air bags in lower limbs during operation.
C. Body position and anesthesia: the patient took the improved lithotomy position, looked up 10 ~ 30, and was anesthetized by tracheal intubation.
D. Preparation of special instruments: 3-4 sets of 10mm casing, 2 sets of 5mm casing, 1 set 12mm casing (unnecessary); Liver retractor; 10mm nondestructive grasping forceps; Ultrasonic knife; 2 needle holders; Intraluminal suture device or suture device (optional); Artificial grid (optional); Esophageal dilator.
E. surgical position: the surgeon is located between the legs of the patient, but he can also stand on the side of the patient.
F. surgical steps:
A. establish pneumoperitoneum.
B. Casing placement: 5 5 ~ 10 mm casings are usually used. The laparoscopic cannula was placed under the xiphoid process 12cm, and the left side was 2cm. The second cannula is located under the left costal margin, with a distance of 0/0 cm from xiphoid process/kloc-.It is the main surgical hole and can be used for placing separation forceps and ultrasonic scalpel. The cannula for placing the liver retractor was placed under the right costal margin, 65438±05cm away from the xiphoid process. The fourth sleeve is placed in the right upper abdomen, corresponding to the position of the second sleeve, and serves as an auxiliary operation hole; Finally, place the 1 sleeve under the left rib, about 7cm away from the second sleeve, and place the 10mm nondestructive grasping forceps.
C. Exploration, reduction of herniated organs and treatment of hernial sac: The assistant operates on the right side of the patient, and pulls the left lateral lobe of the liver with a liver multi-leaf retractor to expose the esophageal hiatus through the xiphoid process diameter. Pay attention to the appropriate force to avoid damage to the liver, generally do not cut off the left triangular ligament of the liver; Another assistant on the left side of the patient held the fundus of the stomach with non-invasive grasping forceps and pulled it to the lower left side of the patient to help expose the annular defect at the enlarged esophageal hiatus, showing different degrees of fundus hernia, omentum hernia and even small intestinal hernia. The surgeon holds the non-invasive grasping forceps in his left hand and right hand, and gradually shrinks the protruding gastric fundus into the abdominal cavity by alternately grasping and pulling with both hands. Circumcision of hernia sac starts from the edge of hernia sac, and hernia sac incision can start from the hiatus in front of esophagus or stomach.
D. Repair of enlarged esophageal hiatus: To prevent dysphagia after suture and repair of esophageal hiatus, an esophageal dilator with appropriate size should be inserted into the esophagus with the assistance of an anesthesiologist before suture and repair. There are two ways to repair esophageal hiatus:
Methods 1, artificial patch repair esophageal hiatus defect: suitable for giant esophageal hiatus hernia. The edge of mesh should cover the edge of hernia ring more than 2cm, and the suture method should be stapler or needle holder (using non-absorbent suture). Artificial patch repair has the advantage of tension-free repair of esophageal hiatus, but long-term contact and friction between patch and esophageal or gastric wall may lead to local ulceration of esophageal or gastric wall.
Method 2: direct suture to repair esophageal hiatus: suture with needle, and internal and external knotting method can be used. Generally, 2 ~ 6 stitches are sutured directly under the esophagus with non-absorbable thread (No.0 polyester thread or silk thread) to close the diaphragm feet on both sides. It is more convenient to use a laparoscopic stapler if possible.
② Laparoscopic fundoplication anti-reflux surgery: Most patients need to add fundoplication anti-reflux surgery to prevent hernia recurrence and gastroesophageal reflux disease.
A preoperative preparation, surgical instruments, surgical position, pneumoperitoneum establishment and intubation position: the same as laparoscopic esophageal hiatal hernia repair.
B. Treat the hernia sac and reset the herniated organ: Usually, after the hernia sac is taken out, the herniated organ can be completely reset. Incision of hernia sac can start from the hiatus in front of esophagus or stomach, and then separate from the left side to the right side, so that the hernia sac is gradually separated from the hiatus arch and mediastinum. For reducible hernia, when the hernia sac is separated near the gastroesophageal junction, the short gastric vessels are usually prolonged without separation. The hepatogastric ligament was cut under the caudate lobe of the liver to expose the omental sac. For larger paraesophageal hernia, the omental sac can extend to the mediastinum. The extension of the omental sac in mediastinum is often restricted by the anterior hepatogastric ligament, gastric hernia and gastrosplenic ligament. Dealing with the omental sac of hernia into mediastinum is often the key to the reduction of paraesophageal hernia. After entering the omental sac from the hepatogastric ligament, the peritoneum is identified in the posterior layer of the omental sac, which covers the left and right feet of the posterior esophagus and the right diaphragm. Further separation to the back and side of the omental sac, and downward separation of the uppermost part of the omentum (herniated into the mediastinum together with the hernia sac in the case of type ⅲ esophageal hiatus hernia) and the hernia sac can reset the omental sac and free the back of the esophagus and the herniated stomach at the same time. After the whole hernia sac and stomach were released, the herniated gastric fundus was gradually reduced to the abdominal cavity with noninvasive grasping forceps. Remove the hernia sac and take it out of the 12mm cannula.
C. Free proximal stomach: It is difficult to separate the left side along the left diaphragm foot due to the obstruction of the gastric fundus and its ligaments. It is necessary to cut off the gastrosplenic ligament first, free the proximal gastric greater curvature side, and make the gastric fundus separate from the diaphragm. The method of cutting short gastric vessels: put two titanium clips at both ends, then cut them off with ultrasonic knife or directly, and cut off and free the small curved side of the proximal stomach. Some doctors don't advocate cutting off the short gastric vessels and freeing the proximal stomach, but most doctors emphasize fully freeing the proximal stomach.
D. Free the lower esophagus: firstly, disconnect the diaphragmatic esophageal ligament and the hepatogastric ligament with an electrocoagulation hook or an ultrasonic scalpel, and free and expose the lower esophagus, cardia, bilateral diaphragmatic feet and gastric fundus, and further separate the posterior wall downward along the bilateral diaphragmatic feet to completely free the esophagus. Traction gastroesophageal junction to determine the length of esophagus. If the esophagus is not long enough, it can be free to the proximal end about 10cm. If the esophagus is still insufficient, esophageal lengthening should be performed. Vagal nerve injury should be avoided when the lower esophagus is free.
E. Repair of esophageal hiatus: Sew PTFE patch on both diaphragmatic feet with non-absorbent suture to repair esophageal hiatus on the back of esophagus, and the distance from the last suture to the back wall of esophagus should be lcm (see laparoscopic hernia repair of esophageal hiatus). For giant hiatal hernia, several stitches are needed in front of the esophagus.
F fundoplication: fundoplication can fix fundoplication and prevent postoperative gastroesophageal reflux.
A. Nissen operation: two non-invasive grasping forceps are used to clamp the gastric wall tissue at the edge of the great curvature of the fundus, and part of the gastric wall at one side of the great curvature of the fundus is pulled to the right side of the esophagus through the back of the esophagus; Inserting an esophageal dilator or a large gastric tube into the stomach; 2 ~ 3 stitches were sutured intermittently at the lower end and front end of esophagus with No.0 non-absorbable thread to complete the gastric fundus with a width of about 2cm. 0? Folding the package, the suture thread passes through the seromuscular layer of the stomach wall and is fixed on the front wall of the lower end of the esophagus.
B.Toupet operation: suture and fix the gastric fundus on both sides of esophagus to the corresponding front wall on both sides of esophagus, and suture and fix the gastric fundus on both sides of diaphragm foot. It is suitable for patients with obvious esophageal motor dysfunction.
G. After the operation, pull out the esophageal dilator, rinse the abdominal cavity with warm normal saline, pull out the cannula and close the incision. Drainage tubes are generally not placed.
③ Postoperative complications: Laparoscopic anti-reflux surgery has a history of 10 years abroad, and the curative effect is exact, but a few patients may also have complications.
A. Intraoperative complications: The most common intraoperative complications reported in the literature are gastroesophageal perforation, hemorrhage (mostly caused by left lateral lobe tear of liver) and pleural tear. Most gastric and esophageal perforations can be repaired by laparoscopy. If laparoscopic repair is difficult, it will be converted to open surgery. The perforation found during the operation will not have serious consequences after repair. Delayed perforation often requires reoperation, which prolongs the hospitalization time. If you accidentally enter the chest cavity during the operation, the residual gas in the chest cavity needs to be released after the operation and before taking out the cannula, and the anesthesiologist will fully inflate the lungs.
B postoperative complications: it is reported that the incidence of complications after laparoscopic repair of esophageal hiatal hernia is 10% ~ 37%. However, compared with open surgery, patients seem to have higher tolerance to laparoscopic surgery and the incidence of serious complications is lower than open surgery. Pneumothorax, mediastinal emphysema and subcutaneous emphysema may occur in the near future after operation, dysphagia and hernia recurrence may occur, and reoperation is needed when non-surgical treatment fails. In addition, elderly patients with paraesophageal hernia are often accompanied by other diseases, and complications such as atelectasis, deep vein thrombosis, pulmonary embolism and myocardial infarction often occur after laparoscopic repair.
④ Postoperative treatment:
Most patients can be sent back to the ward after staying in the recovery room for a few hours. It is suggested that the patient take a flat chest film during the recovery room to check whether there is pneumothorax. A small amount of pneumothorax after repair of esophageal hiatal hernia is not uncommon, but CO2 is easily absorbed, and most of them do not need closed thoracic drainage. Closed thoracic drainage should be considered when patients feel respiratory distress. Chest radiographs often show pneumomediastinum and subcutaneous emphysema, which are absorbed quickly and have little significance.
B. indwelling gastric tube until morning after operation. Before extubation of gastric tube, gastroesophageal radiography was performed with water-soluble contrast agent to check whether there was gastroesophageal fistula and show the repair site. If there is no leakage, after the gastric tube is removed, if there is no abdominal distension or nausea, clean flow can be started, but then full flow and semi-flow can be gradually introduced until ordinary food is eaten. If the esophageal and gastric tears need to be repaired during the operation, it is necessary to postpone the time of pulling out the gastric tube and resuming the diet.
(4) Repair of ligament flap: Using patients' own tissues or artificial materials to restore and fix esophageal hiatal hernia under diaphragm has been rarely used because of poor curative effect.
① Fixation of greater omentum flap: Take out a long omentum flap with vascular pedicle from the left part of greater omentum, and form a collar around the junction of esophagus and stomach, so that the abdominal segment of esophagus can be pulled back to abdominal cavity for fixation.
② Ligamentum teres hepatis flap fixation: Free the umbilical region to the peritoneum 3cm wide in xiphoid level, and sew the ligamentum teres hepatis and falcate ligament flap on the inside of the stomach floor to cover the abdominal segment of esophagus.
(5) Anceiclick anti-reflux ring: In order to prevent gastroesophageal reflux, a silicone ring can be used to cover the cardia with a prosthesis. Its function is to buffer the rising pressure in the stomach, but its long-term effect is poor, and most people do not advocate its application.
Surgical indications: esophagitis grade ⅲ ~ ⅳ and high-risk patients; Gastric fundoplication failed and corrective surgery was performed. Operation: 3cm behind cardia and esophagus, carefully protect the external branch of vagus nerve. Expose the hiatus and restore the hernia without releasing the fundus of the stomach. Cover the cardia with silica gel ring and tie the ring in front. Check the tightness with your fingers. Generally, it can be accommodated with one index finger, and no additional suture is needed. If the postoperative symptoms recur and the silicone ring shifts, the erosion should be corrected again. The anti-reflux ring must be removed and the defect covered with improved fundoplication.
(6) Paraesophageal hernia repair can exist for many years, and patients only have symptoms such as epigastric discomfort, nausea and mild dyspnea after meals. However, because it is caused by anatomical defects, it is difficult to cure with drugs, and because it may cause many life-threatening complications, even if there are no typical symptoms, it must be repaired by surgery. Once the patient has symptoms such as jaw necrosis, massive hemorrhage and gastrointestinal organ obstruction, emergency surgery is needed.
A. Treatment principle and choice of surgical approach: The surgical treatment principle of esophageal hernia is the same as that of general hernia repair, that is, the herniated contents are restored to the abdominal cavity, fixed at the opening of the enlarged hiatus in the abdomen (abdominal wall or diaphragm), and the hernia sac is removed if necessary. The treatment of mixed hiatal hernia, such as gastroesophageal reflux, should be based on the specific situation of sliding hiatal hernia after esophageal hernia repair, and some anti-reflux operations should be taken. Only in the case of paraesophageal hernia, the lower esophageal sphincter fixed to the posterior mediastinum and diaphragm is normal and should not be free. Otherwise, there will be a sliding hernia after operation.
Paraesophageal hernia can be repaired by abdominal or thoracic methods. Abdominal approach can provide more adequate exposure, better examine the organs reintegrated into the abdominal cavity, fix them in the abdominal cavity and suture the enlarged hiatus, and can also deal with complicated diseases, such as duodenal ulcer and gallstones. The structure of cardia can be examined in detail through abdominal approach. If the lower esophagus is located under the diaphragm and still firmly fixed to the posterior mediastinum, it can be determined that this is a paraesophageal hernia, not a mixed hiatal hernia. If it is a huge paraesophageal hernia, it is estimated that it is a serious adhesion to internal organs in the chest and complicated with short esophagus, so the transthoracic approach should be chosen. In order to avoid postoperative hernia recurrence or serous cyst formation in the chest, the hernia sac should be removed as much as possible.
B. Preoperative preparation: Preoperative preparation includes application of antibiotics, maintenance of water-electrolyte balance and nutritional support. Preoperative indwelling nasogastric tube. 18 should be inserted for continuous suction. Because part or all of the stomach has herniated into the abdominal cavity and the cardia is angled, it is often difficult to decompress the gastrointestinal tract before operation, so it is necessary to prevent aspiration during anesthesia induction.
C, surgery; The patient was lying on his back or right side, and the operation was performed under general anesthesia, using the median incision of upper abdomen or the seventh intercostal incision on the left side.
① Hernia reduction and hiatus repair; For example, through the thoracic approach, after entering the chest cavity, do a detailed exploration to see if there is inflammatory effusion and adhesion in the chest cavity, and whether there is perforation or necrosis in the internal organs of hernia. The chest must be closely protected from pollution. After hernia sac incision, it can be distinguished whether the contents of hernia are stomach, colon, spleen, omentum or small intestine. If it is the stomach, it is necessary to recognize its rotating or tumbling shape and carefully reset the protruding organs to the abdomen. If there is any difficulty, puncture the stomach contents first, or perform decompression gastrostomy. It can be fixed on the front wall at the end of the operation, which can not only fix the stomach, but also replace the postoperative malocclusion or colic of gastrointestinal organs (stomach), causing ulcers and adhesions. We should separate and enlarge the hernia ring more carefully. Before the internal organs of hernia are reset, it is necessary to carefully check whether the organs are damaged, and if necessary, do resection, anastomosis or repair. For gastric ulcer, if there is no history of ulcer in the past, gastroscopy and biopsy should be considered during operation to rule out malignant transformation.
After the hernia is reset, take out the residual hernia sac, sew it as low as possible, send it to the abdomen, and sew it on the edge of the hiatus. After the hole edge is free, suture the enlarged hole with intermittent unattractive suture (with gasket). The examination can be done with the index finger.
If anti-reflux surgery is needed at the same time, Belsey operation or Nissen hernia repair can be performed after hernia reduction and hernia sac treatment; If the abdominal approach is adopted, Hill's retrogastric fixation or Nissen hernia repair is performed.
② Gastric immobilization: Nissen gastric immobilization is to repair paraesophageal hernia (the content of hernia is stomach) by abdominal route. After the contents of hernia were reduced by abdominal approach, the hiatus was sutured with 3 ~ 4 intermittent sutures at the anterolateral edge of the hiatus, and the gastric fundus was fixed on the lateral part of diaphragm to cover the suture part of the hiatus. Then the anterior rib wall is sutured to the anterior abdominal wall along the longitudinal axis of the stomach to prevent the cardia from sliding and the stomach from rotating.
Postoperative treatment: special attention should be paid to avoid vomiting in the early postoperative period. Therefore, in order to keep the gastrointestinal decompression tube or gastrostomy tube unobstructed and avoid giving morphine, it is suggested to give trifluoperazine 10mg every 6 hours for 24 hours. All these patients had stomach weakness after operation and needed gastrointestinal decompression for 65438 0 weeks. When intestinal peristalsis and ventilation are restored, tea, broth, jelly ice cream, water and ginger steam can be given to cool Zhanjiang or? Carbon dioxide drinks. After a week, gradually transition to soft food.
(7) Surgical treatment of digestive stricture of esophagus Severe stricture of esophagogastric junction can be caused by primary reflux disease or partial local acid products of lower esophagus. In the latter case, the lower esophageal sphincter is intact, such as Barrett syndrome.
The treatment of peptic stenosis includes preoperative or postoperative esophageal stenosis and dilatation, followed by anti-reflux surgery. If the reflux is caused by gastric emptying disorder, gastrectomy, vagotomy or pyloroplasty should be considered. When a few cases of esophageal shortening have serious lesions and it is difficult to recover the abdominal part of esophagus, supradiaphragmatic fundoplication or esophageal Collis gastric tube lengthening should be done, so that fundoplication or partial fundoplication can be completed under the diaphragm. Cases of severe peptic stenosis in the lower esophagus are difficult to expand or seriously damaged. In order to prevent Barrett's esophageal cancer from becoming cancerous, we can consider removing the narrow segment and anastomosing jejunum or colon to restore the passage. The cases of reflux esophagitis caused by hiatal hernia, which leads to lower esophageal stenosis, can be solved if the treatment of posterior gastric fixation or fundoplication can be extended. Simple dilatation can only relieve dysphagia, but corrosive gastric juice can easily flow back to esophagus after dilatation, which makes the symptoms of esophagitis recur. Therefore, hernia repair and anti-reflux surgery must be done after expansion.
A, Collis gastroplasty: This operation is suitable for the following situations: cases of peptic lower esophageal stenosis with short and concealed esophagus, and it is difficult to fold the gastric fundus and abdominal esophagus through abdominal approach; Cases with high surgical risk and surgeons lacking experience in replacing esophagus with colon or jejunum.
The patient was lying on the right side, and under general anesthesia, thoracoabdominal incision was made through the left 7th or 8th costal bed. Free the esophagus as far as possible to the level of aortic arch and cover it with esophageal band. If the stomach can be incorporated into the abdominal cavity, the operation should be completed after Belsey or Nissen hernia repair. If you can't put the stomach back into the abdominal cavity, you should insert a big stomach tube when the stomach passes through the esophagus, and the tube should fall to the side of the small bend as a sign. Gastrointestinal stapler will be used to cut off and sew the esophagus and the stomach bottom next to the stomach tube to form a 5 cm long stomach tube and prolong the esophagus. If necessary, you can use the stapler for the second time and extend it by 3cm again. Check the suture edge in detail to stop bleeding. Methylene blue solution can be injected through the stomach tube to check whether the esophagus and the fundus of the stomach are tight without leakage. The newly formed distal esophagus folds around the fundus of the stomach and is sent to the abdominal cavity. Expose the diaphragmatic foot and the arch ligament, and fix the gastric minor bend suture on the arch ligament at the level of the newly formed Hiss angle. Suture the hiatus in front of the esophagus through the diaphragm foot, so that it can easily pass through the index finger.
B Thal patch and Nissen fundoplication: In the case of peptic stricture with hard annular scar, hernia repair after tension expansion can also lead to the recurrence of stricture. For these patients, the patch technique can be used to cut the narrow segment longitudinally, and the gastric fundus can be used as a graft to fill the cut defect with serosa facing the esophageal cavity. Generally, within 3 weeks, the serosal surface will be covered by a scaly upper piece, or a free skin piece can be attached to the serosal surface, which can accelerate healing, reduce contracture and prevent the recurrence of stenosis. That patch technique can't prevent gastroesophageal reflux, and fundoplication must be done. After the above comprehensive surgery, 85% of the patients can be cured for a long time.
(8) Surgical effect: Most cases treated by surgery can achieve the goal of complete remission of symptoms. A few cases may have early reflux. Whether the patient has symptoms or not, early postoperative reflux indicates that the operation failed. The failure of operation includes: ① Postoperative examination found that esophageal hiatal hernia still exists or gastroesophageal reflux was found, but it was asymptomatic; ② Symptomatic gastroesophageal reflux occurred after operation; ③ Non-reflux symptoms caused by surgical technique failure. According to some data, about 50% of failed cases can be found before discharge, and those who recur within 1 year after operation can account for 75% of all recurrent cases. Therefore, early follow-up should be strengthened after operation. Generally speaking, for failed patients, if reflux has no clinical symptoms, only long-term follow-up is needed; If it is symptomatic gastroesophageal reflux, non-surgical treatment should be taken first, and reoperation can be considered if it fails.
(2) Prognosis
Some children with mild esophageal hiatal hernia and small esophageal hiatal hernia can improve or disappear their symptoms and signs after non-surgical treatment. According to most scholars, the complete remission rate of patients treated by surgery can reach 80% ~ 90%, the recurrence rate is about 10%, and only 5% of them are completely ineffective. There are also a few reports that the complete remission rate of symptoms is only 47%, and the symptoms of other cases have improved to varying degrees. In the cases with remission of clinical symptoms, the histological changes of esophagitis can be improved by 65%, and about 20% patients did not show corresponding improvement in reflux test.