Nissen's fundoplication

At present, it is considered that gastroesophageal reflux disease (GERD) is a primary upper gastrointestinal motility disorder caused by multiple factors. Due to the dysfunction of the lower esophageal sphincter (LES), the contents of the stomach enter the esophagus, causing symptoms and esophageal mucosal lesions. The main performance within 1 year of age is milk or vomiting, generally 9 to 24 months improved. Childhood performance is similar to that of adults. The most common symptoms are acid reflux, hiccups, heartburn, chest pain, cough, asthma, nocturnal apnea and recurrent pneumonia, tracheal spasm, and pharyngitis. For a long time, GERD was not recognized and thus was not treated properly. In severe cases, dysphagia can occur and develop into Barrett's esophagus. Since the 1960s, there has been a new understanding of the etiology, pathology, and physiology of GERD. The pathological and physiological factors that cause GERD are considered to be: decreased esophageal acid clearance, decreased esophageal sphincter tension, and increased gastric acid levels. The esophageal epithelium has colonized Helicobacter pylori (HP). Among the many factors in the pathogenesis of GERD, the most important is the functional status of the lower esophageal sphincter. Studies have shown that the anatomical structure of the gastroesophageal junction is conducive to anti-reflux. The lower esophageal sphincter pressure and contraction of the diaphragmatic foot have antagonistic effects on gastroesophageal reflux. Advances in examination methods in recent years, such as: esophageal manometry, endoscopy, esophageal barium meal examination, gastroesophageal gamma photography and 24-hour continuous esophageal pH measurement, enable early diagnosis and treatment of GERD. The purpose of GERD treatment is to reduce the damage of the reflux to the esophageal tissue and enhance the anti-reflux defense mechanism of the esophagus. At present, GERD is mainly treated by internal medicine, and most of the sick children can be improved after systematic medical treatment. Only a small number of sick children need surgery. Nissen surgery has been in use since the 1960s and has been widely used until now. This method is to curl the fundus, around the abdomen esophagus and gastroesophageal junction, so as to replace the insufficiency of the lower esophageal sphincter to prevent reflux. The surgical satisfaction rate is over 90%. Through the bottom of the stomach, you can achieve the following purposes: 1. Increase the lower esophageal sphincter pressure. 2. The folded fundus acts as a flap, allowing only food to pass in one direction. 3. Increase the length of the intra-abdominal esophagus. 4. The fundus fold prevents the expansion of the bottom of the stomach. Treatment of diseases: reflux esophagitis Indication Nissen's fundoplication is suitable for: 1. Reflux esophagitis: gastroesophageal reflux is the main problem. Although the esophagus has different degrees of ulceration and even bleeding, the esophagus has no clear stenosis, or only mild stenosis. 2. Medical treatment failure: refers to adequate drug treatment can not alleviate reflux symptoms and comorbidities or patients can not tolerate drug treatment. Contraindications 1. Medical treatment is inadequate. 2. There is no objective evidence of gastroesophageal reflux. 3. Simple gastroesophageal reflux without comorbidities. 4. Important organ function cannot withstand upper abdominal surgery. 5. Giant esophageal hiatus or paralysis of the hiatus, or the esophagus has been severely narrowed and shortened. Preoperative preparation 1. Improve the nutritional status of patients, correct anemia, hypoproteinemia and so on. 2. Give diet therapy and acid-fast treatment to make esophageal inflammation relatively stable. 3. Control respiratory infections, and smokers stop smoking. Surgical procedure Transabdominal approach This approach is often used clinically. (1) Place the esophageal support tube: Before the endotracheal intubation, a thick tube (anal tube) or a Maloney dilatation probe of 46F to 50F is placed in the esophagus as an intraluminal support when the fundus is folded. (2) Incision: midline incision in the upper abdomen. (3) Free abdominal esophagus: After the laparotomy, the hepatic triangle ligament was cut, and the left lobe of the liver was pulled to the right to expose the esophageal hiatus. The peritoneum covered by the esophagogastric junction was cut from the anterior segment of the esophagus, and the mediastinum around the esophagus was bluntly separated by fingers, and the lower part of the esophagus was separated and the band was bypassed as traction. (4) Free gastric fundus: Lift the stomach bottom, fully free the stomach base, cut the upper part of the liver and stomach ligament on the small curved side, and cut off the left gastric artery if necessary. The spleen and stomach ligament was cut in the large curved side and 2 to 3 short gastric arteries were disconnected. Remove the adipose tissue from the cardia. (5) Stomach fold folding suture: the surgeon puts the right posterior wall on the posterior wall of the stomach, bypasses the free posterior wall of the fundus from the posterior part of the esophagus, and completes the wrapping of the gastroesophageal junction in front of the esophagus and the anterior wall of the stomach. Use the thin wire to make 4~6 needles for the intermittent muscle suture, and suspend some esophageal muscle layers in the middle of each suture to prevent the fundus from slipping off. The maximum length of the wrapped part should not exceed 3 to 5 cm. A few needles were sutured around the top of the fundus and the perforation hole to prevent the stomach from entering the mediastinum. 2. Transthoracic approach This approach is often used in the following situations: 1 history of upper abdominal surgery or history of failed antireflux surgery; 2 shortness after esophageal stricture; 3 chest internal conditions requiring thoracic treatment, such as esophageal ulcer, stenosis or sputum Diverticulum; 4 extremely obese, difficult to expose through the abdominal operation field; 5 surgical patients with lung disease at the same time. Surgical procedure (1) Incision: The seventh intercostal space was inserted into the chest through the posterior lateral incision of the left chest. (2) Free gastric fundus: Cut off the lower lung ligament and pull the left lung upward, free the lower part of the esophagus and pull the traction belt. The diaphragm is cut radially from the esophageal hiatus, and the phrenic nerve is protected. Treatment of short blood vessels in the stomach allows the stomach to fully dissipate. (3) Folding of the fundus: the stomach is lifted into the chest cavity, and the fundus is wrapped around the lower part of the esophagus. After the suture is completed, the wrapped part is fixed on the esophagus with a thin wire. If the hole is too large, the needle can be sutured at the foot of the diaphragm. Not tied. Try to put the folded part back into the abdominal cavity. If the tension is large, the part can be fixed on the diaphragm. Do not tighten the diaphragm when it is closed, otherwise it may cause difficulty in swallowing after surgery. Finally, the suture of the diaphragmatic foot is ligated. complication Dysphagia The main part is that the wrapping part is too tight or too long and can be removed by several expansions. Other reasons include the direct trauma of the intraoperative gastric and support tubes and the indirect trauma of the esophageal free in the operation, causing edema of the lower esophageal mucosa and esophageal stricture. It usually recovers in about 1 week. 2. Flatulence syndrome The clinical manifestations are bloating, difficulty in hernia or vomiting, which is about 10%. Generally, it can gradually heal itself, and if necessary, the stomach tube can be reduced. But there are also people who are difficult to heal, which seriously affects the quality of life. 3. Recurrence The recurrence rate is about 1%, mainly due to partial slippage or suture splitting, requiring surgery. 4. General complications of abdominal surgery Caused by accidental injury to hollow organs or parenchymal organs during surgery. 5. Pulmonary complications The incidence of pulmonary infection through the chest is higher, patients should be encouraged to drain their own sputum, if necessary, nasal catheter suction or fibrous bronchoscopy to absorb respiratory secretions.

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