Belsey type 4 fundoplication

Reflux esophagitis refers to the damage of the esophageal mucosa caused by the reflux of the contents of the stomach and duodenum to the esophagus, and a series of clinical symptoms and digestive inflammatory manifestations. Reflux esophagitis is a common and frequently-occurring disease in Western countries, with an incidence of about 8%. In the past, reflux esophagitis was not found to be common in Asian countries, but a recent survey showed that reflux esophagitis is not very rare in the Chinese population. Common causes of reflux esophagitis include hiatal hernia, primary esophageal sphincter dysfunction, pregnancy, gastroesophageal surgery, congenital malformations, and other causes. Studies have confirmed that gastroesophageal reflux is a disease of the upper digestive tract dysmotility caused by a variety of factors. However, among the many pathogenic factors, it is often not a single factor that causes disease alone, but multiple factors coexist, synergistic or chain reaction, and even form a vicious circle, which aggravates the damage to the esophagus. The extent and extent of injury to reflux esophagitis depends on the length of contact between the esophageal mucosa and gastric acid, the nature of gastric acid, and the susceptibility of esophageal epithelial cells to reflux contents. The extent of the lesion is different from the corresponding pathomorphological features. It can usually be divided into early stage (slight stage of disease), medium stage (inflammation progression and erosion stage) and advanced stage (chronic ulcer formation and inflammatory proliferative phase). The most common symptoms of reflux esophagitis are heartburn, chest pain, difficulty swallowing, and can cause difficulty in pronunciation, cough, plum sensation, laryngitis, hoarseness, cough, suffocation, bronchitis, asthma-like episodes, aspiration pneumonia. Extra-esophageal symptoms such as atelectasis, lung abscess and pulmonary fibrosis. The clinical manifestations of reflux esophagitis vary in severity, mild symptoms are not obvious, often overlooked; severe cases are manifested as angina pectoris and other comorbidities, such as bleeding, stenosis, etc., making diagnosis more difficult. Therefore, patients with the following clinical manifestations should be highly suspected of reflux esophagitis: 1 severe heartburn symptoms; 2 clinical manifestations of atypical angina-like symptoms; 3 recurrent asthma or lung infections. The diagnosis of reflux esophagitis is not difficult, and most of them can be diagnosed by esophageal barium meal, endoscopy and esophageal function tests. The inspection method should be selected as needed. Radiological examination of the digestive tract can reveal gastroesophageal reflux and esophageal inflammation. However, the severity of reflux and esophagitis was not parallel. Esophagoscopy and biopsy can clearly diagnose and judge the severity of reflux esophagitis, and it is also helpful for differential diagnosis and therapeutic observation. Although esophageal pressure measurement can not diagnose reflux esophagitis, it can help to understand the function of the lower esophageal sphincter and cause gastroesophageal reflux. 24h esophageal pH monitoring is the most sensitive and specific method for diagnosing reflux esophagitis. It can understand the dynamic changes of pH in the esophageal lumen, especially through comprehensive analysis of the measured parameters to determine clinical symptoms and acidity. The relationship between reflux. Other tests include acid perfusion test, acid scavenging test, esophageal scintigraphy and electrogastrogram, but they are less clinically useful due to their poor specificity and sensitivity. Reflux esophagitis should also be distinguished from the following diseases: esophageal and cardiac cancer, angina pectoris, certain abdominal diseases, achalasia and other causes of esophagitis. The main complications of reflux esophagitis include esophageal stricture, esophageal ulcer, Barrett's esophagus, and malignant transformation. Treatment of reflux esophagitis includes non-drug therapy, medication, esophageal dilation, and surgery. The purpose of various treatments is to: 1 reduce or eliminate the symptoms of gastroesophageal reflux; 2 reduce the damage of the reflux to the esophageal mucosa, enhance the esophageal defense function, prevent and treat serious complications; 3 prevent the recurrence of gastroesophageal reflux. The treatment strategy for reflux esophagitis can be carried out as follows: 1 Medical treatment to control symptoms and prevent recurrence. Once the reflux esophagitis is diagnosed, systematic medical treatment should be performed, including non-pharmacological treatment (adjustment of body position, diet structure and lifestyle) and medication (mucosal protective agent, antacid, antacid and gastrointestinal motility). medicine). For patients without complications, strict medical treatment can often be cured. 2 Patients with ineffective medical treatment or complications should undergo surgical anti-reflux surgery. 3 esophageal irreversible lesions should be surgically removed lesions of the esophagus. Belsey No. 4 fundoplication is considered a classic surgical procedure for the treatment of reflux esophagitis caused by hiatal hernia. Treatment of diseases: hiatal hernia Indication Belsey Type 4 fundoplication is suitable for: 1. Examination confirmed that there was esophageal hiatus hernia, esophagitis was caused by hiatal hernia. Reflux esophagitis is severe, with ulcers, hemorrhage, stenosis or inhaled pulmonary complications. 2. Reflux esophagitis is not effective in systemic medical treatment. 3. The patient is fatter. 4. It is estimated that the esophageal wall is hard and there are more adhesions around. 5. Although reflux esophagitis is not very serious, there are huge esophageal hiatus hernias. Contraindications 1. People with severe cardiopulmonary dysfunction. 2. The nutritional status is too poor, and the hemoglobin is too low. 3. Other serious diseases that are not suitable for thoracotomy. Preoperative preparation 1. Correct nutritional disorders such as anemia and hypoproteinemia. 2. Treatment and control of respiratory tract inflammation. Smokers should stop smoking. 3. Apply diet therapy, alkaline drugs, bed height 20cm. 4. Treatment of esophagitis, so that acute inflammation and ulcer bleeding are static. 5. Place the stomach tube before surgery. Surgical procedure 1. Incision left chest posterolateral incision, the 7th or 8th intercostal space into the chest. 2. Expose the lower esophagus, cut off the lower lung ligament, push the lower lobe of the lung upward, so that the invaded chest and stomach are located in the lower esophageal triangle of the pericardium, iliac crest and thoracic aorta. Free the lower esophagus and the fundus, cardia. 3. Pull out the esophagus. Open the mediastinal pleura from the normal esophagus above the hiatal hernia, and go straight down to the gingival margin, then extend along the sulcus and forward, fully free the lower esophagus and cardia, the fundus, cut off 1 to 2 gastric short vessels, and remove the adipose tissue in the lower esophagus. . If there is inflammation around the esophagus or shortening of the esophageal scar, the affected esophagus is released upward to the normal esophagus. 4. Stitching and strengthening the tendon of the diaphragm. The left and right muscle bundles on both sides of the esophageal hiatus were exposed behind the cardia, and the muscle bundle (including the fibrous margin) was sutured 3 to 6 needles on the 1st line, but not tied. Remove the fat tissue around the cardia. 5. The first row of sutures is placed at the junction of the fundus and the esophagus. The purpose is to fold the bottom of the stomach at 2 to 5 cm (240 °) around the esophagus at the lower end of the esophagus. When suturing, 2-0 silk thread was used, and the needle was inserted from the stomach, and then the needle was obliquely passed through the esophageal wall 2cm above the junction of the esophagus and stomach, and the needle was folded back in the opposite direction, that is, the needle was passed through the fundus wall. This type of suture is a total of 3 needles, and the knot is completed after suturing. The oblique needle of the esophageal wall should be sutured to the muscular layer to avoid suturing the esophageal adventitia or deep into the mucosa. After the first row of sutures are knotted, the second layer of suture stitches is fixed on the top of the esophagus 2 cm from the hiatus of the esophagus. The suture No. 0 is used, and the suture direction is from the ankle to the underarm, and then the stomach-esophage-stomach is sutured. Finally, it is worn by the armpit to the sputum, and it is near the beginning of the suture point. The second row is also stitched with 3 stitches. This line of sutures in the stomach-esophagus should be 1.5 to 2 cm from the first row of sutures. After the suture is completed, the first row of sutures is delivered to the lower part of the diaphragm by hand, and the second row of 3 needles is completely knotted. At this time, the gastroesophageal junction is lowered to the underarm, and finally the suture of the diaphragmatic foot is knotted. It is a sagittal view of the Belsey No. 4 fundoplication. complication 1. Dysphagia may occur within 2 weeks after surgery, which may be caused by tissue edema of the suture site leading to esophageal stenosis, but it can be gradually relieved after the reflux disappears, or can be relieved after several expansions. 2. bloating syndrome: that is, bloating but no suffocation, no vomiting. 3. Recurrence. 4. Esophageal perforation, less common.