食管裂孔疝

能耐受全身麻醉手术的患者应进行紧急外科手术。

存在上消化道出血或梗阻患者手术前需要复苏和稳定支持治疗。

去除胸腔内脏器以及修补食管裂孔可能解决并发症。

胃切除仅用于存在不可逆性缺血或坏死的食管裂孔疝患者。手术切除还适用于其他疝出的器官，如小肠或结肠。对于这类患者，如果进行胃食管切除术，其胃肠道的连续性可能暂时被中断。对于有纵隔炎证据的体弱患者，应避免胸内吻合。在这些情况下，应缝合胃，并放置胃造口管进行胃肠减压，应采用颈段食管造口对近端食管进行转流。

对于具有胃食管反流病症状的患者，使用质子泵抑制剂进行药物治疗。

生活方式的改变，如减肥，提高床头，避免暴饮暴食，睡前进食，酒精和酸性食物。

应避免可能抑制食管下括约肌的物质。这些物质包括尼古丁、巧克力、薄荷、咖啡因、高脂肪食品，以及钙离子通道阻滞剂、硝酸盐和 β-受体阻滞剂等药物。

是手术治疗还是选择药物治疗取决于病人及医生。

考虑手术治疗的适应证是患者药物治疗效果不佳。在无并发症的 I 型滑动型食管裂孔疝的患者中，药物治疗失败有着广泛的定义，包括患者不依从药物治疗、有持续性反流、有反流性哮喘，或者患者单纯选择手术来治疗 GORD 和食管裂孔疝以及其他示例。

一般而言，只要可行，就应该进行松散的 Nissen 胃底折叠术（即 360° 反折），即使患者无胃食管反流病，亦应如此。此操作基于以下观察结果：在食管裂孔疝修补术时，进行切开通常会破坏组成生理性抗反流机制的所有组织关系。关于此争议，现在有许多已发布的观点，但是仅有非对照数据的支持。

现在大多数食管裂孔疝的手术都采用微创（腹腔镜）技术来进行。[22]Carlson MA, Frantzides CT. Complications and results of primary minimally invasive antireflux procedures: a review of 10,735 reported cases. J Am Coll Surg. 2001 Oct;193(4):428-39.http://www.ncbi.nlm.nih.gov/pubmed/11584971?tool=bestpractice.com 另外，不管是对照的还是非对照的数据都表明，如果使用人造补片，则食管裂孔疝的修补维持时间会更长（即假体补片）。[31]Müller-Stich BP, Holzinger F, Kapp T, et al. Laparoscopic hiatal hernia repair: long-term outcome with the focus on the influence of mesh reinforcement. Surg Endosc. 2006 Mar;20(3):380-4.http://www.ncbi.nlm.nih.gov/pubmed/16432659?tool=bestpractice.com[32]Johnson JM, Carbonell AM, Carmody BJ, et al. Laparoscopic mesh hiatoplasty for paraesophageal hernias and fundoplications: a critical analysis of the available literature. Surg Endosc. 2006 Mar;20(3):362-6.http://www.ncbi.nlm.nih.gov/pubmed/16437267?tool=bestpractice.com[33]Oelschlager BK, Pellegrini CA, Hunter J, et al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial. Ann Surg. 2006 Oct;244(4):481-90.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1856552/http://www.ncbi.nlm.nih.gov/pubmed/16998356?tool=bestpractice.com[34]Ringley CD, Bochkarev V, Ahmed SI, et al. Laparoscopic hiatal hernia repair with human acellular dermal matrix patch: our initial experience. Am J Surg. 2006 Dec;192(6):767-72.http://www.ncbi.nlm.nih.gov/pubmed/17161091?tool=bestpractice.com[35]Carlson MA, Condon RE, Ludwig KA, et al. Management of intrathoracic stomach with polypropylene mesh prosthesis reinforced transabdominal hiatus hernia repair. J Am Coll Surg. 1998 Sep;187(3):227-30.http://www.ncbi.nlm.nih.gov/pubmed/9740178?tool=bestpractice.com[36]Basso N, De Leo A, Genco A, et al. 360 degrees laparoscopic fundoplication with tension-free hiatoplasty in the treatment of symptomatic gastroesophageal reflux disease. Surg Endosc. 2000 Feb;14(2):164-9.http://www.ncbi.nlm.nih.gov/pubmed/10656953?tool=bestpractice.com[37]Champion JK, Rock D. Laparoscopic mesh cruroplasty for large paraesophageal hernias. Surg Endosc. 2003 Apr;17(4):551-3.http://www.ncbi.nlm.nih.gov/pubmed/12582773?tool=bestpractice.com[38]Keidar A, Szold A. Laparoscopic repair of paraesophageal hernia with selective use of mesh. Surg Laparosc Endosc Percutan Tech. 2003 Jun;13(3):149-54.http://www.ncbi.nlm.nih.gov/pubmed/12819496?tool=bestpractice.com[39]Gryska PV, Vernon JK. Tension-free repair of hiatal hernia during laparoscopic fundoplication: a ten-year experience. Hernia. 2005 May;9(2):150-5.http://www.ncbi.nlm.nih.gov/pubmed/15723153?tool=bestpractice.com[40]Granderath FA, Carlson MA, Champion JK, et al. Prosthetic closure of the esophageal hiatus in large hiatal hernia repair and laparoscopic antireflux surgery. Surg Endosc. 2006 Mar;20(3):367-79.http://www.ncbi.nlm.nih.gov/pubmed/16424984?tool=bestpractice.com[41]Frantzides CT, Madan AK, Carlson MA, et al. A prospective, randomized trial of laparoscopic polytetrafluoroethylene (PTFE) patch repair vs simple cruroplasty for large hiatal hernia. Arch Surg. 2002 Jun;137(6):649-52.http://archsurg.ama-assn.org/cgi/content/full/137/6/649http://www.ncbi.nlm.nih.gov/pubmed/12049534?tool=bestpractice.com

在这一点上，食管裂孔疝修补手术的发展中，可能需要权衡选择哪种假体补片：选择永久性补片，有糜烂的风险；选择生物补片，有复发的风险。关于如何具体选择补片种类，目前缺乏良好的科学数据。[48]Antoniou SA, Pointner R, Granderath FA. Hiatal hernia repair with the use of biologic meshes: a literature review. Surg Laparosc Endosc Percutan Tech. 2011 Feb;21(1):1-9.http://www.ncbi.nlm.nih.gov/pubmed/21304379?tool=bestpractice.com[49]Antoniou SA, Müller-Stich BP, Antoniou GA, et al. Laparoscopic augmentation of the diaphragmatic hiatus with biologic mesh versus suture repair: a systematic review and meta-analysis. Langenbecks Arch Surg. 2015 Jul;400(5):577-83.http://www.ncbi.nlm.nih.gov/pubmed/26049745?tool=bestpractice.com 可用轻质涂层非生物补片进行疝环填充式修补，或者使用聚四氟乙烯补片进行食管裂孔疝修补。[50]Frantzides CT, Carlson MA. Laparoscopic hiatal herniorrhaphy. In: Frantzides CT, Carlson M, eds. Atlas of minimally invasive surgery. 1st ed. Philadelphia, PA: Saunders Elsevier; 2009:31-40.

如果没有可用的微创手术技术，开放手术是一个可以接受的选择。治疗胃食管反流病和食管裂孔疝可以使用抗反流手术及疝修补术相结合的术式。[22]Carlson MA, Frantzides CT. Complications and results of primary minimally invasive antireflux procedures: a review of 10,735 reported cases. J Am Coll Surg. 2001 Oct;193(4):428-39.http://www.ncbi.nlm.nih.gov/pubmed/11584971?tool=bestpractice.com[54]Muller-Stich BP, Achtstatter V, Diener MK, et al. Repair of paraesophageal hiatal hernias - is a fundoplication needed? A randomized controlled pilot trial. J Am Coll Surg. 2015 Aug;221(2):602-10.http://www.ncbi.nlm.nih.gov/pubmed/25868406?tool=bestpractice.com

对于 II 到 IV 型食管裂孔疝患者，应该考虑修补，因为具有绞窄及纵隔炎的长期风险。

然而，关于在食管裂孔疝修补术时常规联合进行抗反流手术是有争议的，特别是对于没有任何胃食管反流病 (GORD) 症状的患者。一般而言，只要可行，就应该进行松散的 Nissen 胃底折叠术（即 360° 反折），即使患者无胃食管反流病，亦应如此。此操作基于以下观察结果：在食管裂孔疝修补术时，进行切开通常会破坏组成生理性抗反流机制的所有组织关系。关于此争议，现在有许多已发布的观点，但是仅有非对照数据的支持。

现在大多数食管裂孔疝的手术都采用微创（腹腔镜）技术来进行。[22]Carlson MA, Frantzides CT. Complications and results of primary minimally invasive antireflux procedures: a review of 10,735 reported cases. J Am Coll Surg. 2001 Oct;193(4):428-39.http://www.ncbi.nlm.nih.gov/pubmed/11584971?tool=bestpractice.com 另外，不管是对照的还是非对照的数据都表明，如果使用人造补片，则食管裂孔疝的修补维持时间会更长（即假体补片）。[31]Müller-Stich BP, Holzinger F, Kapp T, et al. Laparoscopic hiatal hernia repair: long-term outcome with the focus on the influence of mesh reinforcement. Surg Endosc. 2006 Mar;20(3):380-4.http://www.ncbi.nlm.nih.gov/pubmed/16432659?tool=bestpractice.com[32]Johnson JM, Carbonell AM, Carmody BJ, et al. Laparoscopic mesh hiatoplasty for paraesophageal hernias and fundoplications: a critical analysis of the available literature. Surg Endosc. 2006 Mar;20(3):362-6.http://www.ncbi.nlm.nih.gov/pubmed/16437267?tool=bestpractice.com[33]Oelschlager BK, Pellegrini CA, Hunter J, et al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial. Ann Surg. 2006 Oct;244(4):481-90.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1856552/http://www.ncbi.nlm.nih.gov/pubmed/16998356?tool=bestpractice.com[34]Ringley CD, Bochkarev V, Ahmed SI, et al. Laparoscopic hiatal hernia repair with human acellular dermal matrix patch: our initial experience. Am J Surg. 2006 Dec;192(6):767-72.http://www.ncbi.nlm.nih.gov/pubmed/17161091?tool=bestpractice.com[35]Carlson MA, Condon RE, Ludwig KA, et al. Management of intrathoracic stomach with polypropylene mesh prosthesis reinforced transabdominal hiatus hernia repair. J Am Coll Surg. 1998 Sep;187(3):227-30.http://www.ncbi.nlm.nih.gov/pubmed/9740178?tool=bestpractice.com[36]Basso N, De Leo A, Genco A, et al. 360 degrees laparoscopic fundoplication with tension-free hiatoplasty in the treatment of symptomatic gastroesophageal reflux disease. Surg Endosc. 2000 Feb;14(2):164-9.http://www.ncbi.nlm.nih.gov/pubmed/10656953?tool=bestpractice.com[37]Champion JK, Rock D. Laparoscopic mesh cruroplasty for large paraesophageal hernias. Surg Endosc. 2003 Apr;17(4):551-3.http://www.ncbi.nlm.nih.gov/pubmed/12582773?tool=bestpractice.com[38]Keidar A, Szold A. Laparoscopic repair of paraesophageal hernia with selective use of mesh. Surg Laparosc Endosc Percutan Tech. 2003 Jun;13(3):149-54.http://www.ncbi.nlm.nih.gov/pubmed/12819496?tool=bestpractice.com[39]Gryska PV, Vernon JK. Tension-free repair of hiatal hernia during laparoscopic fundoplication: a ten-year experience. Hernia. 2005 May;9(2):150-5.http://www.ncbi.nlm.nih.gov/pubmed/15723153?tool=bestpractice.com[40]Granderath FA, Carlson MA, Champion JK, et al. Prosthetic closure of the esophageal hiatus in large hiatal hernia repair and laparoscopic antireflux surgery. Surg Endosc. 2006 Mar;20(3):367-79.http://www.ncbi.nlm.nih.gov/pubmed/16424984?tool=bestpractice.com[41]Frantzides CT, Madan AK, Carlson MA, et al. A prospective, randomized trial of laparoscopic polytetrafluoroethylene (PTFE) patch repair vs simple cruroplasty for large hiatal hernia. Arch Surg. 2002 Jun;137(6):649-52.http://archsurg.ama-assn.org/cgi/content/full/137/6/649http://www.ncbi.nlm.nih.gov/pubmed/12049534?tool=bestpractice.com

在这一点上，食管裂孔疝修补手术的发展中，可能需要权衡选择哪种假体补片：选择永久性补片，有糜烂的风险；选择生物补片，有复发的风险。关于如何具体选择补片种类，目前缺乏良好的科学数据。[48]Antoniou SA, Pointner R, Granderath FA. Hiatal hernia repair with the use of biologic meshes: a literature review. Surg Laparosc Endosc Percutan Tech. 2011 Feb;21(1):1-9.http://www.ncbi.nlm.nih.gov/pubmed/21304379?tool=bestpractice.com[49]Antoniou SA, Müller-Stich BP, Antoniou GA, et al. Laparoscopic augmentation of the diaphragmatic hiatus with biologic mesh versus suture repair: a systematic review and meta-analysis. Langenbecks Arch Surg. 2015 Jul;400(5):577-83.http://www.ncbi.nlm.nih.gov/pubmed/26049745?tool=bestpractice.com 可用轻质涂层非生物补片进行疝环填充式修补，或者使用聚四氟乙烯补片进行食管裂孔疝修补。[50]Frantzides CT, Carlson MA. Laparoscopic hiatal herniorrhaphy. In: Frantzides CT, Carlson M, eds. Atlas of minimally invasive surgery. 1st ed. Philadelphia, PA: Saunders Elsevier; 2009:31-40.[51]Antoniou SA, Koch OO, Antoniou GA, et al. Mesh-reinforced hiatal hernia repair: a review on the effect on postoperative dysphagia and recurrence. Langenbecks Arch Surg. 2012 Jan;397(1):19-27.http://www.ncbi.nlm.nih.gov/pubmed/21792699?tool=bestpractice.com

如果没有可用的微创手术技术，开放手术是一个可以接受的选择。治疗胃食管反流病和食管裂孔疝可以使用抗反流手术及疝修补术相结合的术式。[22]Carlson MA, Frantzides CT. Complications and results of primary minimally invasive antireflux procedures: a review of 10,735 reported cases. J Am Coll Surg. 2001 Oct;193(4):428-39.http://www.ncbi.nlm.nih.gov/pubmed/11584971?tool=bestpractice.com[54]Muller-Stich BP, Achtstatter V, Diener MK, et al. Repair of paraesophageal hiatal hernias - is a fundoplication needed? A randomized controlled pilot trial. J Am Coll Surg. 2015 Aug;221(2):602-10.http://www.ncbi.nlm.nih.gov/pubmed/25868406?tool=bestpractice.com