腹腔镜抗反流手术对胃食管反流病主观症状的影响因素分析

目的分析腹腔镜胃底折叠术和食管裂孔疝修补术治疗胃食管反流病（GERD）主观症状改善的因素分析。 方法回顾分析2011年1月至2019年12月于上海长征医院甲乳疝外科接受腹腔镜下抗反流手术92例患者的临床资料。胃底折叠术包括Nissen患者54例和Toupet患者38例。随访108个月，所有患者均通过电话随访，内容包括反流症状（反酸、胃灼热）的改善，术后并发症、满意度等。并以反流和胃灼热症状的复发作为评判抗反流术后疗效的标准。通过χ²检验单因素分析和Logistic回归多因素分析，分析了性别、年龄（60岁为界）、质子泵抑制剂（PPI）使用时间（30和60个月为界）、PPI反应性（良好/不佳）、裂孔疝复发、手术方式（Nissen/Toupet）以及是否应用补片等因素对于GERD相关症状的影响。 结果所有手术均顺利完成，末次随访时共有11例出现反流复发和21例胃灼热复发，其中12例患者自觉食管炎症状（反流、胃灼热）无缓解，手术总满意率为81.52%。末次随访时共有16例存在不同程度的吞咽困难，Niseen组10例，Toupet组6例。反流复发的单因素分析结果表明性别、年龄、手术方式、术前PPI使用时间以及PPI反应性与反流复发无相关性（P>0.05），裂孔疝复发和是否应用补片是术后反流复发的影响因素（P<0.05），多因素分析提示裂孔疝复发是术后反流复发的独立影响因素。胃灼热复发的单因素分析结果表明性别、年龄、手术方式、术前PPI使用时间以及应用补片与胃灼热复发无相关性（P>0.05），但PPI反应性和裂孔疝复发是术后胃灼热复发的影响因素（P<0.05），多因素分析表明PPI反应性是术后胃灼热复发的独立影响因素。 结论腹腔镜抗反流手术（胃底折叠术和食管裂孔疝修补术）治疗GERD是安全有效的，对于术前PPI反应性较差的患者，手术指征应更加慎重。

Analysis of the influencing factors of laparoscopic anti-reflux surgery on subjective symptoms of gastroesophageal reflux disease

ObjectiveWe analyze the factors of laparoscopic anti-reflux surgery to improve the subjective symptoms of gastroesophageal reflux disease (GERD). MethodsThe clinical data of 92 patients who underwent laparoscopic anti-reflux surgery in the Department of Thyroid Breast Hernia Surgery of Shanghai Changzheng Hospital from January 2011 to December 2019 were retrospectively analyzed. Fundoplication included 54 cases of Nissen and 38 cases of Toupet. All patients were followed up by telephone for 108 months, including the improvement of reflux symptoms (acid reflux, heartburn), postoperative complications, satisfaction, etc. The recurrence of reflux and heartburn symptoms was used to evaluate the efficacy of anti-reflux surgery. χ² test, univariate analysis and logistic regression multivariate analysis were used to analyze the effects of gender, age (60 years old as the cut off value), PPI use time (30 months and 60 months as the cut off value), PPI reactivity (good/poor), hiatal hernia recurrence, operation method (Nissen/Toupet) and whether or not mesh was used on GERD related symptoms. ResultsAll operations were successfully completed. At the last follow-up, 11 cases had reflux recurrence and 21 cases had heartburn recurrence. Among them, 12 patients felt that the symptoms of esophagitis (reflux and heartburn) were not relieved. The overall satisfaction rate of operation was 81.52%. At the last follow-up, 16 cases had dysphagia of varying degrees, including 10 cases in Niseen group and 6 cases in Toupet group. The results of univariate analysis of reflux recurrence showed that gender, age, operation method, preoperative PPI use time and PPI reactivity has no correlation with reflux recurrence (P>0.05). The recurrence of hiatal hernia and the application of mesh were the influencing factors of postoperative reflux recurrence (P<0.05). Multivariate analysis showed that recurrence of hiatal hernia was independent influencing factor of postoperative reflux recurrence. Univariate analysis of heartburn recurrence showed that gender, age, operation method, preoperative PPI use time and mesh application has no correlation with heartburn recurrence (P>0.05), but PPI reactivity and hiatal hernia recurrence were the influencing factors of postoperative heartburn recurrence (P<0.05). Further multivariate analysis showed that PPI reactivity was the independent influencing factor of postoperative heartburn recurrence. ConclusionLaparoscopic anti-reflux surgery (fundoplication and hiatal hernia repair) is safe and effective in the treatment of GERD. For patients with poor preoperative PPI reactivity, the surgical indications should be more cautious.