Mohr Cassandra, Ciomperlik Hailie, Dhanani Naila, Olavarria Oscar A, Hannon Craig, Hope William, Roth Scott, Liang Mike K, Holihan Julie L
Department of Surgery, McGovern Medical School, Houston, TX, USA.
Department of Surgery, Lyndon B. Johnson Hospital, 5656 Kelley St, Houston, TX, 77026, USA.
J Gastrointest Surg. 2023 Feb;27(2):390-397. doi: 10.1007/s11605-023-05590-3. Epub 2023 Jan 17.
The ICARUS guidelines are a systematic review and Delphi process that provide recommendations in the treatment and management of patients with gastroesophageal reflux disease (GERD). Many of the recommendations were supported by randomized trials; some were not. This study assesses guidelines with limited evidence and weak endorsement.
Four ICARUS guidelines were chosen: the role of fundoplication for patients with BMI > 35, regurgitation, chest pain, and extra-esophageal symptoms. A multicenter database of patients undergoing fundoplication surgery for GERD between 2015 and 2020 was used. Outcomes assessed were anatomic failure and symptom recurrence. Multivariable regression was performed.
Five institutions performed a fundoplication on 461 patients for GERD with a median of follow-up of 14.7 months (IQR 14.2). On multivariate analysis, patients with the chosen pre-operative comorbidities achieved comparable post-operative benefits. Patients with a BMI > 35 were not more likely to experience anatomic failure. Patients with pre-operative regurgitation had similar symptom recurrence rates to those without. Patients with non-cardiac chest pain had comparable rates of symptom recurrence to those without. Reporting a pre-operative chronic cough attributable to reflux was not associated with higher rates of post-operative symptom recurrence.
Among the ICARUS guidelines and recommendations, a small proportion was lacking evidence at low risk for bias and endorsement. The results of this multicenter study evaluated outcomes of patients with various pre-operative conditions: BMI > 35, chest pain attributable to reflux, extra-esophageal symptoms attributable to reflux, and regurgitation. Our findings endorse patients with these characteristics as candidates for anti-reflux surgery.
ICARUS指南是一个系统评价和德尔菲法流程，为胃食管反流病（GERD）患者的治疗和管理提供建议。许多建议得到了随机试验的支持；有些则没有。本研究评估了证据有限且支持力度较弱的指南。
选择了四项ICARUS指南：针对BMI>35、反流、胸痛和食管外症状患者的胃底折叠术的作用。使用了一个多中心数据库，该数据库包含2015年至2020年间因GERD接受胃底折叠术的患者。评估的结果是解剖学失败和症状复发。进行了多变量回归分析。
五家机构对461例GERD患者进行了胃底折叠术，中位随访时间为14.7个月（四分位间距14.2）。多变量分析显示，具有所选术前合并症的患者术后获益相当。BMI>35的患者发生解剖学失败的可能性并不更高。术前有反流症状的患者与无反流症状的患者症状复发率相似。非心源性胸痛患者与无胸痛患者的症状复发率相当。报告术前因反流引起的慢性咳嗽与术后症状复发率较高无关。
在ICARUS指南和建议中，一小部分缺乏低偏倚风险的证据和支持。这项多中心研究的结果评估了各种术前情况患者的结局：BMI>35、反流引起的胸痛、反流引起的食管外症状和反流。我们的研究结果支持将具有这些特征的患者作为抗反流手术的候选者。
