Patterson E J, Davis D G, Khajanchee Y, Swanström L L
Department of Minimally Invasive Surgery, Legacy Health System, 501 North Graham Street, Suite 120, Portland, OR 97227, USA.
Surg Endosc. 2003 Oct;17(10):1561-5. doi: 10.1007/s00464-002-8955-y. Epub 2003 Jul 21.
Heartburn and gastroesophageal reflux disease (GERD) affects approximately 25-50% of morbidly obese patients. Although objective physiologic testing has been reported extensively in patients following Nissen fundoplication, there are no previous reports of such testing in morbidly obese patients. A life-saving surgical alternative for the morbidly obese patient is gastric bypass surgery, which usually improves heartburn symptoms in addition to many serious health conditions such as diabetes, hypertension, and sleep apnea. We hypothesized that, in morbidly obese patients, gastric bypass surgery would be as effective as Nissen fundoplication in reducing both heartburn symptoms and esophageal acid exposure, as reflected by the DeMeester score.
Between 1995 and 2000, all patients undergoing laparoscopic Nissen fundoplication (LN) and laparoscopic gastric bypass (LGB) in our practice underwent preoperative and postoperative esophageal physiologic testing. Patients were included in this study that were morbidly obese and had significant heartburn symptoms or objective evidence of acid reflux, and had repeat esophageal physiologic testing after either LN or LGB. Data were obtained through retrospective review of prospectively collected data.
Twelve patients met the inclusion criteria: six patients who had LN and six who had LGB. The mean body mass index (BMI) was 55 kg/m2 in the LGB group and 39.8 in the LN group. After surgery, the mean DeMeester score decreased from 64.3 to 2.8 in the LN group ( p = 0.01) and from 34.7 to 5.7 in the LGB group ( p = 0.1). Both groups' mean postoperative DeMeester scores were normal after surgery, and there was no significant difference between the two groups ( p = 0.3). Both groups experienced a significant improvement in heartburn symptoms postoperatively. The mean preoperative symptom score improved from 3.5 to 0.5 in the LN group ( p = 0.01) and from 2.2 to 0.2 in the LGB group ( p = 0.003). There was no difference in the mean postoperative symptom scores between the groups ( p = 0.35). After surgery, mean LES resting pressures increased from 12.9 to 35.5 ( p = 0.003) in the LN group and from 23.6 to 29.7 ( p = 0.45) in the LGB group. There were no complications in either group.
Results of this study show that laparoscopic gastric bypass and laparoscopic Nissen fundoplication are both effective in treating heartburn symptoms and objective acid reflux in morbidly obese patients. The health benefits of weight loss after laparoscopic gastric bypass should make this operation the procedure of choice in the morbidly obese patient with heartburn.
胃灼热和胃食管反流病（GERD）影响约25%-50%的病态肥胖患者。尽管在nissen胃底折叠术后患者中已广泛报道了客观生理测试，但此前尚无关于病态肥胖患者进行此类测试的报道。对于病态肥胖患者，一种挽救生命的手术替代方案是胃旁路手术，除了改善糖尿病、高血压和睡眠呼吸暂停等许多严重健康状况外，通常还能改善胃灼热症状。我们推测，在病态肥胖患者中，胃旁路手术在减轻胃灼热症状和食管酸暴露方面与nissen胃底折叠术一样有效，这一点通过DeMeester评分得以体现。
1995年至2000年间，我们诊所所有接受腹腔镜nissen胃底折叠术（LN）和腹腔镜胃旁路术（LGB）的患者均接受了术前和术后食管生理测试。本研究纳入了病态肥胖且有明显胃灼热症状或酸反流客观证据的患者，他们在接受LN或LGB后均进行了重复食管生理测试。数据通过对前瞻性收集的数据进行回顾性分析获得。
12名患者符合纳入标准：6名接受LN手术的患者和6名接受LGB手术的患者。LGB组的平均体重指数（BMI）为55kg/m²，LN组为39.8。手术后，LN组的平均DeMeester评分从64.3降至2.8（p = 0.01），LGB组从34.7降至5.7（p = 0.1）。两组术后的平均DeMeester评分术后均正常，两组之间无显著差异（p = 0.3）。两组术后胃灼热症状均有显著改善。LN组术前平均症状评分从3.5降至0.5（p = 0.01），LGB组从2.2降至0.2（p = 0.003）。两组术后平均症状评分无差异（p = 0.35）。手术后，LN组LES静息压力从12.9升至35.5（p = 0.003），LGB组从23.6升至29.7（p = 0.45）。两组均无并发症。
本研究结果表明，腹腔镜胃旁路术和腹腔镜nissen胃底折叠术在治疗病态肥胖患者的胃灼热症状和客观酸反流方面均有效。腹腔镜胃旁路术后体重减轻带来的健康益处应使该手术成为患有胃灼热的病态肥胖患者的首选手术方式。
