胃食道逆流症に対する腹腔鏡下Nissen噴門形成術における食道直接固定の重要性に関する検討

【Background】 For the neurologically impaired（NI）patients with gastro-esophageal reflux disease（GERD） who underwent laparoscopic Nissen fundoplication, the direct suture between the esophagus and diaphragmatic crus（esophagus direct suture）was changed from one to three stiches in order to prevent the postoperative recurrence due to wrap herniation. Therefore, the postoperative outcome was evaluated before and after this change retrospectively.
【Methods】 Seventy-two NI patients（ ５３ boys and １９ girls, mean age９１. years old）with GERD performed laparoscopic Nissen fundoplication from ２００５ to ２０１２ were enrolled in this study. Surgical procedure was laparoscopic Nissen fundoplication for all patients and additional gastrostomy at the same time for６８cases（９４％）. Patients were divided into the following two groups : early period group（n＝２７）and late period group（n＝４５）. The early period group included the number of esophagus direct suture was one stitch from２００５to２００７and the late period group included the number of esophagus direct suture was three stitches from２００８to２０１２．
【Results】 There was no intraoperative complication in both two groups. In postoperative complication rate, there was no significant difference between the two groups though one case（２．２％）showed a gastric perforation in the late period group. Postoperative recurrence was found ９ cases （１２．５％）due to wrap herniation. In postoperative recurrence rate, the early period group was ２２．２％（n＝６）and the late period group was ６．７％（n＝３）. The modified esophagus direct suture by from one stitch to three stitches had a tendency to decrease the postoperative recurrence rate（p＝０．０５）. For nine recurrent cases, re‐operation was performed in two patients, esophagogastric dissociation in one patients and observation in six patients.
【Conclusions】 Devising the esophagus direct suture in the laparoscopic Nissen fundoplication for NI patients might have the possibility to prevent the recurrence due to wrap herniation.