Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri; USA.
Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky; USA.
Am J Gastroenterol. 2023 Dec 1;118(12):2148-2156. doi: 10.14309/ajg.0000000000002374. Epub 2023 Jun 19.
Sleeve gastrectomy (SG) results in persistent or de novo reflux more often than Roux-en-Y gastric bypass (RYGB). We investigated pressurization patterns in the proximal stomach on high-resolution manometry (HRM) to determine associations with reflux after SG.
Patients undergoing HRM and ambulatory pH-impedance monitoring after SG and RYGB over a 2-year period (2019-2020) were included. For each included patient, 2 symptomatic control patients with HRM and pH-impedance monitoring for reflux symptoms were identified within the same time frame; 15 asymptomatic healthy controls with HRM studies were also studied. Concurrent myotomy and preoperative diagnosis of obstructive motor disorders were exclusions. Conventional HRM metrics, esophagogastric junction (EGJ) pressures, contractile integral (EGJ-CI), acid exposure time (AET), and reflux episode numbers were extracted. Intragastric pressure was sampled at baseline, during swallows, and with straight leg raise maneuver, and compared with intraesophageal pressure and reflux burden.
Patient cohorts included 36 SG patients, 23 RYGB patients, 113 symptomatic controls, and 15 asymptomatic controls. While both SG and RYGB patients pressurized the stomach during swallows and straight leg raise, SG patients had higher AET (median 6.0% vs 0.2%), reflux episode numbers (median 63.0 vs 37.5), and baseline intragastric pressure (median 17.3 mm Hg vs 13.1 mm Hg) ( P < 0.001). SG patients also had lower trans-EGJ pressure gradients when reflux episodes were >80 or AET was >6.0% ( P = 0.018 and 0.08, respectively, compared with no pathologic reflux). On multivariable analysis, SG status and low EGJ-CI independently associated with AET and reflux episode numbers ( P ≤ 0.04).
Impaired EGJ barrier function and proximal gastric pressurization after SG are associated with gastroesophageal reflux, especially during strain maneuvers.
袖状胃切除术（SG）比 Roux-en-Y 胃旁路术（RYGB）更常导致持续性或新发反流。我们通过高分辨率测压（HRM）研究胃近端的加压模式，以确定其与 SG 后反流的关系。
纳入了 2019 年至 2020 年期间接受 SG 和 RYGB 后 HRM 和动态 pH 阻抗监测的患者。对于每一位纳入的患者，在同一时间段内确定了 2 例具有 HRM 和 pH 阻抗监测的症状性对照患者（有反流症状）；同时还研究了 15 例具有 HRM 研究的无症状健康对照者。同时存在肌切开术和术前诊断为阻塞性运动障碍的患者被排除在外。提取了常规 HRM 指标、食管胃结合部（EGJ）压力、收缩积分（EGJ-CI）、酸暴露时间（AET）和反流事件次数。在基线时、吞咽时和直腿抬高时采集胃内压力，并与食管内压力和反流负担进行比较。
患者队列包括 36 例 SG 患者、23 例 RYGB 患者、113 例症状性对照患者和 15 例无症状对照患者。虽然 SG 和 RYGB 患者在吞咽和直腿抬高时都会使胃加压，但 SG 患者的 AET（中位数 6.0% vs. 0.2%）、反流事件次数（中位数 63.0 次 vs. 37.5 次）和基线胃内压力（中位数 17.3mmHg vs. 13.1mmHg）更高（P<0.001）。当反流事件>80 次或 AET>6.0%时，SG 患者的跨食管胃结合部压力梯度也较低（与无病理性反流相比，P=0.018 和 0.08）。多变量分析显示，SG 状态和低 EGJ-CI 独立与 AET 和反流事件次数相关（P≤0.04）。
SG 后食管胃结合部屏障功能受损和胃近端加压与胃食管反流有关，尤其是在应变操作时。
