Roux-en-Y 胃旁路术作为治疗胃底折叠术失败的复杂患者的挽救性手术。
Roux-en-Y gastric bypass as a salvage procedure in complicated patients with failed fundoplication(s).
机构信息
Department of Surgery, Division of General Surgery, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI, 53226, USA.
出版信息
Surg Endosc. 2019 Mar;33(3):738-744. doi: 10.1007/s00464-018-6337-3. Epub 2018 Jul 12.
BACKGROUND
In symptomatic patients after failed fundoplication, reoperation is considered. In complex or obese patients, Roux-en Y gastric bypass (RYGB) may be the best operation. We sought to characterize the outcomes of patients with failed fundoplication to undergo salvage RYGB, and to compare these outcomes to patients undergoing reoperative fundoplication.
METHODS
A prospectively maintained database was queried for procedures performed at a single institution from 2011 to 2017. GERD health-related quality of life (HRQL) surveys were administered at defined intervals.
RESULTS
Thirty-six patients underwent salvage RYGB and 84 patients underwent reoperative fundoplication. The RYGB cohort had a higher BMI (35.5 ± 6.8 vs. 28.7 ± 5.3, p < 0.01), more gastroparesis (52.8% vs. 9.5%, p < 0.01), more esophagitis (42.9% vs. 20.2%, p = 0.01), and more prior fundoplications (1.9 vs. 1.2, p < 0.01). The incidence of gastroparesis and esophagitis was directly related to the number of failed fundoplications (p < 0.05). Operative times were longer with RYGB (332.7 ± 131.5 vs. 200.0 ± 67.6 min, p < 0.01) as was length of stay (4.3 ± 3.4 vs. 2.8 ± 1.5 days, p = 0.02), incidence of Clavien-Dindo complications ≥ Grade 3 (19.4% vs. 4.8%, p = 0.01), 30-day reoperation (11.1% vs. 1.2%, p = 0.01), and 30-day readmission (32.4% vs. 11.9%, p < 0.01). In five patients with three or more prior fundoplication attempts, an esophagojejunostomy was necessary. If these patients are excluded, there was no difference for RYGB with gastrojejunostomy compared to reoperative fundoplication for complications, reoperations, or readmissions. GERD-HRQL scores were similar prior to surgery in both cohorts and improved significantly and to a similar degree on long-term follow-up.
CONCLUSIONS
In a complex cohort of patients with high rates of obesity and numerous failed previous fundoplication attempts, conversion to RYGB results in good symptomatic outcomes. Patients with three or more previous fundoplication attempts are more likely to require esophagojejunostomy. Complication rates in this subset of patients appear to be quite high.
背景
在胃食管反流病（GERD）症状复发的胃底折叠术（fundoplication）失败患者中，通常会考虑再次手术。在复杂或肥胖的患者中，Roux-en Y 胃旁路术（RYGB）可能是最佳的手术方式。本研究旨在分析胃底折叠术失败后行挽救性 RYGB 患者的结局，并与再次行胃底折叠术的患者进行比较。
方法
通过查询一家机构从 2011 年到 2017 年的前瞻性数据库，寻找接受治疗的患者。在规定的时间间隔内，患者会被要求填写胃食管反流病健康相关生活质量（HRQL）调查问卷。
结果
36 例患者接受挽救性 RYGB，84 例患者接受再次行胃底折叠术。RYGB 组的 BMI（35.5±6.8 vs. 28.7±5.3，p<0.01）、胃轻瘫（52.8% vs. 9.5%，p<0.01）、食管炎（42.9% vs. 20.2%，p=0.01）和先前接受的胃底折叠术次数（1.9 vs. 1.2，p<0.01）均较高。胃轻瘫和食管炎的发生率与先前胃底折叠术的次数直接相关（p<0.05）。RYGB 的手术时间更长（332.7±131.5 vs. 200.0±67.6min，p<0.01），住院时间更长（4.3±3.4 vs. 2.8±1.5d，p=0.02），Clavien-Dindo 并发症分级≥3 级的发生率更高（19.4% vs. 4.8%，p=0.01），30 天内再次手术（11.1% vs. 1.2%，p=0.01）和 30 天内再次住院（32.4% vs. 11.9%，p<0.01）。在 5 例曾尝试过三次或以上胃底折叠术的患者中，需要行食管空肠吻合术。如果排除这些患者，RYGB 与再次行胃底折叠术在并发症、再次手术或再次住院方面没有差异。两组患者在手术前的胃食管反流病健康相关生活质量（HRQL）评分相似，且在长期随访中均显著改善，且改善程度相似。
结论
在肥胖率高且先前多次尝试胃底折叠术的复杂患者中，转为 RYGB 可获得良好的症状缓解效果。曾接受过三次或以上胃底折叠术的患者更有可能需要行食管空肠吻合术。该亚组患者的并发症发生率似乎很高。
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