中华胃肠外科杂志最新文献

The esophagogastric junction serves as a natural anti-reflux barrier and possesses a complex anatomical configuration composed of several key components, including the lower esophageal sphincter, diaphragmatic crura, His angle, and phrenoesophageal ligament. Alterations in these anatomical structures or dysfunction thereof may predispose individuals to gastroesophageal reflux disease (GERD). In response to such structural and functional impairments, various therapeutic strategies have been developed. Surgical intervention is currently regarded as an effective approach for fundamentally addressing GERD, with commonly employed techniques including laparoscopic fundoplication, magnetic sphincter augmentation, and endoscopic radiofrequency ablation. The author classifies the anti-reflux mechanisms at the esophagogastric junction into intramural and extramural components, and based on this classification, systematically reviews and evaluates the indications and clinical applications of major surgical interventions for GERD, aiming to provide clinicians with evidence-based guidance for selecting appropriate therapeutic modalities.

Gastroesophageal reflux disease (GERD) is a chronic digestive system disorder triggered by multiple factors, which is clinically prevalent and affects patients' quality of life. Laparoscopic fundoplication serves as the mainstay of surgical treatment for GERD, requiring standardized preoperative examinations to assess patients' reflux status and esophageal motility for individualized selection of fundoplication techniques. Intraoperative regulation of the fundoplication tension with a bougie aims to balance the anti-reflux efficacy and the risk of postoperative dysphagia. Additionally, membranous anatomy research guided by embryonic development facilitates optimization of surgical approaches and provides a theoretical basis for surgical innovation. This article deeply discusses the status of GERD diagnosis and treatment, as well as the surgical anti-reflux mechanisms, from multiple aspects including pathogenesis, diagnosis, and surgical management. We also contemplate the existing challenges in the embryonic development and anatomy of the anti-reflux barrier.

Objective: To analyze the incidence of surgical site infection (SSI) in patients undergoing colorectal cancer (CRC) surgery and to identify risk factors associated with SSI in an attempt to provide a reference for clinical prevention strategies. Methods: A retrospective cohort study was conducted. Clinical data were retrospectively collected from a total of 2,248 patients who underwent surgery for pathologically confirmed CRC between 2017 and 2022 at two centers: Huangshan Shoukang Hospital (n=649) and Northern Jiangsu People's Hospital (n=1 599). Inclusion criteria consisted of the following: (1) age >18 years; (2) pathologically confirmed CRC treated with curative resection, including extended resections (e.g. pelvic exenteration); (3) no surgical incisions other than abdominal or perineal; and (4) no use of prosthetic implants. The incidence of SSI was analyzed, and multivariate logistic regression was used to identify independent its risk factors. Results: A total of 121 patients (5.4%) developed SSI. Among them, 68 cases (56.2%) were organ/space infections, 35 cases (28.9%) were deep incisional infections, and 18 cases (14.9%) were superficial incisional infections. The median postoperative hospital stay was significantly longer in patients with SSI compared to those without (21.0 days vs. 13.0 days, U=65,754, P<0.001). The median hospitalization cost was also significantly higher in the SSI group (56,550 yuan vs. 43,645 yuan, U=72,008, P<0.001). Multivariate logistic regression analysis identified body mass index (BMI) ≤ 20 kg/m² (OR=4.25, 95%CI: 3.38-5.34, P<0.001), diabetes mellitus (OR=3.44, 95%CI: 1.89-6.24, P<0.001), open surgery (OR=4.23, 95%CI: 2.37-7.56, P<0.001), and colostomy or ileostomy (OR=1.67, 95% CI: 1.04-2.69, P=0.034) as independent risk factors for SSI. Conclusion: To prevent SSI following CRC surgery, attention should be given to optimizing body weight and glycemic control, promoting minimally invasive surgical approaches when feasible, and cautiously considering the necessity of colostomy or ileostomy.

Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder, with increasing prevalence due to obesity and lifestyle changes. Although proton pump inhibitors (PPIs) remain the first-line therapy, a proportion of patients have an unsatisfactory response, require long-term medication, or experience symptom relapse after discontinuation. Positioned between pharmacotherapy and surgery as a third therapeutic option, endoscopic therapy offers an additional choice for patients with refractory GERD. Based on current evidence, this article examines the optimal timing of endoscopic intervention, with particular attention to intervention after PPI failure, indications for endoscopic therapy, and individualized strategies for special populations. It also summarizes limitations of the existing evidence and outlines priorities for future research, including the need for long-term follow-up, robust cost-effectiveness evaluation, and exploration of biomarkers to inform timing decisions. In summary, evidence-based and individualized selection of intervention timing is essential to optimize the therapeutic efficacy of endoscopic management for GERD.

Objective: To evaluate the anti-reflux effect of digestive tract reconstruction using esophageal-tubular gastric asymmetric anastomosis after radical resection of esophageal and esophagogastric junction cancer. Methods: The main steps were as follows:(1)oblique incision of the lower esophagus;(2)curved incision of the tubular anterior gastric wall;(3)the lower end of the esophagus was anastomosed to the tubular gastric incision with a 90-degree torsion; (4)The anterior wall of the anastomosis was reinforced with a transverse-inverted suture,the posterior wall with a folded suture,and the corners of the gastric stump were buried with sutures.The anastomosis operation time,postoperative complications and postoperative hospital stay were recorded;the reconstructed structure and anti-reflux effect of the anastomosis were observed by digestive tract radiography,gastroscopy and follow-up investigation. Results: The Department of Gastrointestinal and Thoracic Surgery of Huaian First People's Hospital, affiliated to Nanjing Medical University, treated 5 patients of esophagogastric junction cancer and 20 esophageal cancer cases between August 2022 and November 2024, including 19 men and 6 women, with a mean age of (66.7±7.4) years. The mean anastomosis time was (35.4±5.9) minutes, the intraoperative blood loss was (117.6±33.4) ml and the mean postoperative hospital stay was(16.6±5.2) days, with no complications such as anastomotic leakage and bleeding. Postoperative digestive tract radiography (Trendelenburg position)showed that all the patients had no contrast reflux,gastroscopy showed no signs of reflux esophagitis and bile reflux gastritis, the anastomosis showed an inverted whiskers valve-like structure. The median follow-up time was (16.8±6.3) months, and all patients had no reflux symptoms such as acid reflux and belching,and no acid suppressive medication was needed. Conclusion: The esophageal-tubular gastric asymmetric anastomosis is a safe and effective antireflux reconstruction technique.

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.

Gastroesophageal reflux disease (GERD) is characterized by significant clinical heterogeneity. Conventional diagnostic approaches, including symptom-based questionnaires, empirical acid suppression trials, and single-modality objective tests, demonstrate limited sensitivity and specificity, often resulting in diagnostic inaccuracies and inefficient resource utilization. To overcome these diagnostic challenges, this article provides a systematic review of recent advancements and ongoing debates in GERD diagnostics, with a focus on the diagnostic value of multimodal parameters as outlined in the Lyon Consensus 2.0. It also explores the clinical relevance of emerging auxiliary diagnostic metrics. We emphasize that integrating clinical symptomatology, endoscopic findings, esophageal physiological measurements, and psychosocial factors (augmented by composite scoring systems and artificial intelligence), offers a promising strategy for accurate diagnosis and personalized treatment of GERD.

Objective: This study aims to conduct a systematic review and network meta-analysis comparing the safety and efficacy of endoscopic versus surgical treatments for gastroesophageal reflux disease (GERD). Methods: Randomized controlled trials were identified through systematic searches of MEDLINE, Embase, Web of Science, and CNKI. Both direct effect models and Bayesian random-effects network meta-analysis were used to compare treatments directly and indirectly. The following types of studies were included : (1) RCTs involving endoscopic or surgical treatment for adult GERD patients aged ≥18 years with no previous history of gastroesophageal surgery; (2) studies comparing two or more treatment methods, including different endoscopic or surgical procedures, proton pump inhibitor (PPI) therapy, and/or sham surgery; and (3) articles published in Chinese or English. Review articles and conference abstracts were excluded. Results: A total of 47 randomized controlled trials were enrolled, and 43 studies were network meta-analyzed. Both endoscopic and surgical treatments significantly reduced postoperative PPI use compared to PPI therapy (P <0.05). Among all treatment modalities, laparoscopic Nissen fundoplication (LNF, SUCRA=0.84) demonstrated the highest efficacy, followed by laparoscopic Toupet fundoplication (LTF, SUCRA=0.71) and anterior partial fundoplication (APF, SUCRA=0.70). Transoral incisionless fundoplication (TIF) demonstrated the best outcomes in relieving heartburn (SUCRA=0.87) and bloating (SUCRA=0.86) symptoms. The overall safety of surgical treatment was comparable to that of PPI therapy. However, LNF was associated with a higher incidence of postoperative dysphagia and gas-related symptoms, whereas TIF had a lower risk of postoperative complications. Conclusions: Both endoscopic and surgical treatments are effective for GERD. LNF provides the highest rate of medication discontinuation but carries a higher risk of postoperative complications. TIF offers better relief of heartburn and bloating with fewer complications.

The nervous system, as the core hub of physiological regulation in the human body, plays a key role in the tumor microenvironment through the neuro-immune-tumor axis. Studies have shown that tumor-infiltrating nerve fibers regulate immune cell functions by releasing neurotransmitters, while immune cells can feedback and modulate neuronal activity, forming a dynamic bidirectional interaction network. The emerging field of cancer neuroimmunology focuses on the complex dialogue mechanisms between the nervous and immune systems in the tumor microenvironment. In-depth analysis of the neuro-immune interaction network not only provides new perspectives for understanding tumor immune escape, but also lays the theoretical foundation for developing novel combination therapies targeting the neuro-immune axis, potentially providing breakthrough strategies to overcome resistance to current immunotherapies.

The rapid development of immunotherapy has changed the treatment pattern of gastric cancer surgery, constantly advancing from the battlefield of advanced gastric cancer treatment to neoadjuvant therapy. The combination of immunotherapy and chemotherapy has become a new trend in the treatment of locally advanced gastric cancer. This change has prompted us to re-examine the concept of traditional radical surgery for gastric cancer, especially for lymph node dissection, it presents new challenges. As the core site of immune response, lymph node dissection strategy has become one of the key factors affecting the overall efficacy of gastric cancer, and it urgently needs to be re optimized and evaluated in the wave of immunotherapy. Thus, a more precise and personalized new paradigm for radical gastric cancer surgery can be established, ultimately achieving multiple improvements in short-term and long-term efficacy, as well as quality of life.