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中华肥胖与代谢病电子杂志

中华肥胖与代谢病电子杂志 ›› 2023, Vol. 09 ›› Issue (01) : 4 -11. doi: 10.3877/cma.j.issn.2095-9605.2023.01.002

论著

腹腔镜袖状胃切除术中胃窦切缘与幽门的距离对术后胃食管反流病及减重效果的影响
伍振鹏, 乔钰涵, 向林, 江云颂, 彭居正, 吴丽娜, 程吕佳, 关炳生, 庄子康, 杨景哥†()   
  1. 510630　广州，暨南大学附属第一医院胃肠外科一区
  • 收稿日期:2022-12-28 出版日期:2023-02-28
  • 通信作者: 杨景哥
  • 基金资助:
    广州市科技计划项目资助(202201020064); 广东省自然科学基金(2017A030313855)

Effect of different antrum margin to pylorus distance on postoperative gastroesophageal reflux disease and weight loss in laparoscopic sleeve gastrectomy

Zhenpeng Wu, Yuhan Qiao, Lin Xiang, Yunsong Jiang, Junzheng Peng, Lina Wu, Lvjia Cheng, Bingsheng Guan, Zikang Zhuang, Jingge Yang†()   

  1. Department of Gastrointestinal Surgery, the First Affiliated Hospital of Jinan University, Guangzhou 510630, China
  • Received:2022-12-28 Published:2023-02-28
  • Corresponding author: Jingge Yang
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引用本文：

伍振鹏, 乔钰涵, 向林, 江云颂, 彭居正, 吴丽娜, 程吕佳, 关炳生, 庄子康, 杨景哥. 腹腔镜袖状胃切除术中胃窦切缘与幽门的距离对术后胃食管反流病及减重效果的影响[J]. 中华肥胖与代谢病电子杂志, 2023, 09(01): 4-11.

Zhenpeng Wu, Yuhan Qiao, Lin Xiang, Yunsong Jiang, Junzheng Peng, Lina Wu, Lvjia Cheng, Bingsheng Guan, Zikang Zhuang, Jingge Yang. Effect of different antrum margin to pylorus distance on postoperative gastroesophageal reflux disease and weight loss in laparoscopic sleeve gastrectomy[J]. Chinese Journal of Obesity and Metabolic Diseases(Electronic Edition), 2023, 09(01): 4-11.

目的

探讨腹腔镜袖状胃切除术（LSG）中不同胃窦切缘与幽门的距离对术后胃食管反流病（GERD）和减重效果之间的关系。

方法

采取单中心前瞻性随机对照研究，纳入2018年3月至2019年3月在暨南大学附属第一医院接受LSG的肥胖症患者45例，并将其随机平均分为3组，分别为G1组：胃窦切缘距幽门2 cm；G2组：胃窦切缘距幽门4 cm；G3组：胃窦切缘距幽门6 cm。在LSG术前以及术后的1月、3月、6月和1年采集相关数据，包括体重、BMI、多余体重减少百分比（%EWL）、总体重减轻百分比（%TWL）、胃食管反流病健康相关生活质量问卷（GERD-HRQL）评分等，并进行分析。

结果

各组间术后1月、3月、6月及1年体重、BMI下降和%TWL变化差异均有统计学意义（P<0.05）。在GERD-HRQL评分中，与术前相比，各组间术后1月的总分及胃灼热分数均明显升高（P<0.05）。术前2例伴有GERD的患者术后症状均有所改善。术后1年随访中发现了6例新发的GERD，分别为：G1组1例，G2组3例和G3组2例，各组间GERD的发生差异无统计学意义。单因素分析结果提示手术方案与术后体重变化明显相关：G1组术后平均BMI下降和术后平均%TWL的变化较G2和G3两组明显，差异有统计学意义（P<0.05）。

结论

LSG术后患者GERD-HRQL评分总体呈上升趋势，但不同的胃窦切缘距离与术后GERD的发生无显著相关性。相比于4 cm和6 cm，胃窦切缘距幽门2 cm可能是LSG术后获得更好减重效果的安全距离。

关键词: 腹腔镜袖状胃切除术, 胃窦切缘距离, 胃食管反流病, 肥胖症, 减重手术
Objective

To investigate the effect of the distance between gastric antrum margin and pylorus in laparoscopic sleeve gastrectomy (LSG) on postoperative gastroesophageal reflux disease (GERD) and weight loss.

Methods

A single-center prospective randomized controlled study was used. 45 patients who received LSG during March 2018 to March 2019 were included. Patients were equally divided into 3 groups according to the distance between antral margin and pylorus by computerized random grouping method: G1 (2 cm), G2 (4 cm), and G3 (6 cm). Data were collected and analyzed before and 1 month, 3 months, 6 months and 1 year after LSG.

Results

There were statistically significant differences in the postoperative BMI decrease and %TWL between the groups (P<0.05). The postoperative symptoms of 2 patients with GERD before surgery were improved. There have 6 patients were new-onset of the GERD after 1 year of follow-up. In the GERD-HRQL score, the total score and heartburn score at 1 month after surgery were significantly higher among all groups compared with those before surgery (P<0.05). Compared with G2 and G3 groups, the average postoperative BMI decreased and the average %TWL increased more significantly in G1 group, with statistically significant differences (P<0.05).

Conclusions

This study found that postoperative GERD-HRQL scores have generally increase. Yet, there was no significant correlation between different antral margin distances and the occurrence of postoperative GERD. Compared with 4 cm and 6 cm, 2 cm between antral margin and pylorus may be a safe distance to achieve better weight loss after LSG.

Key words: Laparoscopic sleeve gastrectomy, Incisal margin of antrum, Gastroesophageal reflux disease, Obesity, Bariatric surgery
表1 三组患者术前一般资料
基本特征 总人群 G1组（距幽门2 cm） G2组（距幽门4 cm） G3组（距幽门6 cm） P值
总例数 45 15 15 15  
男女比例 13/32 4/11 2/13 7/8 0.087
身高（cm） 160.51±9.74 159.9±9.65 158.44±10.18 161.81±9.76 0.000*
体重（kg） 99.90±19.12 104.31±20.94 96.19±19.33 99.19±17.36 0.803
BMI（kg/m2） 38.89 ± 5.81 40.67±6.54 38.00± 4.15 38.00±6.41 0.800
吸烟史 12(26.7%) 2 (13.3%) 3(20%) 7(46.7%) 0.196
胃食管反流症 2(4.4%) 0 1(6.7%) 1(6.7%) 0.253
食管炎 2(4.4%) 0 1(6.7%) 1(6.7%) 0.253
食管炎分级 2例LA-A级 - LA-A级 LA-A级  
图1 减重手术前后各组间体重指标和反流评分变化趋势。1A-1H分别表示各组间体重、BMI、BMI下降值、%EWL、%TWL、GERD-HRQL评分总分、胃灼热分数、反流分数变化的变化趋势
表2 G1组（距幽门2 cm）LSG术后随访结果
基本特征 术前 术后1月 术后3月 术后半年 术后1年
体重（kg） 104.31±20.94 82.15±17.10* 77.07±15.04* 70.49±13.05* 64.40±11.57*
BMI（kg/m2） 40.67±6.54 31.92±4.59* 30.07±4.85* 27.52±4.26* 24.27±2.60*
BMI的变化（kg/m2）   8.74±2.98 10.60±1.89 13.14±2.62 16.40± 4.57
%EWL   63.51±31.94 80.79±41.26 98.83±46.79 117.75±41.94
%TWL   21.13±5.25 26.04±1.87 32.20±2.62 39.66±5.32
GERD-HRQL评分          
总分 2.00±4.52 6.33±2.02* 3.67±6.7 8.20±7.23* 3.33±3.97
胃灼热分数 0.60±1.84 2.53±0.99* 1.60±1.76* 3.33±3.26* 0.4±1.29
反流分数 1.53±3.11 2.73±0.79 1.33±3.33 3.80±4.87 1.33±1.63
表3 G2组（距幽门4 cm）LSG术后随访结果
基本特征 术前 术后1月 术后3月 术后半年 术后1年
体重（kg） 96.19±19.32 78.85±15.38 72.47±13.53 65.93±11.83 62.38±10.30
BMI（kg/m2） 38.00±4.15 31.24±4.05 28.71±3.45 28.71±3.45 24.76±2.39
BMI的变化（kg/m2）   6.77±1.88 9.29±1.69 11.85±2.89 13.25±2.93
%EWL   56.39±23.67 77.04±23.58 96.10±28.05 106.53±19.70
%TWL   17.86±4.96 24.46±3.60 30.99±6.09 34.58±5.00
GERD-HRQL评分          
总分 1.20±1.90 7.00±8.72* 4.93±12.96 6.00±10.64 5.13±8.36
胃灼热分数 0 1.80±2.88* 1.73±3.99* 2.27±4.03* 2.20±4.06*
反流分数 1.20±1.90 4.00±4.19* 2.00±5.52 2.27±4.10 2.33±3.77
表4 G3组（距幽门6 cm）LSG术后随访结果
基本特征 术前 术后1月 术后3月 术后半年 术后1年
体重（kg） 99.20±17.36 81.90±14.42* 77.20±13.03* 72.27±12.66* 67.63±12.82*
BMI（kg/m2） 38.00±6.41 31.23±4.28* 29.48±4.15* 27.63±4.460* 25.77±4.08*
BMI的变化（kg/m2）   6.77±2.74 8.52±2.67 10.36±2.38 12.22±3.69
%EWL   58.72±23.46 76.99±35.42 96.96±47.84 106.46±30.11
%TWL   17.31±4.89 22.01±3.95 27.09±3.38 31.67±6.92
GERD-HRQL评分          
总分 2.53±3.23 10.47±5.41* 4.87±5.32 6.33±5.341* 2.73±4.99
胃灼热分数 0.87±1.89 3.00±2.88* 1.87±1.64 2.6±3.47* 0.4±1.549*
反流分数 1.40±1.72 6.33±1.59* 2.33±3.68 3.47±2.64 1.6±3.04
表3 不同胃窦切缘距离与减重效果及GERD相关性分析
相关因素 不同胃窦切缘距离
r值 P值
体重（kg） 0.173 0.255
BMI（kg/m2） 0.126 0.410
BMI的变化（kg/m2） -0.381 0.010*
%EWL -0.078 0.613
%TWL -0.583 0.000*
胃食管反流病 -0.080 0.601
GERD-HRQL评分    
总分 -0.222 0.142
胃灼热分数 -0.057 0.710
反流分数 0.080 0.601
表4 不同胃窦切缘距离对减重效果的影响
手术方案 体重 BMI BMI的变化 %TWL %EWL
Z P Z P Z P Z P Z P
G1 vs. G2 -0.083 0.935 -0.436 0.683 -1.970 0.049* -0.311 0.001* -0.311 0.775
G1 vs. G3 -1.101 0.285 -0.809 0.419 -2.426 0.015* -03.422 0.001* -0.601 0.548
G2 vs. G3 -1.142 0.267 -0.436 0.683 -0.726 0.486 -1.597 0.116 -0.021 1.00
统计值 χ2 P χ2 P χ2 P χ2 P χ2 P
1.696 0.428 0.696 0.706 6.923 0.031* 15.685 0.000* 0.293 0.864
表5 不同胃窦切缘距离对术后GERD的影响
手术方案 总分 胃灼热分数 反流分数
Z P Z P Z P
G1 vs. G2 -0.364 0.744 -1.683 0.202 -0.340 0.775
G1 vs. G3 -1.332 0.233 -0.518 0.605 -0.901 0.368
G2 vs. G3 -1.469 0.1187 -2.101 0.126 -0.817 0.512
统计值 χ2 P χ2 P χ2 P
2.543 0.280 5.808 0.055 1.015 0.602
[1]
Blüher M. Obesity: global epidemiology and pathogenesis [J]. Nat Rev Endocrinol, 2019, 15(5): 288-298.
[2]
NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128.9 million children, adolescents, and adults [J]. Lancet, 2017, 390(10113): 2627-2642.
[3]
Piché ME, Tchernof A, Després JP. Obesity Phenotypes, Diabetes, and Cardiovascular Diseases [J]. Circ Res, 2020, 126(11):1477-1500.
[4]
Arterburn DE, Telem DA, Kushner RF, et al. Benefits and Risks of Bariatric Surgery in Adults: A Review [J]. JAMA, 2020, 324(9): 879-887.
[5]
olquitt JL, Pickett K, Loveman E, et al. Surgery for weight loss in adults [J]. Cochrane Database Syst Rev, 2014, 2014(8): CD003641.
[6]
English WJ, DeMaria EJ, Brethauer SA, et al. American Society for Metabolic and Bariatric Surgery estimation of metabolic and bariatric procedures performed in the United States in 2016 [J]. Surg Obes Relat Dis, 2018, 14(3): 259-263.
[7]
李世星, 姜涛, 于洋. 腹腔镜袖状胃切除术治疗肥胖型2型糖尿病的疗效分析 [J/CD]. 中华肥胖与代谢病电子杂志, 2017, 3(4): 215-219.
[8]
Tack J, Deloose E. Complications of bariatric surgery: dumping syndrome, reflux and vitamin deficiencies [J]. Best Pract Res Clin Gastroenterol, 2014, 28(4): 741-749.
[9]
Katzka DA, Kahrilas PJ. Advances in the diagnosis and management of gastroesophageal reflux disease [J]. BMJ, 2020, 371: m3786.
[10]
Gyawali CP, Kahrilas PJ, Savarino E, et al. Modern diagnosis of GERD: the Lyon Consensus [J]. GUT, 2018, 67(7): 1351-1362.
[11]
El-Serag HB, Graham DY, Satia JA, et al. Obesity is an independent risk factor for GERD symptoms and erosive esophagitis [J]. Am J Gastroenterol, 2005, 100(6): 1243-1250.
[12]
Anand G, Katz PO. Gastroesophageal reflux disease and obesity [J]. Gastroenterol Clin North Am, 2010, 39(1): 39-46.
[13]
Yuan S, Larsson SC. Adiposity, diabetes, lifestyle factors and risk of gastroesophageal reflux disease: a Mendelian randomization study [J]. Eur J Epidemiol, 2022, 37(7): 747-754.
[14]
Sucandy I, Chrestiana D, Bonanni F, et al. Gastroesophageal Reflux Symptoms After Laparoscopic Sleeve Gastrectomy for Morbid Obesity. The Importance of Preoperative Evaluation and Selection [J]. N Am J Med Sci, 2015, 7(5): 189-193.
[15]
Carabotti M, Silecchia G, Greco F, et al. Impact of laparoscopic sleeve gastrectomy on upper gastrointestinal symptoms [J]. Obes Surg, 2013, 23(10): 1551-1557.
[16]
Daes J, Jimenez ME, Said N, Dennis R. Improvement of gastroesophageal reflux symptoms after standardized laparoscopic sleeve gastrectomy [J]. Obes Surg, 2014, 24(4): 536-540.
[17]
刘彦旸, 姚琪远. 腹腔镜袖状胃切除术后胃食管反流病的治疗进展 [J/CD]. 中华肥胖与代谢病电子杂志, 2019, 5(4): 205-208.
[18]
Hayat JO, Wan A. The effects of sleeve gastectomy on gastro-esophageal reflux and gastro-esophageal motility [J]. Expert Rev Gastroenterol Hepatol, 2014, 8(4): 445-452.
[19]
Oor JE, Roks DJ, ünlü Ç, et al. Laparoscopic sleeve gastrectomy and gastroesophageal reflux disease: a systematic review and meta-analysis [J]. Am J Surg, 2016, 211(1): 250-267.
[20]
Yormaz S, Yılmaz H, Ece I, et al. Midterm Clinical Outcomes of Antrum Resection Margin at Laparoscopic Sleeve Gastrectomy for Morbid Obesity [J]. Obes Surg, 2017, 27(4): 910-916.
[21]
中华医学会肠外肠内营养学分会营养与代谢协作组, 北京协和医院减重多学科协作组. 减重手术的营养与多学科管理专家共识 [J]. 中华外科杂志, 2018, 56(2): 81-90.
[22]
高歌, 艾自胜. 使用计算机随机分组与随机抽样的方法及应用 [J]. 中国卫生统计, 2002, 1: 48-49.
[23]
Velanovich V. The development of the GERD-HRQL symptom severity instrument [J]. Dis Esophagus, 2007, 20(2): 130-134.
[24]
Korner J, Inabnet W, Febres G, et al. Prospective study of gut hormone and metabolic changes after adjustable gastric banding and Roux-en-Y gastric bypass [J]. Int J Obes (Lond), 2009, 33(7): 786-795.
[25]
Valderas JP, Irribarra V, Boza C, et al. Medical and surgical treatments for obesity have opposite effects on peptide YY and appetite: a prospective study controlled for weight loss [J]. J Clin Endocrinol Metab, 2010, 95(3): 1069-1075.
[26]
van de Laar AW, Acherman YI. Weight loss percentile charts of large representative series: a benchmark defining sufficient weight loss challenging current criteria for success of bariatric surgery [J]. Obes Surg, 2014, 24(5): 727-734.
[27]
Ionut V, Burch M, Youdim A, et al. Gastrointestinal hormones and bariatric surgery-induced weight loss [J]. Obesity (Silver Spring), 2013, 21(6): 1093-1103.
[28]
De Groot NL, Burgerhart JS, Van De Meeberg PC, et al. Systematic review: the effects of conservative and surgical treatment for obesity on gastro-oesophageal reflux disease [J]. Aliment Pharmacol Ther, 2009, 30(11-12): 1091-1102.
[29]
Tai CM, Lee YC, Wu MS, et al. The effect of Roux-en-Y gastric bypass on gastroesophageal reflux disease in morbidly obese Chinese patients [J]. Obes Surg, 2009, 19(5): 565-570.
[30]
Perry Y, Courcoulas AP, Fernando HC, et al. Laparoscopic Roux-en-Y gastric bypass for recalcitrant gastroesophageal reflux disease in morbidly obese patients [J]. JSLS, 2004, 8(1): 19-23.
[31]
Ayazi S, Hagen JA, Chan LS, et al. Obesity and gastroesophageal reflux: quantifying the association between body mass index, esophageal acid exposure, and lower esophageal sphincter status in a large series of patients with reflux symptoms [J]. J Gastrointest Surg, 2009, 13(8): 1440-1447.
[32]
Himpens J, Dapri G, Cadière GB. A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years [J]. Obes Surg, 2006, 16(11): 1450-1456.
[33]
Melissas J, Leventi A, Klinaki I, et al. Alterations of global gastrointestinal motility after sleeve gastrectomy: a prospective study [J]. Ann Surg, 2013, 258(6): 976-982.
[34]
Shah S, Shah P, Todkar J, et al. Prospective controlled study of effect of laparoscopic sleeve gastrectomy on small bowel transit time and gastric emptying half-time in morbidly obese patients with type 2 diabetes mellitus [J]. Surg Obes Relat Dis, 2010, 6(2): 152-1577.
[35]
Sucandy I, Chrestiana D, Bonanni F, et al. Gastroesophageal Reflux Symptoms After Laparoscopic Sleeve Gastrectomy for Morbid Obesity. The Importance of Preoperative Evaluation and Selection [J]. N Am J Med Sci, 2015, 7(5): 189-193.
[36]
McGlone ER, Gupta AK, Reddy M, et al. Antral resection versus antral preservation during laparoscopic sleeve gastrectomy for severe obesity: Systematic review and meta-analysis [J]. Surg Obes Relat Dis, 2018, 14(6): 857-864.
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[12] 颜宥彤, 赵锐, 万谦益, 张贵祥, 沈弘毅, 程中, 陈亿. GLP-1受体激动剂——司美格鲁肽的应用及安全性[J]. 中华肥胖与代谢病电子杂志, 2024, 10(02): 88-93.
[13] 崔磊, 徐东升. 减重手术治疗肥胖患者胰岛素抵抗的研究进展[J]. 中华肥胖与代谢病电子杂志, 2024, 10(02): 127-132.
[14] 邢颖, 闫文貌. 单孔腹腔镜袖状胃切除术发展现状[J]. 中华肥胖与代谢病电子杂志, 2024, 10(02): 133-137.
[15] 中国医师协会外科医师分会肥胖和代谢病外科专家工作组, 中国医师协会外科医师分会肥胖代谢外科综合管理专家工作组, 中国肥胖代谢外科研究协作组. 中国肥胖代谢外科数据库：2023年度报告[J]. 中华肥胖与代谢病电子杂志, 2024, 10(02): 73-83.
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