Maret-Ouda John, Wahlin Karl, El-Serag Hashem B, Lagergren Jesper
Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas.
JAMA. 2017 Sep 12;318(10):939-946. doi: 10.1001/jama.2017.10981.
Cohort studies, mainly based on questionnaires and interviews, have reported high rates of reflux recurrence after antireflux surgery, which may have contributed to a decline in its use. Reflux recurrence after laparoscopic antireflux surgery has not been assessed in a long-term population-based study of unselected patients.
To determine the risk of reflux recurrence after laparoscopic antireflux surgery and to identify risk factors for recurrence.
Nationwide population-based retrospective cohort study in Sweden between January 1, 2005, and December 31, 2014, based on all Swedish health care and including 2655 patients who underwent laparoscopic antireflux surgery according to the Swedish Patient Registry. Their records were linked to the Swedish Causes of Death Registry and Prescribed Drug Registry.
Primary laparoscopic antireflux surgery due to gastroesophageal reflux disease in adults (>18 years).
The outcome was recurrence of reflux, defined as use of antireflux medication (proton pump inhibitors or histamine2 receptor antagonists for >6 months) or secondary antireflux surgery. Multivariable Cox regression was used to assess risk factors for reflux recurrence.
Among all 2655 patients who underwent antireflux surgery (median age, 51.0 years; interquartile range, 40.0-61.0 years; 1354 men [51.0%]) and were followed up for a median of 5.6 years, 470 patients (17.7%) had reflux recurrence; 393 (83.6%) received long-term antireflux medication and 77 (16.4%) underwent secondary antireflux surgery. Risk factors for reflux recurrence included female sex (hazard ratio [HR], 1.57 [95% CI, 1.29-1.90]; 286 of 1301 women [22.0%] and 184 of 1354 men [13.6%] had recurrence of reflux), older age (HR, 1.41 [95% CI, 1.10-1.81] for age ≥61 years compared with ≤45 years; recurrence among 156 of 715 patients and 133 of 989 patients, respectively), and comorbidity (HR, 1.36 [95% CI, 1.13-1.65] for Charlson comorbidity index score ≥1 compared with 0; recurrence among 180 of 804 patients and 290 of 1851 patients, respectively). Hospital volume of antireflux surgery was not associated with risk of reflux recurrence (HR, 1.09 [95% CI, 0.77-1.53] for hospital volume ≤24 surgeries compared with ≥76 surgeries; recurrence among 38 of 266 patients [14.3%] and 271 of 1526 patients [17.8%], respectively).
Among patients who underwent primary laparoscopic antireflux surgery, 17.7% experienced recurrent gastroesophageal reflux requiring long-term medication use or secondary antireflux surgery. Risk factors for recurrence were older age, female sex, and comorbidity. Laparoscopic antireflux surgery was associated with a relatively high rate of recurrent gastroesophageal reflux disease requiring treatment, diminishing some of the benefits of the operation.
队列研究主要基于问卷调查和访谈，报告了抗反流手术后反流复发率较高，这可能导致了该手术使用量的下降。在一项针对未经筛选患者的长期基于人群的研究中，尚未对腹腔镜抗反流手术后的反流复发情况进行评估。
确定腹腔镜抗反流手术后反流复发的风险，并识别复发的危险因素。
2005年1月1日至2014年12月31日在瑞典进行的全国性基于人群的回顾性队列研究，基于瑞典所有医疗保健数据，包括根据瑞典患者登记处接受腹腔镜抗反流手术的2655例患者。他们的记录与瑞典死亡原因登记处和处方药登记处相关联。
因胃食管反流病在成人（>18岁）中进行的初次腹腔镜抗反流手术。
结局为反流复发，定义为使用抗反流药物（质子泵抑制剂或组胺2受体拮抗剂超过6个月）或二次抗反流手术。采用多变量Cox回归评估反流复发的危险因素。
在接受抗反流手术的所有2655例患者中（中位年龄51.0岁；四分位间距40.0 - 61.0岁；1354例男性[51.0%]），中位随访5.6年，470例患者（17.7%）出现反流复发；393例（83.6%）接受了长期抗反流药物治疗，77例（16.4%）接受了二次抗反流手术。反流复发的危险因素包括女性（风险比[HR]，1.57[95%置信区间，1.29 - 1.90]；1301例女性中有286例[22.0%]、1354例男性中有184例[13.6%]出现反流复发）、年龄较大（与年龄≤45岁相比，年龄≥61岁时HR为1.41[95%置信区间，1.10 - 1.81]；715例患者中有156例、989例患者中有133例分别出现复发）以及合并症（与Charlson合并症指数评分为0相比，评分为≥1时HR为1.36[95%置信区间，1.13 - 1.65]；804例患者中有180例、1851例患者中有290例分别出现复发）。抗反流手术的医院手术量与反流复发风险无关（与手术量≥76例相比，手术量≤24例时HR为1.09[95%置信区间，0.77 - 1.53]；266例患者中有38例[14.3%]、1526例患者中有271例[17.8%]分别出现复发）。
在接受初次腹腔镜抗反流手术的患者中，17.7%经历了复发性胃食管反流，需要长期用药或进行二次抗反流手术。复发的危险因素是年龄较大、女性和合并症。腹腔镜抗反流手术与需要治疗的复发性胃食管反流病发生率相对较高相关，这削弱了该手术的一些益处。
