Greenberg Jacques A, Palacardo Federico, Edelmuth Rodrigo C L, Egan Caitlin E, Lee Yeon Joo, Dakin Gregory, Zarnegar Rasa, Afaneh Cheguevara, Bellorin Omar
Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA.
Department of Surgery, Division of Gastrointestinal Metabolic & Bariatric Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 520 East 70th Street, Starr Pavillion, 8th Floor, New York, NY, 10021, USA.
Surg Endosc. 2023 Feb;37(2):1543-1550. doi: 10.1007/s00464-022-09450-0. Epub 2022 Jul 20.
Sleeve gastrectomy is among the most commonly-performed procedures for morbid obesity. However, patients occasionally develop post-sleeve gastroesophageal reflux disease (GERD). Identifying patients most at risk for this complication remains difficult. We aimed to correlate intra-operative physiologic measurements of the lower esophageal sphincter (LES) at the gastroesophageal junction (GEJ) during robotic sleeve gastrectomy in an attempt to identify predictors of post-sleeve GERD symptoms.
A retrospective chart review of a prospectively maintained database identified 28 patients in whom robotic sleeve gastrectomy was performed utilizing EndoFLIP™ technology between January and September 2021. Intraoperative LES measurements at the GEJ including cross-sectional area (CSA), distensibility index (DI), intra-balloon pressure, and high-pressure zone (HPZ length) were correlated with post-operative GERD.
GEJ CSA, pressure, and DI increased over the course of the surgery (CSA pre-op: 31 (IQR 19.3-39.5) mm vs. post-op: 67 (IQR 40.8-95.8) mm, p < 0.001; pressure: 25.8 (IQR 20.2-33.1) mmHg vs. 31.5 (IQR 28.9-37.0) mmHg, p = 0.007; DI 1.1 (IQR 0.8-1.8) mm/mmHg vs. 2.0 (IQR 1.2-3.0) mm/mmHg, p = < 0.001), whereas HPZ length decreased (2.5 (IQR 2.5-3) cm vs. 2.0 (IQR 1.3-2.5) cm, p = 0.022). Twenty-three patients (82.1%) completed a post-operative GERD questionnaire. Fifteen (65.2%) had no GERD symptoms before or after surgery; 5 (21.7%) reported new post-sleeve GERD symptoms; 3 (13.0%) reported exacerbation of pre-existing GERD symptoms. Patients with new or worsening GERD symptoms had higher post-sleeve DIs (3.2 (IQR 1.9-4.5) mm/mmHg vs. 1.5 (IQR 1.2-2.4) mm/mmHg, p = 0.024) and lower post-sleeve LES pressures (29.9 (IQR 26.3-32.9) mmHg vs. 35.2 (IQR 31.0-38.0) mmHg, p = 0.023) than those without.
An increase in GEJ CSA, pressure, and DI, and a decrease in GEJ length can be expected during robotic sleeve gastrectomy. Patients with new or worsening post-sleeve GERD symptoms have higher post-sleeve DI and lower post-sleeve LES pressure than their asymptomatic counterparts.
袖状胃切除术是治疗病态肥胖最常用的手术之一。然而，患者偶尔会发生袖状胃切除术后胃食管反流病（GERD）。确定最易发生这种并发症的患者仍然很困难。我们旨在关联机器人袖状胃切除术中胃食管交界处（GEJ）下食管括约肌（LES）的术中生理测量值，以试图确定袖状胃切除术后GERD症状的预测因素。
对一个前瞻性维护的数据库进行回顾性图表审查，确定了28例在2021年1月至9月期间使用EndoFLIP™技术进行机器人袖状胃切除术的患者。GEJ处术中LES测量值，包括横截面积（CSA）、扩张性指数（DI）、球囊内压力和高压区（HPZ长度），与术后GERD相关。
手术过程中GEJ的CSA、压力和DI增加（术前CSA：31（四分位间距19.3 - 39.5）mm，术后：67（四分位间距40.8 - 95.8）mm，p < 0.001；压力：25.8（四分位间距20.2 - 33.1）mmHg，对31.5（四分位间距28.9 - 37.0）mmHg，p = 0.007；DI 1.1（四分位间距0.8 - 1.8）mm/mmHg，对2.0（四分位间距1.2 - 3.0）mm/mmHg，p = < 0.001），而HPZ长度减少（2.5（四分位间距2.5 - 3）cm，对2.0（四分位间距1.3 - 2.5）cm，p = 0.022）。23例患者（82.1%）完成了术后GERD问卷调查。15例（65.2%）在手术前后均无GERD症状；5例（21.7%）报告有新的袖状胃切除术后GERD症状；3例（13.0%）报告原有GERD症状加重。有新的或加重的GERD症状的患者术后DI较高（3.2（四分位间距1.9 - 4.5）mm/mmHg，对1.5（四分位间距1.2 - 2.4）mm/mmHg，p = 0.024），术后LES压力较低（29.9（四分位间距26.3 - 32.9）mmHg，对35.2（四分位间距31.0 - 38.0）mmHg，p = 0.023）。
机器人袖状胃切除术中可预期GEJ的CSA、压力和DI增加，GEJ长度减少。有新的或加重的袖状胃切除术后GERD症状的患者比无症状的患者术后DI更高，术后LES压力更低。
