胃袖状切除术后胃食管反流病发生的相关因素的多中心回顾性队列研究

A multicenter retrospective cohort study on factors associated with the occurrence of gastroesophageal reflux disease after sleeve gastrectomy

摘要:

背景与目的 胃袖状切除术（SG）已成为全球应用最广的减重术式，但术后胃食管反流病（GERD）仍是主要并发症之一。本研究旨在通过多中心数据分析，探讨SG术后GERD发生的独立危险因素，为术前评估与术中操作提供循证依据。方法 回顾性收集6家减重代谢外科中心2020年1月—2022年12月接受SG并完成12个月随访的672例患者临床资料。比较GERD组与无GERD组的术前一般情况、内镜下食管胃结合部（EGJ）结构分级、手术参数及术后随访结果，采用多因素Logistic回归分析GERD发生的相关因素。结果 SG术后GERD总体发生率为24.7%（166/672）。多因素分析显示，术前体质量指数（BMI）>35 kg/m²（OR=1.68，P=0.033）、EGJ结构AFS分级>2级（OR=2.90，P=0.006）、术前反酸胃灼热症状（OR=2.44，P=0.030）为GERD的独立危险因素；而切缘距His角距离>1 cm（OR=0.45，P<0.001）及胃支撑管直径>36 Fr（OR=0.08，P=0.001）与GERD发生呈负相关。结论 术前高BMI、EGJ结构异常及典型反流症状显著增加SG术后GERD风险，而合理的切缘距离和适当的支撑管直径具有保护作用。术前系统评估EGJ结构及术中规范化操作可有效降低术后反流风险。

Abstract:

Background and Aims Sleeve gastrectomy (SG) has become the most widely performed bariatric procedure worldwide, but postoperative gastroesophageal reflux disease (GERD) remains a major concern. This multicenter study aimed to identify independent risk factors associated with GERD after SG to guide preoperative assessment and intraoperative management.Methods Clinical data of 672 patients who underwent SG between January 2020 and December 2022 in six bariatric centers and completed a 12-month follow-up were retrospectively analyzed. Demographic characteristics, esophagogastric junction (EGJ) integrity graded by the AFS system, operative parameters, and postoperative outcomes were compared between patients with and without GERD. Multivariate logistic regression was used to identify predictors of postoperative GERD.Results The overall incidence of GERD after SG was 24.7% (166/672). Multivariate analysis revealed that a preoperative BMI>35 kg/m² (OR=1.68, P=0.033), EGJ integrity AFS grade>2 (OR=2.90, P=0.006), and preoperative reflux symptoms (OR=2.44, P=0.030) were independent risk factors for GERD. A staple line more than 1 cm from the angle of His (OR=0.45, P<0.001) and a bougie size>36 Fr (OR=0.08, P=0.001) were protective factors.Conclusion High BMI, impaired EGJ integrity, and preoperative reflux symptoms significantly increase the risk of GERD after SG, whereas adequate preservation of the His angle and appropriate bougie calibration may reduce it. Comprehensive preoperative EGJ assessment and standardized surgical techniques are essential for minimizing postoperative reflux.