中国实用外科杂志

中国实用外科杂志

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胃食管反流的力学基础与外科治疗策略

陈    双，周太成，李英儒，曾    兵   

  1. 中山大学附属第六医院普通外科（疝和腹壁外科）    广东省结直肠盆底疾病研究重点实验室  广州市黄埔区中六生物医学创新研究院，广东广州  510655
  • 出版日期:2024-04-01

  • Online:2024-04-01

摘要： 食管裂孔疝（HH）和胃食管反流病（GERD）为临床多发病，手术是其治愈的重要方法。生理性反流与生物进化的“反刍”活动可能具一定的关联性，基因组学研究可能为以后在分子水平防治GERD提供靶点。在力学角度上，胸腹腔的压力差、食管下括约肌（LES）松弛尤其是暂时性LES松弛（tLESR）的过度发生等均是导致病理性反流发生的力学基础。LES、膈肌脚、LES与膈肌脚的空间位置以及胃食管阀瓣（GEV）是抗反流的重要屏障。从力学角度分析，HH为一种“轴向疝”，轴向移位破坏了正常的抗反流机制，在时间上疾病可由轻至重逐步发展。HH手术无法改变tLESR，目的在于改变结构，重建抗反流结构关系，即：通过游离延长食管下端及LES长度、胃底折叠形成的折叠圈及胃内的GEV、“向心化”缝合形成的膈肌脚与LES互相重叠结构（coincide），构成一个暴露在腹腔内的稳定的抗反流系统，最终实现改善功能、治愈疾病。

关键词: 食管裂孔疝, 胃食管反流病, 抗反流屏障, 力学, 外科策略

Abstract: The mechanical basis and surgical strategy for gastroesophageal reflux        CHEN Shuang, ZHOU Tai-Cheng, LI Ying-Ru, et al. Department of General Surgery（Hernia and Abdominal Wall Surgery）, the Sixth Affiliated Hospital, Sun Yat-sen University, & Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, & Guangzhou Zhongliu Biomedical Innovation Center, Guangzhou 510655, China
Corresponding author： CHEN Shuang, E-mail：chensh223@
mail.sysu.edu.cn
Abstract    Hiatal hernia（HH） and gastroesophageal reflux disease (GERD) are commonly encountered digestive system disorders in clinical practice. Anti-reflux surgery is a crucial method for their treatment. As a surgeon, the level of understanding of such diseases can significantly impact the efficacy of the surgical interventions. Physiological reflux has a certain correlation with biological evolutionary rumination, which may provide a target for the prevention and treatment of GERD at the molecular level in the future. The pressure difference in the thoracoabdominal cavity and relaxation of the lower esophageal sphincter, especially the excessive occurrence of transient sphincter relaxation (tLESR), underlie the dynamics of pathological reflux. The spatial position of the Lower esophageal sphincter (LES), Crural diaphragm (CD), and gastroesophageal valve (GEV) are important anti-reflux barriers. From the perspective of mechanics, this paper proposes that a hiatal hernia is an axial hernia, which destroys the normal anti-reflux barrier, and can gradually develop from mild to severe. The surgical strategy for hiatal hernia surgery is to reconstruct the anti-reflux structure: through the free extension of the lower end of the esophagus and the length of the LES, the folding circle outside and the gastroesophageal valve inside formed by the fundoplication, as well as the LES-CD formed by centripetal suture are in place at the same time to form a stable anti-reflux system exposed to the abdominal cavity to improve the function and cure the disease.

Key words: hiatal hernia（HH）, gastroesophageal reflux disease（GERD）, anti-reflux barrier, mechanics, surgical strategy