袖状胃切除术患者胃食管反流病诊治专家共识（2024版）

doi:10.3877/cma.j.issn.2095-9605.2024.03.001

病态肥胖及其伴随疾病已是全世界需要共同面对的严重公众卫生问题之一，而减重代谢手术到目前为止是长期控制体重最有效的方法。在所有的减重术式中，袖状胃切除术（SG）是目前应用最广泛的一种术式，但它并不是完美的术式。术后可能加重原有的或出现新发的胃食管反流病（GERD）一直是SG所要面对的最严重的问题之一。然而目前关于SG患者GERD的诊治方面还缺乏高级别临床实验的证据。因此，由国内四家减重中心发起，并联合来自中日韩三国的41位在减重代谢手术及GERD诊治上有丰富经验的专家，以Delphi法来达成SG患者GERD诊治的共识。该共识59个征询问题，其中44个达成共识，旨在为临床诊断与治疗提供参考，为未来高质量临床研究指明方向。

关键词: 肥胖症, 减重代谢手术, 袖状胃切除术, 胃食管反流病, 食管裂孔疝, 并发症

Mobid obesity and its accompanying diseases have become one of the most serious public health problems that the whole world needs to face together, and bariatric and metabolic surgery is still the most effective method for long-term weight control. Among all bariatric and metabolic procedures, sleeve gastrectomy (SG) is currently the most widely used, but it is not a perfect procedure. One of the most serious issues that this surgical procedure faces is the possibility of worsening existing or developing de novo gastroesophageal reflux disease (GERD) after surgery. Moreover, there is currently a lack of high-level clinical trial evidence on the diagnosis and treatment of GERD in patients undergoing SG. Therefore, initiated by four domestic bariatric and metabolic surgery centers, 41 experts with rich experience in metabolic and bariatric surgery and diagnosis and treatment of GERD from China, Japan, and South Korea reached a consensus on the diagnosis and treatment of gastroesophageal reflux disease in sleeve gastrectomy patients using the Delphi method. There are a total of 59 consultation questions in this consensus, of which 44 have reached a consensus. We hope that this consensus can not only serve as a reference for clinical diagnosis and treatment, but also provide more possible directions for future high-quality clinical research.

Key words: Obesity, Metabolic and bariatric surgery, Sleeve gastrectomy (SG), Gastroesophageal reflux disease (GERD), Hiatal hernia, Complication

表1 SG患者术前GERD的评估及术式选择

征询问题	同意（票）	不同意（票）	不确定（票）	比例（%）	是否达成共识
1.病态肥胖合并GERD患者需要手术治疗时，建议行减重手术	41	0	0	100.00%	是
2.除了少部分严重的GERD患者，大多数病态肥胖伴GERD患者可以选择SG	33	6	2	80.49%	是
3.对于LA-C或LA-D的严重GERD或者BE患者，应避免行SG/OAGB	31	4	6	75.61%	是
4.对于LA-C或LA-D的严重GERD或者巴雷特食管患者，应建议行RYGB	38	0	3	92.68%	是
5.对于术前存在烧心、反流或胸痛、上腹痛、上腹胀、嗳气等不典型症状的病态肥胖患者，应常规进行反流性疾病问卷量表和GERD问卷量表的评估	37	1	3	90.24%	是
6.建议所有拟接受减重代谢手术的患者术前常规进行上消化道内镜检查	39	2	0	95.12%	是
7.术前对是否合并HH及其分型进行详尽的评估，为术式选择提供参考	40	0	1	97.56%	是
8.对于术前高度怀疑GERD又缺乏诊断依据的患者应转至有条件的医院行食管反流监测及高分辨率食管测压明确诊断	28	8	5	68.29%	否

表1 SG患者术前GERD的评估及术式选择

征询问题	同意（票）	不同意（票）	不确定（票）	比例（%）	是否达成共识
1.病态肥胖合并GERD患者需要手术治疗时，建议行减重手术	41	0	0	100.00%	是
2.除了少部分严重的GERD患者，大多数病态肥胖伴GERD患者可以选择SG	33	6	2	80.49%	是
3.对于LA-C或LA-D的严重GERD或者BE患者，应避免行SG/OAGB	31	4	6	75.61%	是
4.对于LA-C或LA-D的严重GERD或者巴雷特食管患者，应建议行RYGB	38	0	3	92.68%	是
5.对于术前存在烧心、反流或胸痛、上腹痛、上腹胀、嗳气等不典型症状的病态肥胖患者，应常规进行反流性疾病问卷量表和GERD问卷量表的评估	37	1	3	90.24%	是
6.建议所有拟接受减重代谢手术的患者术前常规进行上消化道内镜检查	39	2	0	95.12%	是
7.术前对是否合并HH及其分型进行详尽的评估，为术式选择提供参考	40	0	1	97.56%	是
8.对于术前高度怀疑GERD又缺乏诊断依据的患者应转至有条件的医院行食管反流监测及高分辨率食管测压明确诊断	28	8	5	68.29%	否

表2 SG术中减少GERD发生的技术要点

征询问题	同意（票）	不同意（票）	不确定（票）	比例（%）	是否达成共识
9.重视SG的手术操作细节，在一定程度上可以避免加重术后的GERD	36	1	4	87.80%	是
10.手术时应通过合理保留胃窦，距离幽门4~6 cm以上开始切割可以有效降低术后GERD的发生率	29	6	6	70.73%	是
11.合理选择支撑管的大小可以在保证手术效果的同时减少术后GERD的发生，推荐使用36~38 Fr的支撑管。	35	6	0	85.37%	是
12.完整切除胃底，同时注意距离His角1.0~1.5 cm进行切割，有助于缓解SG后GERD的发生	34	1	6	82.93%	是
13.尽量保持残胃上窄下宽的形态；避免对左侧膈肌脚的过度分离和破坏，有助于缓解SG术后GERD的发生	35	2	4	85.37%	是
14.手术时不应该切除胃食管结合部的脂肪垫，可以减少SG术后胃上移进入纵膈的机会	28	7	6	68.29%	否
15.选择适当的缝合材料和技术对于减少SG术后的GERD有重要意义	26	10	5	63.41%	否
16.在行SG时，如术中发现存在HH，应同时行修补以减少术后GERD的发生	34	3	4	82.93%	是
17.当食管食管前上方韧带凹陷，横径≥2 cm或食管周围有组织疝出进入胸腔时，应考虑存在HH？	37	2	2	90.24%	是
18.如术中考虑有HH，应该选择的修补的方式是：完全游离，按照标准的HH直接缝合方式进行修补	32	3	6	78.05%	是
19.加做抗反流术式的各种新型减重术式有较好的缓解GERD的近期疗效。但其安全性和远期效果还有待更长时间和更多病例的随访	36	1	4	87.80%	是

表2 SG术中减少GERD发生的技术要点

征询问题	同意（票）	不同意（票）	不确定（票）	比例（%）	是否达成共识
9.重视SG的手术操作细节，在一定程度上可以避免加重术后的GERD	36	1	4	87.80%	是
10.手术时应通过合理保留胃窦，距离幽门4~6 cm以上开始切割可以有效降低术后GERD的发生率	29	6	6	70.73%	是
11.合理选择支撑管的大小可以在保证手术效果的同时减少术后GERD的发生，推荐使用36~38 Fr的支撑管。	35	6	0	85.37%	是
12.完整切除胃底，同时注意距离His角1.0~1.5 cm进行切割，有助于缓解SG后GERD的发生	34	1	6	82.93%	是
13.尽量保持残胃上窄下宽的形态；避免对左侧膈肌脚的过度分离和破坏，有助于缓解SG术后GERD的发生	35	2	4	85.37%	是
14.手术时不应该切除胃食管结合部的脂肪垫，可以减少SG术后胃上移进入纵膈的机会	28	7	6	68.29%	否
15.选择适当的缝合材料和技术对于减少SG术后的GERD有重要意义	26	10	5	63.41%	否
16.在行SG时，如术中发现存在HH，应同时行修补以减少术后GERD的发生	34	3	4	82.93%	是
17.当食管食管前上方韧带凹陷，横径≥2 cm或食管周围有组织疝出进入胸腔时，应考虑存在HH？	37	2	2	90.24%	是
18.如术中考虑有HH，应该选择的修补的方式是：完全游离，按照标准的HH直接缝合方式进行修补	32	3	6	78.05%	是
19.加做抗反流术式的各种新型减重术式有较好的缓解GERD的近期疗效。但其安全性和远期效果还有待更长时间和更多病例的随访	36	1	4	87.80%	是

表3 SG术后GERD的评估及非手术治疗

征询问题	同意（票）	不同意（票）	不确定（票）	比例（%）	是否达成共识
20. SG术后会出现GERD的加重或出现新发的GERD	35	2	4	85.37%	是
21. SG术后，BE的发生率升高	19	7	15	46.34%	否
22. SG术后，高发的GERD并不会引起食管腺癌发生率的增加	18	8	15	43.90%	否
23. SG术后是否存在GERD，也需要与术前相同的方法进行准确评估	38	2	1	92.68%	是
24. SG术后的患者，均需要进行GERD相关病史的采集及主观症状的评分	41	0	0	100.00%	是
25.术后出现GERD的患者，根据患者症状的严重程度决定胃镜随访时间，建议在SG术后3~6个月	31	6	4	75.61%	是
26.术后无GERD的患者，也需要行胃镜检查评估，建议在SG术后12月	40	0	1	97.56%	是
27.术后GERD长时间不缓解或症状不典型的，需要食管高分辨率压力检测及食管24 h pH监测	33	4	4	80.49%	是
28.术后GERD长时间不缓解，需要行进一步检查除外HH	37	3	1	90.24%	是
29.生活方式改变是帮助缓解术后GERD的重要手段	39	2	0	95.12%	是
30.术后需要预防性用药缓解GERD	35	3	3	85.37%	是
31.术后预防性抑酸治疗一般在术后3~7 d开始	35	5	1	85.37%	是
32.术后预防性抑酸治疗一般持续3~6个月	27	8	6	65.85%	否
33.改变生活习惯后，GERD症状仍不缓解，应按需给予药物治疗	40	1	0	97.56%	是
34.药物治疗首选PPI，治疗方案和其他病因引起的GERD相同	40	1	0	97.56%	是
35.术后GERD的患者，药物治疗效果不佳的，要充分考虑心理社会因素的影响并给予适当的干预	39	1	1	95.12%	是
36.术后GERD的患者，药物治疗效果不佳或不能停药的，要进行进一步评估	40	1	0	97.56%	是
37.对于诊断明确又没有明显解剖异常的GERD，药物治疗效果不佳或者不能停药的，可以考虑内镜下抗反流黏膜干预措施	32	2	7	78.05%	是
38.抗反流黏膜干预措施早期疗效较好，但其长期的治疗效果还有待更长时间的随访和更多病例的积累	39	0	2	95.12%	是
39.残胃狭窄引起的GERD，可考虑行内镜下扩张术	39	2	0	95.12%	是

表3 SG术后GERD的评估及非手术治疗

征询问题	同意（票）	不同意（票）	不确定（票）	比例（%）	是否达成共识
20. SG术后会出现GERD的加重或出现新发的GERD	35	2	4	85.37%	是
21. SG术后，BE的发生率升高	19	7	15	46.34%	否
22. SG术后，高发的GERD并不会引起食管腺癌发生率的增加	18	8	15	43.90%	否
23. SG术后是否存在GERD，也需要与术前相同的方法进行准确评估	38	2	1	92.68%	是
24. SG术后的患者，均需要进行GERD相关病史的采集及主观症状的评分	41	0	0	100.00%	是
25.术后出现GERD的患者，根据患者症状的严重程度决定胃镜随访时间，建议在SG术后3~6个月	31	6	4	75.61%	是
26.术后无GERD的患者，也需要行胃镜检查评估，建议在SG术后12月	40	0	1	97.56%	是
27.术后GERD长时间不缓解或症状不典型的，需要食管高分辨率压力检测及食管24 h pH监测	33	4	4	80.49%	是
28.术后GERD长时间不缓解，需要行进一步检查除外HH	37	3	1	90.24%	是
29.生活方式改变是帮助缓解术后GERD的重要手段	39	2	0	95.12%	是
30.术后需要预防性用药缓解GERD	35	3	3	85.37%	是
31.术后预防性抑酸治疗一般在术后3~7 d开始	35	5	1	85.37%	是
32.术后预防性抑酸治疗一般持续3~6个月	27	8	6	65.85%	否
33.改变生活习惯后，GERD症状仍不缓解，应按需给予药物治疗	40	1	0	97.56%	是
34.药物治疗首选PPI，治疗方案和其他病因引起的GERD相同	40	1	0	97.56%	是
35.术后GERD的患者，药物治疗效果不佳的，要充分考虑心理社会因素的影响并给予适当的干预	39	1	1	95.12%	是
36.术后GERD的患者，药物治疗效果不佳或不能停药的，要进行进一步评估	40	1	0	97.56%	是
37.对于诊断明确又没有明显解剖异常的GERD，药物治疗效果不佳或者不能停药的，可以考虑内镜下抗反流黏膜干预措施	32	2	7	78.05%	是
38.抗反流黏膜干预措施早期疗效较好，但其长期的治疗效果还有待更长时间的随访和更多病例的积累	39	0	2	95.12%	是
39.残胃狭窄引起的GERD，可考虑行内镜下扩张术	39	2	0	95.12%	是

表4 SG术后GERD的修正手术

征询问题	同意（票）	不同意（票）	不确定（票）	比例（%）	是否达成共识
40.修正手术的目的是改善患者GERD症状，提高患者生活质量，并防止GERD及GERD并发症的进一步进展	41	0	0	100.00%	是
41.修正手术前应该至少有6~12个月的正规GERD治疗证据（包括强化生活方式干预和药物治疗）	38	2	1	92.68%	是
42.无论进行何种修正手术，术前都需要以同样的方法进行准确评估GERD，减重效果以及全身情况	41	0	0	100.00%	是
43.对于减重效果理想，GERD诊断明确又没有明确HH的患者，可考虑行RYGB	34	7	0	82.93%	是
44.减重效果理想，GERD诊断明确又有明确HH的患者，药可考虑行HH修补+RYGB	33	6	2	80.49%	是
45.对于减重效果理想，GERD诊断明确又没有明确HH的患者，可考虑行磁环抗反流装置治疗	26	6	9	63.41%	否
46.减重效果理想，GERD诊断明确又有明确HH的患者，可考虑行HH修补术+磁环抗反流装置。	20	12	9	48.78%	否
47.减重效果理想，GERD诊断明确又有明确HH的患者，可考虑行单纯HH修补术	32	8	1	78.05%	是
48.减重效果理想，GERD诊断明确又有明确HH的患者，可考虑行HH修补术+胃固定术	28	11	2	68.29%	否
49.减重效果不理想/复胖，GERD诊断明确又无明确HH的患者，胃扩张、胃形态正常，可考虑行Re-SG	21	17	3	51.22%	否
50.减重效果不理想/复胖，GERD诊断明确又有明确HH的患者，胃扩张、胃形态正常，可考虑行管裂孔疝修补+Re-SG	20	19	2	48.78%	否
51.减重效果不理想/复胖，GERD诊断明确又无明确HH的患者，胃扩张、胃形态正常，可考虑行Re-SG+胃底折叠术	19	18	4	46.34%	否
52.减重效果不理想/复胖，GERD诊断明确又有明确HH的患者，胃扩张、胃形态正常，可考虑行管裂孔疝修补+Re-SG+胃底折叠术	18	18	5	43.90%	否
53.减重效果不理想/复胖，GERD诊断明确又无明确HH的患者，胃扩张、胃形态正常，可考虑行Re-SG+His角重建	24	15	2	54.54%	否
54.减重效果不理想/复胖，GERD诊断明确又有明确HH的患者，胃扩张、胃形态正常，可考虑行管裂孔疝修补+Re-SG+His角重建	21	18	2	51.22%	否
55.减重效果不理想/复胖，GERD诊断明确又没有明确HH的患者，无胃扩张/胃扭转，可考虑行RYGB	35	5	1	85.37%	是
56.减重效果不理想/复胖，GERD诊断明确又有明确HH的患者，无胃扩张/胃扭转，可考虑行HH修补+RYGB	39	1	1	95.12%	是
57.减重效果理想，残胃狭窄引起的GERD，反复内镜下扩张失败的，可考虑行RYGB	37	3	1	90.24%	是
58.减重效果不理想/复胖，残胃狭窄引起的GERD，可考虑行RYGB	39	2	0	95.12%	是
59.若修正手术前合并难以纠正的贫血/营养不良，应慎重考虑RYGB	38	3	0	92.68%	是

表4 SG术后GERD的修正手术

征询问题	同意（票）	不同意（票）	不确定（票）	比例（%）	是否达成共识
40.修正手术的目的是改善患者GERD症状，提高患者生活质量，并防止GERD及GERD并发症的进一步进展	41	0	0	100.00%	是
41.修正手术前应该至少有6~12个月的正规GERD治疗证据（包括强化生活方式干预和药物治疗）	38	2	1	92.68%	是
42.无论进行何种修正手术，术前都需要以同样的方法进行准确评估GERD，减重效果以及全身情况	41	0	0	100.00%	是
43.对于减重效果理想，GERD诊断明确又没有明确HH的患者，可考虑行RYGB	34	7	0	82.93%	是
44.减重效果理想，GERD诊断明确又有明确HH的患者，药可考虑行HH修补+RYGB	33	6	2	80.49%	是
45.对于减重效果理想，GERD诊断明确又没有明确HH的患者，可考虑行磁环抗反流装置治疗	26	6	9	63.41%	否
46.减重效果理想，GERD诊断明确又有明确HH的患者，可考虑行HH修补术+磁环抗反流装置。	20	12	9	48.78%	否
47.减重效果理想，GERD诊断明确又有明确HH的患者，可考虑行单纯HH修补术	32	8	1	78.05%	是
48.减重效果理想，GERD诊断明确又有明确HH的患者，可考虑行HH修补术+胃固定术	28	11	2	68.29%	否
49.减重效果不理想/复胖，GERD诊断明确又无明确HH的患者，胃扩张、胃形态正常，可考虑行Re-SG	21	17	3	51.22%	否
50.减重效果不理想/复胖，GERD诊断明确又有明确HH的患者，胃扩张、胃形态正常，可考虑行管裂孔疝修补+Re-SG	20	19	2	48.78%	否
51.减重效果不理想/复胖，GERD诊断明确又无明确HH的患者，胃扩张、胃形态正常，可考虑行Re-SG+胃底折叠术	19	18	4	46.34%	否
52.减重效果不理想/复胖，GERD诊断明确又有明确HH的患者，胃扩张、胃形态正常，可考虑行管裂孔疝修补+Re-SG+胃底折叠术	18	18	5	43.90%	否
53.减重效果不理想/复胖，GERD诊断明确又无明确HH的患者，胃扩张、胃形态正常，可考虑行Re-SG+His角重建	24	15	2	54.54%	否
54.减重效果不理想/复胖，GERD诊断明确又有明确HH的患者，胃扩张、胃形态正常，可考虑行管裂孔疝修补+Re-SG+His角重建	21	18	2	51.22%	否
55.减重效果不理想/复胖，GERD诊断明确又没有明确HH的患者，无胃扩张/胃扭转，可考虑行RYGB	35	5	1	85.37%	是
56.减重效果不理想/复胖，GERD诊断明确又有明确HH的患者，无胃扩张/胃扭转，可考虑行HH修补+RYGB	39	1	1	95.12%	是
57.减重效果理想，残胃狭窄引起的GERD，反复内镜下扩张失败的，可考虑行RYGB	37	3	1	90.24%	是
58.减重效果不理想/复胖，残胃狭窄引起的GERD，可考虑行RYGB	39	2	0	95.12%	是
59.若修正手术前合并难以纠正的贫血/营养不良，应慎重考虑RYGB	38	3	0	92.68%	是

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