Rebecchi Fabrizio, Allaix Marco E, Patti Marco G, Schlottmann Francisco, Morino Mario
Fabrizio Rebecchi, Marco E Allaix, Mario Morino, Department of Surgical Sciences, University of Torino, 10126 Torino, Italy.
World J Gastroenterol. 2017 Apr 7;23(13):2269-2275. doi: 10.3748/wjg.v23.i13.2269.
Laparoscopic sleeve gastrectomy (LSG) has reached wide popularity during the last 15 years, due to the limited morbidity and mortality rates, and the very good weight loss results and effects on comorbid conditions. However, there are concerns regarding the effects of LSG on gastroesophageal reflux disease (GERD). The interpretation of the current evidence is challenged by the fact that the LSG technique is not standardized, and most studies investigate the presence of GERD by assessing symptoms and the use of acid reducing medications only. A few studies objectively investigated gastroesophageal function and the reflux profile by esophageal manometry and 24-h pH monitoring, reporting postoperative normalization of esophageal acid exposure in up to 85% of patients with preoperative GERD, and occurrence of de novo GERD in about 5% of cases. There is increasing evidence showing the key role of the surgical technique on the incidence of postoperative GERD. Main technical issues are a relative narrowing of the mid portion of the gastric sleeve, a redundant upper part of the sleeve (both depending on the angle under which the sleeve is stapled), and the presence of a hiatal hernia. Concomitant hiatal hernia repair is recommended. To date, either medical therapy with proton pump inhibitors or conversion of LSG to laparoscopic Roux-en-Y gastric bypass are the available options for the management of GERD after LSG. Recently, new minimally invasive approaches have been proposed in patients with GERD and hypotensive LES: the LINX Reflux Management System procedure and the Stretta procedure. Large studies are needed to assess the safety and long-term efficacy of these new approaches. In conclusion, the recent publication of pH monitoring data and the new insights in the association between sleeve morphology and GERD control have led to a wider acceptance of LSG as bariatric procedure also in obese patients with GERD, as recently stated in the 5 International Consensus Conference on sleeve gastrectomy.
在过去15年中，腹腔镜袖状胃切除术（LSG）已广泛普及，这归因于其较低的发病率和死亡率，以及良好的减重效果和对合并症的改善作用。然而，人们对LSG对胃食管反流病（GERD）的影响仍存在担忧。由于LSG技术尚未标准化，且大多数研究仅通过评估症状和使用抑酸药物来调查GERD的存在，这使得对现有证据的解读面临挑战。少数研究通过食管测压和24小时pH监测客观地研究了胃食管功能和反流情况，报告称术前患有GERD的患者中，高达85%术后食管酸暴露恢复正常，约5%的病例出现新发GERD。越来越多的证据表明手术技术对术后GERD发生率起着关键作用。主要技术问题包括胃袖状中段相对狭窄、袖状上部冗余（两者均取决于袖状胃的缝合角度）以及存在食管裂孔疝。建议同时进行食管裂孔疝修补术。迄今为止，对于LSG术后GERD的治疗，可用的选择包括使用质子泵抑制剂进行药物治疗或将LSG转换为腹腔镜Roux-en-Y胃旁路术。最近，针对GERD和低压力下食管括约肌（LES）的患者，提出了新的微创方法：LINX反流管理系统手术和Stretta手术。需要进行大规模研究来评估这些新方法的安全性和长期疗效。总之，最近pH监测数据的公布以及对袖状胃形态与GERD控制之间关联的新认识，使得LSG作为一种减肥手术在患有GERD的肥胖患者中也得到了更广泛的认可，正如最近在第五届袖状胃切除术国际共识会议中所指出的那样。
