Tadé Yanick, Newman Daniel, Walters Ryan W, Nandipati Kalyana C
School of Medicine, Creighton University, Omaha, NE, USA.
Department of Clinical Research and Public Health, Creighton University, Omaha, NE, USA.
Surg Endosc. 2025 May 29. doi: 10.1007/s00464-025-11856-5.
Gastroesophageal reflux disease (GERD) impacts 10-30% of the population in the Western world. Surgical interventions including Laparoscopic Fundoplication (LF), Transoral Incisionless Fundoplication (TIF), and Magnetic Sphincter Augmentation (MSA) have proven effective in managing GERD. This meta-analysis aims to compare short- and long-term outcomes of these surgical options.
A comprehensive search of PubMed, Embase, Scopus, Cochrane, and Medline from 1980 to 2024 was conducted to identify randomized control trials or cohort designs that included adults with GERD who underwent fundoplication (Nissen, Toupet), MSA, or TIF and had preoperative and post-operative acid exposure time (AET), DeMeester score, and/or relief score (e.g., GERD-HRQL); we considered all post-operative outcome measurements. We excluded studies with any surgical variations of the procedures, reoperations, and studies not published in English. Risk of bias was assessed using the Oxford scoring system for randomized control trials and the Newcastle-Ottawa scale (NOS) for cohort designs. A total of 3912 studies were identified initially, with our review including 78 unique studies providing 166 post-operative outcome measurements. Given studies could include multiple post-operative outcome measurements, we used multilevel random-effects meta-analysis. Between-procedure comparisons were made using multilevel meta-regression. For all outcomes, more positive values indicated greater improvement; mean differences (MD) were estimated for AET and DeMeester scores, whereas standardized mean differences (SMD) were estimated for relief scores.
A total of 9516 patients were included with an average age of 50.8 years (SD: 6.7) with 53.7% male and an average BMI of 27.1 (SD: 2.3). The median length of follow-up across all observations was 12 months (IQR: 6-24 months; range: 0.25-120.5 months). All procedures indicated a statistically significant mean improvement in AET, relief score, and DeMeester scores (Table 1). Compared to Nissen, TIF averaged significantly less mean improvement in AET (MD: - 4.06, 95% CI: - 8.03 to - 0.09, p = .045) and DeMeester score (MD: - 20.60, 95% CI: - 38.33 to - 2.88, p = .023), whereas MSA and Toupet averaged significantly better relief scores (SMD: 0.28, 95% CI: 0.01 to 0.56, p = .044 and SMD = 0.17, 95% CI: 0.01 to 0.32, p = .034, respectively). This review advances understanding of the objective and subjective improvement of the traditional and recent surgical anti-reflux procedures used for symptomatic GERD. Overall, Nissen fundoplication demonstrated significantly better improvement with acid exposure and DeMeester score compared to MSA and TIF. However, symptom relief scores are significantly improved with Toupet fundoplication and MSA compared to other surgical treatment options.
胃食管反流病（GERD）影响着西方世界10%至30%的人口。包括腹腔镜胃底折叠术（LF）、经口无切口胃底折叠术（TIF）和磁括约肌增强术（MSA）在内的手术干预已被证明对治疗GERD有效。本荟萃分析旨在比较这些手术方式的短期和长期疗效。
对1980年至2024年期间的PubMed、Embase、Scopus、Cochrane和Medline进行全面检索，以确定随机对照试验或队列研究设计，这些研究纳入了接受胃底折叠术（nissen、Toupet）、MSA或TIF治疗的成年GERD患者，并记录了术前和术后的酸暴露时间（AET）、DeMeester评分和/或缓解评分（如GERD-HRQL）；我们考虑了所有术后结果测量。我们排除了手术方式有任何变异、再次手术以及未以英文发表的研究。使用牛津随机对照试验评分系统和队列研究设计的纽卡斯尔-渥太华量表（NOS）评估偏倚风险。最初共识别出3912项研究，我们的综述纳入了78项独特研究，提供了166个术后结果测量值。鉴于研究可能包括多个术后结果测量值，我们使用了多水平随机效应荟萃分析。使用多水平元回归进行手术方式之间的比较。对于所有结果，正值越大表明改善越大；对AET和DeMeester评分估计平均差异（MD），而对缓解评分估计标准化平均差异（SMD）。
共纳入9516例患者，平均年龄50.8岁（标准差：6.7），男性占53.7%，平均BMI为27.1（标准差：2.3）。所有观察的中位随访时间为12个月（四分位间距：6-24个月；范围：0.25-120.5个月）。所有手术方式均显示AET、缓解评分和DeMeester评分在统计学上有显著的平均改善（表1）。与nissen相比，TIF在AET（MD：-4.06，95%CI：-8.03至-0.09，p = 0.045）和DeMeester评分（MD：-20.60，95%CI：-38.33至-2.88，p = 0.023）方面的平均改善明显较少，而MSA和Toupet的缓解评分平均明显更好（SMD：0.28，95%CI：0.01至0.56，p = 0.044；SMD = 0.17，95%CI：0.01至0.32，p = 0.034）。本综述增进了对用于有症状GERD的传统和近期手术抗反流手术客观和主观改善情况的理解。总体而言，与MSA和TIF相比，nissen胃底折叠术在酸暴露和DeMeester评分方面的改善明显更好。然而，与其他手术治疗选择相比，Toupet胃底折叠术和MSA的症状缓解评分有显著改善。
