胃食管反流病：治疗胃食管反流病的术后管理（图文演示）

GASTROESOPHAGEAL REFLUX DISEASE: POSTOPERATIVE MANAGEMENT OF ANTI-REFLUX SURGERY

J Marescaux , MD , FRCS , European Institute of Tele-Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France


中文版：胃食管反流病：治疗胃食管反流病的术后管理（中文图文演示）

1. Postoperative pain management
Goals:
treat the pain before its onset;
avoid nausea and vomiting (additional source of pain and potentially detrimental to the surgical repair)
-> use of Droperidol (Inapsine®) at anti-emetic dosage

Note: Doses are standardized for a healthy 70 kg patient (when not specified as dose/kg).

An analgesic ketamine dose (0.5 mg/kg, KETALAR®) is injected during the anesthesiologic induction in order to antagonize the NMDA receptors. (NOTE: there is no effect on the patient’s level of consciousness at these doses).
Excellent curarization and analgesia during the operative procedure. Injection of 1 mg of Droperidol (DROLEPTAN®).
Non-opioid analgesics used about 30 min. before the end of the anesthesia:
NSAID (e.g. Ketoprofen, 50 to 100 mg) (there are no side effects at these doses, notably on hemostasis);
1 g of paracetamol per rectum or 2 g of paracetamol PO.
Tramadol hydrochloride administered (postoperative pain, 100 mg initially then 50 mg every 10-20 min. if necessary during first hour to total maximum 250 mg (including initial dose) in first hour, then 50-100 mg every 4-6 hours; maximum 600 mg daily) with 0.5 mg of Droperidol for every 100 mg of Tramadol hydrochloride to prevent nausea
For breakthrough pain, morphine titration (2 to 3 mg IV morphine every 5 to 10 min. until the visual analogue scale for the assessment of pain <= 3 is reached) in the recovery room:
to anticipate nausea/vomiting, Droperidol is given with morphine (0.5 mg of Droperidol for 10 mg of morphine),
the Patient Controlled Analgesia (PCA) is rarely used: if it is, Droperidol is associated with morphine in the PCA reservoir at the dosage indicated above.
As soon as liquid intake is resumed and if no nausea or vomiting occur, soluble paracetamol is administered: 1 g every 4-6 hours.
Continue regular NSAIDs (eg, Ketoprofen 50 mg every 8 hours orally).

This analgesic protocol has proven to be effective in our services.
Effective relief of postoperative shoulder pain has not yet been found (currently under study).

2. Early complications

                               
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Non-specific morbidity varies between 12% and 16% (parietal or pulmonary complications or thrombo-embolism).
Postoperative mortality in total fundoplication is insignificant, often nonexistent in the series.

Table 2 (Siewert and Stein, 1996)

Author (year) No. of fundoplications Morbidity Mortality DeMeester et al. (1985) 100 13% 0% Shirazi et al. (1987) 150 15% 0% Mc Intyre et al. (1990) 117 14% 0% O’Hanrahan (1990) 125 - 0% Grande et al. (1994) 160 16% 2% Peracchia et al. (1994) 102 - 0% Munich TU (1996) 173 12% 0%

Only series with more than 100 procedures and long-term follow-up are included.


2.1. Intrathoracic migration

• Frequency:
  

About 10%

• When to suspect it:
  

In case of violent chest pain, efforts to vomit, and food intolerance.

• Mechanism:
  
  • Deficient crural approximation;
  • Undiagnosed left pneumothorax;
  • Large peri-esophageal and mediastinal dissections.
    
• What to do:
  
  • Establish diagnosis with a chest X-ray illustrating the intrathoracic migration,
  • Re-operate urgently to bring the fundoplication back into the abdomen, suture the crura, and fix the fundoplication to the crura.
    
  
  
  

2.2. Dysphagia

• Frequency:
  

Transient early dysphagia occurs in 40% to 70% of the patients.

• Mechanism:
  

It is probably caused by the postoperative edema located at the gastroesophageal junction or by transitory motor control problems.

• What to do:
  
  • Monitor,
  • before the operation inform the patient of the need to adapt diet.
    
  
  

2.3. Gastric denervation syndrome

• Symptoms of gastric denervation:
  

Abdominal fullness, delayed gastric emptying, diarrhea

• Mechanism:
  

It probably results from vagus nerve injury.

• What to do:
  

Prevention: identification and isolation of both nerves during the operation.

3. Failures

                               
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Total fundoplications performed by skilled surgeons cure GERD symptoms in 85% to 95% of patients after a 20-year follow-up.
Failure of the fundoplication is characterized by:

• persistent side effects hampering the quality of life (dysphagia (a), gas bloat syndrome (b), diarrhea (c): 4% to 15%),
• persistence or recurrence of GERD symptoms.
  

Table 3: Success rate of laparoscopic fundoplications (long-term follow-up).

Author (year) No. of fundoplications Success rate (reflux control) Long-term side effects DeMeester et al.(1985) 100 91% 13% Shirazi et al. (1987) 150 95% 4.6% Mc Intyre et al.(1990) 117 86% 12.8% O’Hanrahan (1990) 125 90% 15.2% Grande et al. (1994) 160 92% 9% Peracchia et al.(1994) 102 90% 7% Munich TU (1996) 173 91% 8%

Only series with more than 100 procedures and long-term follow-up are included.
3.1. Persistent dysphagia
3.1.1. Failures: persistent dysphagia

• Frequency:
  

The incidence of dysphagia varies from 3% to 12% for a 6 to 30 month postoperative follow-up period.

Table 3.1.1: Results of laparoscopic fundoplications (short term follow-up).

Author/Year Follow-up (months) Dysphagia (%) Halleback (1994) (3-9) 7% Hinder (1994) 12 6% Pitcher (1994) 7.7 7% Swanstrom (1994) 13 5% Anvari (1995) 6 4.7% Dallemagne (1995) 16.2 12% Fontaumard (1995) 6.2 7.4% Patti (1995) 12 7% Gotley (1996) 12 9% Hunter (1996) 17 3% Legrand (1996) 23 6.3% Watson (1996) 12 11% Wu (1996) 17 4% Coster (1997) 22 6%

3.1.2. Failures: persistent dysphagia

• Mechanism:
  

Peptic stenosis (pre-existing)

• What to do:
  

Dilatation

3.1.3. Failures: persistent dysphagia

• Mechanism:
  

Fundoplication that is too long

• What to do:
  
  • begin with an endoscopic dilatation, effective in more than 50% of cases,
  • in case of failure after 3 dilatations, re-operate.
    
  
  

Re-operation for dysphagia requires a flexible strategy, depending on whether the cause is a tight fundoplication or a tight esophageal hiatus.
Once the hiatus is exposed, and a space dissected anteriorly between the esophagus and the hiatus, a large (52 French) bougie is passed through the gastroesophageal junction.
If there is a resistance, or the hiatus is tight around the bougie, and an instrument cannot be insinuated between the esophagus and the hiatus, then a tight hiatus is a likely etiology. This is readily fixed by dividing the hiatus anteriorly to create more space around the esophagus.
If the hiatus is patent, then the fundoplication can be divided along wrap sutures (using an endoscopic stapler): the 2 pieces of stomach are allowed to fall back, and are then re-sutured as a posterior partial fundoplication.


3.1.4. Failures: persistent dysphagia

• Mechanism:
  

Fundoplication that is too tight

• What to do:
  
  • begin with an endoscopic dilatation, effective in more than 50% of cases,
  • in case of failure after 3 dilatations, re-operate.
    
  
  

3.1.5. Failures: persistent dysphagia

• Mechanism:
  

Tight esophageal hiatus

• What to do:
  
  • begin with an endoscopic dilatation, effective in more than 50% of cases,
  • in case of failure after 3 dilatations, re-operate.
    
  

3.1.6. Failures: persistent dysphagia

• Mechanism:
  

Slipped Nissen

• What to do:
  
  • dilatation is less effective,
  • re-operate (more extensive dissection of the esophagus, creation of a floppy Nissen)
    
  

3.1.7. Failures: persistent dysphagia

• Mechanism:
  

Partial or total shifting of the fundoplication toward the mediastinum

• What to do:
  

Re-operate (same procedure as for early paraesophageal hernia)
3.1.8. Failures: persistent dysphagia

• Mechanism:
  

Unrecognized achalasia

• What to do:
  
  • dilatation,
  • in case of failure: Heller myotomy
    
  

3.2. Gas bloat syndrome
3.2.1. Failures: gas bloat syndrome
Woodward et al. described in 1971 the concept of the gas bloat syndrome as abdominal discomfort reported by certain patients after anti-reflux surgery.
This syndrome combines bloating, a feeling of gastric fullness, early satiation, increase in abdominal distention and gas.
These symptoms are usually harmless. They may sometimes be incapacitating, however, and make the patient regret having undergone anti-reflux surgery.
Its frequency is estimated between 1% and 28%.

Table 3.2.1: Results of laparoscopic fundoplications (short term follow-up).

Author/Year Patients Follow-up (months) Gas bloat syndrome Halleback (1994) 41 (68%) (3-9) 28% Hinder (1994) 100 (50%) 12 13% Pitcher (1994) 70 (100%) 7.7 1% Swanstrom (1994) 82 (100%) 13 4% Anvari (1995) 85 (50%) 6 2.4% Dallemagne (1995) 126 (34%) 16.2 4.8% Fontaumard (1995) 117 (79%) 6.2 2% Patti, (1995) 68 (100%) 12 4% Hunter (1996) 126 (42%) 17 7% Legrand (1996) 301 (97%) 23 6.9% Wu (1996) 103 (98%) 17 25%

3.3. Diarrhea
3.3.1. Failures: diarrhea

• Frequency:
  

Occurs in 1% to 7% of patients.

• Mechanism:
  

Diarrhea may be caused by nervous vagus trauma or may be related to an acceleration in gastric emptying following fundoplication.
It generally occurs after eating, and can resemble a dumping syndrome.

• What to do:
  

In general, patients do not consider this symptom incapacitating.
No treatment is necessary.

4. Persistence of symptoms

                               
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These failures are rare.
Heartburn disappears in 99% of patients after 4 weeks and in over 90% of patients after a 2-year follow-up period. When GERD becomes pathological again, its recurrence is often linked to a deterioration or disappearance of the fundoplication. Two therapeutic attitudes may be justified:

• resuming long-term PPI medical treatment,
• repeat surgery, although this represents a major challenge due to the complexity of the procedures.
  

For repeat surgery, the esophageal hiatus can be approached from either the thorax or the abdomen.
Theoretically, we would advocate the approach that was not previously utilized. In practice, however, surgeons tend to use the approach with which they are the most familiar keeping in mind that flexibility is needed in the choice of a repeat procedure.

New total fundoplication remains the preferred procedure (Rieger, N.A. et al. Br J Surg 1994;81:1159-6).
Antrectomy with Roux-en-Y reconstruction is reserved for cases in which repeat fundoplication proves impossible, or when it is a patient's third or subsequent operative procedure.