Department of Surgery, Massachusetts General Hospital, Boston, USA.
Department of Surgery, Indiana University School of Medicine, Indianapolis, USA.
Surg Endosc. 2021 Aug;35(8):4095-4123. doi: 10.1007/s00464-021-08358-5. Epub 2021 Mar 2.
Gastroesophageal reflux disease (GERD) has a high worldwide prevalence in adults and children. There is uncertainty regarding medical versus surgical therapy and different surgical techniques. This review assessed outcomes of antireflux surgery versus medical management of GERD in adults and children, robotic versus laparoscopic fundoplication, complete versus partial fundoplication, and minimal versus maximal dissection in pediatric patients.
PubMed, Embase, and Cochrane databases were searched (2004-2019) to identify randomized control and non-randomized comparative studies. Two independent reviewers screened for eligibility. Random effects meta-analysis was performed on comparative data. Study quality was assessed using the Cochrane Risk of Bias and Newcastle Ottawa Scale.
From 1473 records, 105 studies were included. Most had high or uncertain risk of bias. Analysis demonstrated that anti-reflux surgery was associated with superior short-term quality of life compared to PPI (Std mean difference = - 0.51, 95%CI - 0.63, - 0.40, I = 0%) however short-term symptom control was not significantly superior (RR = 0.75, 95%CI 0.47, 1.21, I = 82%). A proportion of patients undergoing operative treatment continue PPI treatment (28%). Robotic and laparoscopic fundoplication outcomes were similar. Compared to total fundoplication, partial fundoplication was associated with higher rates of prolonged PPI usage (RR = 2.06, 95%CI 1.08, 3.94, I = 45%). There was no statistically significant difference for long-term symptom control (RR = 0.94, 95%CI 0.85, 1.04, I = 53%) or long-term dysphagia (RR = 0.73, 95%CI 0.52, 1.02, I = 0%). Ien, minimal dissection during fundoplication was associated with lower reoperation rates than maximal dissection (RR = 0.21, 95%CI 0.06, 0.67).
The available evidence regarding the optimal treatment of GERD often suffers from high risk of bias. Additional high-quality randomized control trials may further inform surgical decision making in the treatment of GERD.
胃食管反流病（GERD）在成人和儿童中的全球患病率很高。对于医学治疗与手术治疗以及不同的手术技术，存在不确定性。本综述评估了抗反流手术与成人和儿童 GERD 的药物治疗、机器人与腹腔镜胃底折叠术、全胃底折叠术与部分胃底折叠术以及儿科患者最小与最大解剖术的疗效。
检索了 PubMed、Embase 和 Cochrane 数据库（2004-2019 年），以确定随机对照和非随机对照研究。两位独立的审查员筛选了合格研究。对比较数据进行了随机效应荟萃分析。使用 Cochrane 偏倚风险和纽卡斯尔渥太华量表评估了研究质量。
从 1473 条记录中，纳入了 105 项研究。大多数研究的偏倚风险较高或不确定。分析表明，与 PPI 相比，抗反流手术与短期生活质量的提高相关（标准均数差= -0.51，95%CI -0.63，-0.40，I=0%），但短期症状控制无显著优势（RR=0.75，95%CI 0.47，1.21，I=82%）。一部分接受手术治疗的患者继续使用 PPI（28%）。机器人与腹腔镜胃底折叠术的结果相似。与全胃底折叠术相比，部分胃底折叠术与更高的 PPI 长期使用率相关（RR=2.06，95%CI 1.08，3.94，I=45%）。长期症状控制（RR=0.94，95%CI 0.85，1.04，I=53%）或长期吞咽困难（RR=0.73，95%CI 0.52，1.02，I=0%）的差异无统计学意义。在胃底折叠术中，最小程度的解剖与较低的再次手术率相关（RR=0.21，95%CI 0.06，0.67）。
GERD 最佳治疗方法的现有证据往往存在高偏倚风险。进一步开展高质量的随机对照试验可能会为 GERD 的手术治疗决策提供更多信息。
