摘要
胃食管反流病(GERD)的外科治疗已完成从症状姑息向根治性干预的范式转变。对于存在病理性酸暴露(食管酸暴露时间>6%)、进行性解剖破坏(如≥2 cm食管裂孔疝或HillⅢ~Ⅳ级病变)或需阻断癌变进程的高危患者,抗反流手术可提供优于药物治疗的长期疗效。手术适应证需综合解剖、功能与风险三维评估:解剖缺陷主导型患者推荐联合疝修补与胃底折叠术,复发性疝采用生物补片加固可使复发率降至16.7%;功能失代偿群体需基于客观指标(如24 h反流事件>75次)决策;特殊人群如减重术后GERD优选胃旁路术(反流控制率93%),硬皮病等动力障碍者则适用部分折叠术以规避吞咽困难风险(OR=0.285)。术前通过阶梯式评估路径(内镜筛查→pH-阻抗监测→高分辨率测压)实现精准决策,术中依据动力状态个体化选择术式:食管动力正常者采用Nissen术提升括约肌压力,老年或无效食管动力患者首选Toupet术保障长期安全性,而磁力环增强术可使96%的质子泵抑制剂有效但拒绝长期用药者摆脱药物依赖。外科干预的核心价值在于可同步实现解剖结构恢复与功能重建,并可阻断Barrett食管癌变进程,有望实现GERD治疗策略从“静态解剖复位”到“动态生理重建”的重要突破。
The surgical management of gastroesophageal reflux disease(GERD)has completed a paradigm shift from symptomatic palliation to curative intervention.For high-risk patients with pathological acid exposure(AET>6%),progressive anatomical destruction(e.g.,≥2 cm hiatal hernia or Hill grade Ⅲ~Ⅳ lesions),or those requiring interruption of carcinogenic progression(such as Barrett's esophagus with dysplasia),anti-reflux surgery provides superior long-term efficacy compared to pharmacotherapy.Surgical indications require a three-dimensional assessment integrating anatomical,functional,and risk factors:patients with dominant anatomical defects are recommended to undergo combined hernia repair and fundoplication(biological mesh reinforcement for recurrent hernias reduces recurrence rates to 16.7%);functionally decompensated groups require decision-making based on objective reflux metrics(e.g.,>75 reflux events/24 hours);special populations such as post-bariatric GERD should preferentially undergo Roux-en-Y gastric bypass(reflux control rate:93%),while those with motility disorders(e.g.,scleroderma)are suitable for partial fundoplication to mitigate dysphagia risk(OR=0.285).Precision decision-making is achieved through a stepwise evaluation pathway(endoscopy→pH-impedance monitoring→high-resolution manometry).Intraoperative strategies are individualized based on motility status:patients with normal esophageal motility undergo the Nissen procedure,the elderly or those with ineffective esophageal motility are prioritized for Toupet fundoplication for optimized long-term safety,and magnetic sphincter augmentationenables 96%of PPI-responsive but medication-averse patients to discontinue drug dependency.The core value of surgical intervention lies in simultaneously achieving anatomical restoration and functional reconstruction,along with blocking Barrett's esophageal carcinogenesis(OR=0.41).This dual mechanism signifies a fundamental transformation in GERD management strategy.
作者
黄恩民
侯泽辉
马宁
陈双
周太成
Huang Enmin;Hou Zehui;Ma Ning;Chen Shuang;Zhou Taicheng(Department of Hernia and Abdominal Wall Surgery,the Sixth Affiliated Hospital of Sun Yat-sen University,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases,Zhongliu Biomedical Innovation Research Institute of Huangpu District,Guangzhou 510655,China)
出处
《中华胃肠外科杂志》
北大核心
2025年第10期1118-1122,共5页
Chinese Journal of Gastrointestinal Surgery
关键词
胃食管反流病
根治性干预
阶梯评估
个体化术式
Gastroesophageal reflux disease
Curative intervention
Stepwise evaluation
Individualized surgical approach
