背景及目的

腹腔镜下袖状胃切除术（Laparoscopic Sleeve Gastrectomy, LSG）可能会导致患者原有胃食管反流病（Gastroesophageal Reflux Disease, GERD）症状加重或新发的GERD。既往研究报道的LSG术后GERD的危险因素众多，且GERD的评估方法各异，现有评估方式的预测价值尚不明确，因此我们打算筛查LSG术后GERD的危险因素，并综合评估胃食管反流病问卷（Gastroesophageal Reflux Disease Questionnaire, GERD-Q）评分及术前洛杉矶分级对LSG术后早期胃食管反流症状的影响，以及二者单独或联合判断对术后GERD的预测价值。

方法

本研究对2022年6月28日至2023年7月28日在中日友好医院接受LSG治疗的肥胖患者的前瞻性数据进行回顾性分析。使用GERD-Q评分评估患者术前及术后GERD情况，评分≥8分视为存在GERD。同时术前使用洛杉矶分级对患者反流性食管炎的情况进行评估。通过有序Logistic回归分析术后GERD严重程度的影响因素，并绘制Kaplan-Meier曲线评估术后GERD发生时间，结合Log-Rank检验及COX回归探讨术前GERD情况及其他因素与术后GERD风险的关系。

结果

共有371人纳入分析。完成随访时，共有100人（27.0%）曾出现GERD症状，术后3月、半年、1年GERD-Q评估的GERD的累积发病率为6.5%、21.4%和26.7%，而三个节点随访结束时的总患病率分别为18.6%、15.1%、12.1%。术后1年患者体重由术前的119.40±26.65 kg降至85.31±19.25 kg，总体重减轻百分比和多余体重减少百分比分别达到28.28±8.20%和78.42±27.04%。有序Logistic回归发现吸烟史（OR=1.93-2.05，95%CI 1.05-3.74，P均<0.05）术前GERD-Q评估阳性（OR=2.15，95%CI 1.03-4.35，P=0.037）、LA-A（OR=3.15，95%CI 1.76-5.61，P<0.001）是术后GERD严重程度的独立危险因素，而更高的腰臀比为保护因素（OR=0.59-0.64，95%CI 0.42-0.90，P均<0.05）。使用COX回归调整协变量后发现术前GERD-Q评估阳性（HR=1.81，95%CI 1.06-3.10，P=0.030）、LA-A（HR=2.74，95%CI 1.74-4.91，P<0.001）为术后早期出现GERD症状的独立危险因素，而2型糖尿病史（HR=0.64-0.65，95%CI 0.42-0.99，P均<0.05）和更高的腰臀比（HR=0.68-0.76，95%CI 0.53-0.99，P均<0.05）则为保护因素。

结论

本研究证实LSG可显著改善肥胖患者体重，但术后GERD累积发病率呈上升趋势而总体患病率呈下降趋势。在LSG术后GERD的严重程度方面，吸烟史、术前GERD-Q阳性、LA-A是其独立的危险因素，而腰臀比更高的患者术后GERD的严重程度更低。在LSG术后GERD的出现时间方面，术前GERD-Q阳性、LA-A仍是其独立的危险因素，而术前患2型糖尿病及有更高腰臀比的患者术后GERD的出现时间更晚。

Background and Aims Laparoscopic sleeve gastrectomy (LSG) may exacerbate preexisting gastroesophageal reflux disease (GERD) or induce de novo GERD. Previous studies have reported heterogeneous risk factors for postoperative GERD following LSG, and while diverse assessment methods for GERD exist, the predictive value of current approaches remains unclear. Therefore, this study aimed to identify risk factors for postoperative GERD and comprehensively evaluate the impact of preoperative Gastroesophageal Reflux Disease Questionnaire (GERD-Q) scores and Los Angeles (LA) classification on early postoperative GERD symptoms, as well as their individual and combined predictive value for postoperative GERD. Methods This study retrospectively analyzed the prospectively collected data of obese patients who underwent LSG at China-Japan Friendship Hospital between June 28, 2022, and July 28, 2023. GERD symptoms were assessed pre- and postoperatively using the GERD-Q score, with a score ≥8 indicating GERD. Preoperative esophagitis was evaluated via endoscopy using the LA classification. Ordered logistic regression was employed to identify factors influencing postoperative GERD severity. Kaplan-Meier curves were plotted to assess the timing of postoperative GERD onset, and Log-Rank tests combined with Cox regression were used to explore associations between preoperative GERD status, other factors, and postoperative risk. Results A total of 371 individuals were included in the study, 100 (27.0%) developed GERD symptoms during follow-up. The cumulative incidence rates of GERD-Q-assessed GERD at 3 months, 6 months, and 1 year postoperatively were 6.5%, 21.4%, and 26.7%, respectively, while the overall prevalence rates at these timepoints were 18.6%, 15.1%, and 12.1%. At 1 year postoperatively, mean weight decreased from 119.45±26.62 kg to 85.31±19.25 kg, with percentage of total weight loss and percentage of excess weight loss reaching 28.31±8.15% and 78.48±26.99%, respectively. Ordered logistic regression identified smoking history (OR = 1.93-2.05, 95% CI 1.05-3.74, P < 0.05), preoperative GERD-Q positivity (OR = 2.15, 95% CI 1.03–4.35, P = 0.037), and LA-A classification (OR = 3.15, 95% CI 1.76-5.61, P < 0.001) as independent risk factors for postoperative GERD severity, while higher waist-to-hip ratio (WHR) was protective (OR = 0.59-0.64, 95% CI 0.42-0.90, P < 0.05). Cox regression adjusted for covariates revealed preoperative GERD-Q positivity (HR = 1.81, 95% CI 1.06-3.10, P = 0.030) and LA-A classification (HR = 2.74, 95% CI 1.74-4.91, P < 0.001) as independent risk factors for early postoperative GERD onset. Conversely, history of type 2 diabetes (HR = 0.64-0.65, 95% CI 0.42–0.99, P < 0.05) and higher WHR (HR = 0.68-0.76, 95% CI 0.53-0.99, P < 0.05) were protective factors. Conclusion This study confirms that LSG significantly improves weight in obese patients. However, while the cumulative incidence of postoperative GERD increased over time, its overall prevalence decreased. Regarding the severity of GERD after LSG, smoking history, preoperative GERD-Q positivity, and LA-A were identified as independent risk factors, whereas a higher WHR was associated with reduced GERD severity. In terms of the timing of postoperative GERD onset, preoperative GERD-Q positivity and LA-A remained independent risk factors, while patients with a history of type 2 diabetes or a higher WHR experienced delayed onset of GERD symptoms.