腹腔镜袖状胃切除联合锐性His角重建术治疗肥胖症的短期疗效

Short-term effects of laparoscopic sleeve gastrectomy combined with reconstruction of the acute His angle on postoperative gastroesophageal reflux disease

目的比较腹腔镜袖状胃切除术(LSG)结合锐性His角重建术(LSG-His)与传统LSG的短期疗效。方法采用回顾性队列研究方法。收集2022年1—6月期间于首都医科大学附属北京朝阳医院普通外科接受LSG和LSG-His手术且符合国际减重手术标准的肥胖患者临床数据。排除随访资料不全以及合并食管裂孔疝患者后,共83例肥胖患者纳入研究,包括39例LSG患者(LSG手术组)、44例LSG-His患者(LSG-His手术组)。LSG-His手术的基本操作步骤与常规LSG相同,但在连续缝合胃切割线后,将胃大弯切割线头侧和胃底后壁头侧分别与左侧膈肌脚间断缝合一针,最后将胃底右侧与食管间断缝合一针,重建锐性His角。主要观察指标为比较两组术后并发症发生情况,以及出院后1、3、6和12个月时术后体质量减轻和胃食管反流(GERD)发生情况。采用胃食管反流症状问卷(GERD-Q)和反流诊断问卷(RD-Q)用于评估胃食管反流症状。结果两组患者基线特征、住院时间、住院费用、术中出血、术后恶心呕吐、吞咽困难和术后并发症方面差异均无统计学意义(均P>0.05)。与LSG组相比,LSG-His组的手术时间更长[92(80,110)min比80(70,100)min,U=2.227,P=0.026],术后24 h疼痛评分更高[(5.2±1.8)分比(4.3±1.9)分,t=−2.065,P=0.041],术后吗啡使用率更高[70.5%(31/44)比46.2%(18/39),χ^(2)=4.519,P=0.025]。根据GERD-Q以及RD-Q评分变化发现,与LSG组相比,LSG-His组术后12个月GERD新发率明显较低[10.7%(3/28)比61.3%(19/31),χ^(2)=14.00,P<0.001]。与LSG组相比,LSG-His组的反流加重率明显降低(2/16比5/8,χ^(2)=4.27,P=0.021),反流缓解率更高(12/16比2/8,χ^(2)=3.62,P=0.032)。LSG-His组比LSG组的额外体质量降低率在术后3个月[(54.7±18.7)%比(46.5±15.0)%,t=−2.166,P=0.033)]、6个月[(73.8±24.7)%比(64.0±19.1)%,t=−2.018,P=0.047)]和12个月[(82.9±26.7)%比(72.2±19.3)%,t=−2.063,P=0.042)]均明显增高,差异均有统计学意义(均P<0.05)。结论与LSG相比,LSG-His安全可行,在短期内控制术后GERD和减重效果更好。

Objective To compare the short-term efficacy of laparoscopic sleeve gastrectomy(LSG)combined with sharp His angle reconstruction(LSG-His)versus traditional LSG.Methods In this retrospective cohort study we collected clinical data of patients with obesity who had undergone LSG or LSG-His in the Department of General Surgery,Beijing Chaoyang Hospital,Capital Medical University,from January to June 2022.After excluding patients with incomplete follow-up data and those with hiatal hernia,83 obese patients,of which 39 who had undergone LSG(LSG group)and 44 who had undergone LSG-His(LSG-His group),were included in the study.The basic steps in LSG-His are the same as in conventional LSG.After continuous suturing of the gastric staple line,one stitch is placed between the proximal side of the gastric greater curvature staple line and the proximal side of the gastric fundus posterior wall with the left diaphragm,and another stitch between the right side of the gastric fundus and the esophagus,reconstructing the sharp His angle.Clinical data,postoperative complications,and follow-up data on weight loss and gastroesophageal reflux disease(GERD)symptoms 1-,3-,6-,and 12-months post-discharge were compared between the two groups.GERD symptoms were assessed using the Gastroesophageal Reflux Disease Questionnaire and Reflux Diagnostic Questionnaire.Results There were no significant differences between the two groups in baseline characteristics,length of hospital stay,hospitalization costs,intraoperative bleeding,postoperative nausea and vomiting,dysphagia,or postoperative complications(all P>0.05).Compared with the LSG group,the LSG-His group had significantly longer operative times(92[80,100]minutes vs.80[70,100]minutes,U=2.227,P=0.026),higher postoperative 24-hour pain scores(5.2±1.8 vs.4.3±1.9,t=−2.065,P=0.041),and higher rates of morphine use(70.5%[31/44]vs.46.2%[18/39],χ^(2)=4.519,P=0.025).The incidence of new-onset GERD 12 months postoperatively was significantly lower in the LSG-His than the LSG group(10.7%[3/28]vs.61.3%[19/31],χ^(2)=14.00,P<0.001).According to changes in Gastroesophageal Reflux Disease Questionnaire and Reflux Diagnostic Questionnaire scores,the LSG-His group also had significantly lower rates of exacerbation of GERD(2/16 vs.5/8,χ^(2)=4.27,P=0.021)and higher rates of GERD remission(12/16 vs.2/8,χ^(2)=3.62,P=0.032)than did the LSG group.Additionally,excess weight loss rates were significantly higher in the LSG-His group at 3 months[(54.7±18.7)%vs.(46.5±15.0)%,t=−2.166,P=0.033],6 months[(73.8±24.7)%vs.(64.0±19.1)%,t=−2.018,P=0.047],and 12 months[(82.9±26.7)%vs.(72.2±19.3)%,t=−2.063,P=0.042]than in the LSG group.Conclusion Compared with LSG,LSG-His is safe and feasible and achieves better short-term control of postoperative GERD and more effective weight loss.Further large-scale,long-term,prospective studies are needed to confirm the long-term efficacy of LSG-His.