减重代谢手术中处理食管裂孔疝中国专家共识(2025版)

参考文献:

[1] Kohn GP, Price RR, DeMeester SR, et al. Guidelines for the management of hiatal hernia [J]. Surg Endosc, 2013, 27(12):4409-4428.

[2] Horvath KD, Swanstrom LL, Jobe BA. The short esophagus: pathophysiology, incidence, presentation, and treatment in the era of laparoscopic antireflux surgery [J]. Ann Surg, 2000, 232(5):630-640.

[3] 黄晓东,邓长生.老年胃肠病学[M].北京:人民卫生出版社,2017:98-115.

[4] Varela JE, Hinojosa M, Nguyen N. Correlations between intra-abdominal pressure and obesity-related co-morbidities [J]. Surg Obes Relat Dis, 2009, 5(5):524-528.

[5] Che F, Nguyen B, Cohen A, et al. Prevalence of hiatal hernia in the morbidly obese [J]. Surg Obes Relat Dis, 2013, 9(6):920-924.

[6] Bakhos CT, Patel SP, Petrov RV, et al. Management of Paraesophageal Hernia in the Morbidly Obese Patient [J]. Thorac Surg Clin, 2019, 29(4):379-386.

[7] 中华医学会消化病学分会胃肠动力学组,中华医学会消化病学分会胃肠功能性疾病协作组,中华医学会消化病学分会食管疾病协作组,等.中国胃食管反流病诊疗规范[J].胃肠病学,2023,28(10):597-607.

[8] Daly S, Kumar SS, Collings AT, et al. SAGES guidelines for the surgical treatment of hiatal hernias [J]. Surg Endosc, 2024, 38 (9):4765-4775.

[9] Mohammed R, Fei P, Phu J, et al. Efficiency of preoperative esophagogastroduodenoscopy in identifying operable hiatal hernia for bariatric surgery patients [J]. Surg Obes Relat Dis, 2017, 13(2):287-290.

[10] Argüero J, Sifrim D. Pathophysiology of gastro-oesophageal reflux disease: implications for diagnosis and management [J]. Nat Rev Gastroenterol Hepatol, 2024, 21(4):282-293.

[11] Snyder B, Wilson E, Wilson T, et al. A randomized trial comparing reflux symptoms in sleeve gastrectomy patients with or without hiatal hernia repair [J]. Surg Obes Relat Dis, 2016, 12(9):1681-1688.

[12] Page Pl, Martin D, Taylor C, et al. Does hiatal repair affect gastroesophageal reflux symptoms in patients undergoing laparoscopic sleeve gastrectomy? [J]. Surg Endosc, 2018, 32(5):2373-2380.

[13] ASGE Standards of Practice Committee, Desai M, Ruan W, et al. American Society for Gastrointestinal Endoscopy guideline on the diagnosis and management of GERD; summary and recommendations [J]. Gastrointest Endosc, 2025, 101 (2):267-284.

[14] Crozet J, Denneval A, Brosse M, et al. Conversion of Sleeve Gastectomy to Roux-en-Y Gastric Bypass: Is Intrathoracic Migration of the Sleeve of High Incidence? [J]. Obes Surg, 2024,34(8):2907-2913.

[15] 席筱厚,张明鑫,林强,等. 育胃管反流病的诊疗进展[J]. 胃胃肠病学和肝病学杂志,2025,34(2):297-302.

[16] Shaheen NJ, Falk GW, Iyer PG, et al. Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline [J]. Am J Gastroenterol, 2022, 117(4): 5597-587.

[17] Mittal RK. Hiatalhernia: myth or reality? [J]. Am J Med, 1997, 103(5A): 333-39S.

[18] Visaggi P, Del Corso G, Gyawali CP, et al. Ambulatory pH-Impedance Findings Confirm That Grade B Esophagitis Provides Objective Diagnosis of Gastroesophageal Reflux Disease [J]. Am J Gastroenterol, 2023, 118(5):794-801.

[19] Conrado LM, Gurski RR, da Rosa AR, et al. Is there an association between hiatal hernia and ineffective esophageal motility in patients with gastroesophageal reflux disease? [J]. J Gastrointest Surg, 2011, 15(10):1756-1761.

[20] Salminen P, Grönroos S, Helmiö M, et al. Effect of Laparoscopic SleeveCTectomy vs Roux-en-Y Gastric Bypass on Weight Loss, Comorbidities, and Reflux at 10 Years in Adult Patients With Obesity; The SLEEEPASS Randomized Clinical Trial [J]. JAMA Surg, 2022, 157(8):656-666.

[21] Fisher OM, Chan DL, Talbot ML, et al. Barrett's Oesophagus and Bariatric/Metabolic Surgery-IFS2020 Position Statement [J].

第30卷第12期

2025年12月

腹腔镜外科杂志 JOURNAL OF LAPAROSCOPIC SURGERY

JOURNAL OF LAPAROSCOPIC SURGERY

Vol. 30, No. 12 Dec. 2025

Obes Surg, 2021, 31(3):915-934. [22] Cuenca-Abente F, Puma R, Ihhuralde-Argerich J, et al. Non-Bariatric Roux-en-Y Gastric Bypass [J]. J Laparoendosc Adv Surg Tech A, 2020, 30(1):31-35. [23] Castillo-Larios R, Gunturu NS, Cornejo J, et al. Redo fundoplication vs. Roux-en-Y gastric bypass conversion for failed anti-re-flux surgery: which is better? [J]. Surg Endosc, 2023, 37(8):6429-6437. [24] Lewis KH, Callaway K, Argetsinger S, et al. Concurrent hiatal hernia repair and bariatric surgery: outcomes after sleeve gastrecto-my and Roux-en-Y gastric bypass [J]. Surg Obes Relat Dis, 2021, 17(1):72-80. [25] Docimo S Jr, Rahmana U, Bates A, et al. Concomitant Hiatal Hernia Repair Is more Common in Laparoscopic Sleeve Gastrectomy than During Laparoscopic Roux-en-Y Gastric Bypass: an Analysis of 130, 772 Cases [J]. Obes Surg, 2019, 29(2):744-746. [26] Shada AL, Stem M, Funk LM, et al. Concurrent bariatric surgery and paraesophageal hernia repair: comparison of sleeve gastrectomy and Roux-en-Y gastric bypass [J]. Surg Obes Relat Dis, 2018, 14(1):8-13. [27] Rosenthal RJ, International Sleeve Gastrectomy Expert Panel, Diaz AA, et al. International Sleeve Gastrectomy Expert Panel Consensus Statement; best practice guidelines based on experience of >12,000 cases [J]. Surg Obes Relat Dis, 2012, 8(1):8-19. [28] Yeung KTD, Penney N, Ashrafian L, et al. Does Sleeve Gastrectomy Expose the Distal Esophagus to Severe Reflux?: A Systematic Review and Meta-analysis [J]. Ann Surg, 2020, 271(2): 257-265. [29] Chen W, Feng J, Wang C, et al. Effect of Concomitant Laparoscopic Sleeve Gastrectomy and Hiatal Hernia Repair on Gastroe-sophageal Reflux Disease in Patients with Obesity: a Systematic Review and Meta-analysis [J]. Obes Surg, 2021, 31(9):3905-3918. [30] Mills H, Alhindi Y, Idris I, et al. Outcomes of Concurrent Hiatus Hernia Repair with Different Bariatric Surgery Procedures: a Systematic Review and Meta-analysis [J]. Obes Surg, 2023, 33(12):3755-3766. [31] Allison PR. Hiatus hernia: (a 20-year retrospective survey) [J]. Ann Surg, 1973, 178(3):273-276. [32] Frezza EE, Ikramuddin S, Gourash W, et al. Symptomatic improvement in gastroesophageal reflux disease (GERD) following laparoscopic Roux-en-Y gastric bypass [J]. Surg Endosc, 2002, 16(7): 1027-1031. [33] Yadlapati R, Gyawali CP, aLolfino JE, et al. AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review [J]. Clin Gastroenterol Hepatol, 2022, 20(5):984-994. e1. [34] Flanagin BA, Mitchell MT, Thistlethwaite WA, et al. Diagnosis and treatment of atypical presentations of hiatal hernia following bariatric surgery [J]. Obes Surg, 2010, 20(3):386-392. [35] Chaudhry UI, Marr BM, Osayi SN, et al. Laparoscopic Roux-en-Y gastric bypass for treatment of symptomatic paraesophageal her-nia in the morbidly obese: medium-term results [J]. Surg Obes Relat Dis, 2014, 10(6):1063-1067. [36] Arslan E, Banli O, Sipahi M, et al. Effects and Results of Omentopexy During Laparoscopic Sleeve Gastrectomy [J]. Surg Lapar-osc Endosc Percutan Tech, 2018, 28(3):174-177. [37] Wu QL, Zhu Z, Yuan Y, et al. Effect of omentopexy/gastropexy on gastrointestinal symptoms after laparoscopic sleeve gastrectomy: A meta-analysis of randomized controlled trials and systematic review [J]. Asian J Endosc Surg, 2023, 16(3):409-422. [38] Chaouch MA, Khalfallah M, Jabra SB, et al. Omentopexy versus no omentopexy in sleeve gastrectomy: an updated systematic review and meta-analysis [J]. Updates Surg, 2024, 76(3):811-827. [39] Jones R, Simorov A, Lomelin D, et al. Long-term outcomes of radiologic recurrence after paraesophageal hernia repair with mesh [J]. Surg Endosc, 2015, 29(2):425-430. [40] Morgenthal CB, Lin E, Shane MD, et al. Who will fail laparoscopic Nissen fundoplication? Preoperative prediction of long-term outcomes [J]. Surg Endosc, 2007, 21(11):1978-1984. [41] Logarajah SI, Karumuri J, Ahle D, et al. Roux-en-Y Gastrojejunostomy: is it an effective treatment for complex Hiatal hernias in the morbidly obese? [J]. Surg Endosc, 2023, 37(1):450-455. [42] Betzler J, Wiegand N, Kantorez A, et al. Antireflux Surgery in Patients with Moderate Obesity-Fundoplication or Roux-en-Y Gas-tric Bypass? [J]. Obes Surg, 2025, 35(5): 1750-1760. [43] Petro CC, Ellis RC, Maskal SM, et al. Anterior Gastropexy for Paraesophageal Hernia Repair: A Randomized Clinical Trial [J]. JAMA Surg, 2025, 160(3):247-255. [44] Østerballe L, Aahlin EK, Goll R, et al. No advantage of fundoplication in paraesophageal hernia repair: a retrospective multicenter study [J]. Dis Esophagus, 2025, 38(3): doaf036.

第30卷第12期 2025年12月

腹腔镜外科杂志 JOURNAL OF LAPAROSCOPIC SURGERY

Vol.30,No.12 Dec.2025

《减重代谢手术中处理食管裂孔疝中国专家共识(2025版)》问卷统计结果

|关键问题|完全同意 (票)|基本同意 (票)|部分反对 (票)|完全反对 (票)|通过率 (%)|是否达成共识| |---|---|---|---|---|---|---| |1. 术前胃镜提示 HH 患者,应进一步做上腹部 CT 和/或加 UGI,以进一步明确诊断及分型。|80|12|1|0|98.92|是| |2. 术中腹腔镜探查主要观察腹段食管与食管裂孔之间有无凹陷、GEJ 是否移位、疝入胸腔内组织、器官等,并对 HH 进行分型。|80|12|1|0|98.92|是| |3. 有明确的反酸烧心症状(GerdQ评分≥8分),但胃镜未提示反流性食管炎和HH;术前CT和/或UGI未提示HH;术中腹腔镜探查没有明确的HH,不建议游离GEJ周围韧带及筋膜组织进一步探查食管裂孔。|73|16|3|1|95.70|是| |4. 术前胃镜提示反流性食管炎LA-A级或B级,但胃镜未提示HH。术前CT和/或上消化道造影未提示HH、术中腹腔镜探查没有明确的HH,不建议游离GEJ周围韧带及筋膜组织进一步探查食管裂孔。|68|20|3|2|94.62|是| |5. 术前胃镜提示反流性食管炎LA-C级或D级,但未提示HH,CT和/或上消化道造影也未提示HH者,建议术前进行食管反流监测及食管高分辨率测压。如果术中腹腔镜探查也没有明确的HH,不建议游离GEJ周围韧带及筋膜组织进一步探查食管裂孔。|54|26|9|4|86.02|是| |6. 术前胃镜提示 Barrett食管但未提示HH,建议术前行胃镜同时取病理排除恶变。不论术前CT、上消化道造影检查及术中腹腔镜探查有无HH,建议选择RYGB。|50|26|16|1|81.72|是| |7. 术前胃镜提示HH,CT和/或上消化道造影未提示HH。应以术中腹腔镜探查为主,术中没有明确的HH证据情况下,不建议游离GEJ周围韧带及筋膜组织进一步探查食管裂孔。|61|22|6|4|89.25|是| |8. 术中腹腔镜探查明确HH时,应按关键问题2给出的分型选择具体术式。|73|19|0|1|98.92|是| |9. 术前胃镜反流性食管炎A级或B级,术前CT检查GEJ没有明显的移位,SC术中腹腔镜探查明确I型HH,同期HHR有一定的临床获益。|57|30|5|1|93.55|是| |10. 术前胃镜反流性食管炎A级或B级,术前CT检查GEJ没有明显的移位,RYGB中探查明确I型食管裂孔疝,建议慎重同期行HHR。|49|29|10|5|83.87|是| |11. 术中腹腔镜探查明确I型食管裂孔疝,术前CT检查GEJ没有明显的移位。进行SG时,建议残胃切缘与大网膜(复位)或与胰腺被膜、结肠系膜缝合固定,以预防或减少残胃上移。|48|32|9|4|86.02|是| |12. MBS中腹腔镜探查明确的II、III、IV型HH,RYGB可能是一种更好的术式选择。|59|27|7|0|92.47|是|

注: UGI 上消化道造影; GEJ 胃食管结合部; HH 食管裂孔疝; HHR 食管裂孔疝修补术; RYGB 胃旁路术; SG 胃袖状切除术; MBS 减重代谢手术。

(收稿日期:2025-11-20)

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