腹腔镜食管裂孔修补联合改良Hill术在袖状胃术后胃食管反流病的应用价值
Laparoscopic hiatal hernia repair combined with modified Hill technique in the application value of gastroesophageal reflux disease after sleeve gastrectomy

李世红1 牛钦王2 刘科豪1 侯康1 聂攀1 余佳慧1 詹大方1 郭沛森1 张元川1 1.成都市第三人民医院/西南交通大学附属医院 普通外科•胃肠微创中心
Li Shihong1, Niu Qinwang2, Liu Kehao1, Hou Kang1, Nie Pan1, Yu Jiahui1, Zhan Dafang1, Guo Pisen1, Zhang Yuanchuan1. Third Hospital of Chengdu/ Affiliated Hospital of Southwest Jiaotong University, General Surgery • Minimally Invasive Gastroenterology Center

2. 四川省工程职业技术大学
2. Sichuan Province Engineering Vocational Technical University

Li Shihong1 Niu Qinwang2 Nie Pan1 Zhang Yuanchuan1 Zhan Dafang1 Yu Jiahui1 Guo Peishen1 Liu Kehao1 Hou Kang1

1.Center of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, Chengdu, Sichuan, China
1. Center of Gastrointestinal and Minimally Invasive Surgery, Department of General Surgery, The Third People's Hospital of Chengdu, Affiliated Hospital of Southwest Jiaotong University, Chengdu, Sichuan, China

2.Sichuan Polytechnic University,Deyang,Sichuan, China
2. Sichuan Polytechnic University, Deyang, Sichuan, China

摘要
Summary

目的：探查腹腔镜食管裂孔修补联合改良Hill术在袖状胃术后胃食管反流病的应用价值。方法：回顾性分析2023年4月至2024年4月共11例袖状胃切作术后胃食管反流病患者采用腹腔镜经腹食管裂孔修补联合改良Hill术的临床资料进行分析。阐述手术方法，术中出血，手术时间、术中并发症（脏器损伤、出血），平均住院时间，术后吞咽困难，症状、超声检查复发，术后药物使用情况进行可行性、安全性和有效性进行分析。结果 11例患者手术均获得成功，术中无脏器损伤，无中转开腹手术，平均手术时间137±27.8min，术后平均住院时间3.7±0.6d，术后随访时间1月，术后无吞咽困难，无症状复发，所有患者全部停用质子泵抑制剂，胃肠充盈超声提示3例好转、余均未见反流；术后3-6月典型症状复发和药物复用1例，胃肠充盈超声提示复发1例，好转2例；在食管裂孔疝和胃上移、夜间呛咳等方面均无复发。结论 采用腹腔镜食管裂孔修补联合改良Hill术在袖状胃术后胃食管反流病的应用是安全有效的治疗方法
Objective: To explore the application value of laparoscopic hiatal hernia repair combined with modified Hill technique in the treatment of gastroesophageal reflux disease after sleeve gastrectomy. Methods: A retrospective analysis was conducted on the clinical data of 11 patients with gastroesophageal reflux disease after sleeve gastrectomy who underwent laparoscopic transabdominal hiatal hernia repair combined with modified Hill technique from April 2023 to April 2024. The surgical method, intraoperative bleeding, operation time, intraoperative complications (organ injury, bleeding), average hospital stay, postoperative dysphagia, symptoms, ultrasound recurrence, and postoperative medication use were analyzed for feasibility, safety, and efficacy. Results: All 11 patients had successful surgeries, with no organ injury, no conversion to open surgery, an average operation time of 137±27.8min, an average postoperative hospital stay of 3.7±0.6d, a postoperative follow-up period of 1 month, no dysphagia, no symptom recurrence, and all patients discontinued proton pump inhibitors. Gastrointestinal distension ultrasound indicated improvement in 3 cases, with no reflux observed in the remaining cases; 1 case had recurrence of typical symptoms and medication reuse at 3-6 months postoperatively, with ultrasound indicating recurrence in 1 case and improvement in 2 cases; there was no recurrence in esophageal hiatus hernia, upward migration of the stomach, and nocturnal coughing. Conclusion: The application of laparoscopic hiatal hernia repair combined with modified Hill technique in the treatment of gastroesophageal reflux disease after sleeve gastrectomy is a safe and effective treatment method.

关健词:腹腔镜，食管裂孔修补术，改良Hill，袖状胃切除术后胃食管反流病
Keywords: Laparoscopy, hiatal hernia repair, modified Hill, gastroesophageal reflux disease after sleeve gastrectomy

GERD是一种常见病，全球不同地方的患病率不同。2018年Eusebi等人开展的一项纳入102篇研究(460,984例患者)的全球流行病学研究，结果显示：GERD的全球汇总患病率为14.8%[1]。我国GERD的患病率为7%左右，由于人口老龄化加剧、超重和肥胖患病率增加、GERD诊断率升高，且患病率呈逐年上升趋势[2]。超重与肥胖也随着生活水平提高人群也逐年增加，减重手术也日益增加，目前国内减重手术仍以袖状胃切除术为主；胃食管反流又是袖状胃切除术术后的常见并发症，而我们常用的腹腔镜胃底折叠术，因袖状胃切除后胃结构的破坏，失去了行胃底折叠的机会。我们回顾性分析2023年4月至2024年4月成都市第三人民医院针对袖状胃切除术后胃食管反流病采用腹腔镜经腹食管裂孔修补术联合改良Hill术治疗15例患者进行临床评价分析。
Gastroesophageal Reflux Disease (GERD) is a common disease with varying prevalence rates across different regions of the world. A global epidemiological study conducted by Eusebi et al. in 2018, which included 102 studies (with 460,984 patients), showed that the global pooled prevalence of GERD was 14.8% [1]. The prevalence of GERD in our country is around 7%, and due to the intensification of population aging, increasing prevalence of overweight and obesity, rising diagnosis rates of GERD, and an upward trend in prevalence year by year [2]. Overweight and obesity also increase with the improvement of living standards, and weight-loss surgery is increasingly common; currently, weight-loss surgery in our country is mainly sleeve gastrectomy. Gastroesophageal reflux is also a common complication after sleeve gastrectomy, and the laparoscopic fundoplication, which we commonly use, loses the opportunity for fundoplication due to the destruction of the gastric structure after sleeve gastrectomy. We retrospectively analyzed the clinical evaluation of 15 patients treated with laparoscopic transabdominal esophageal hiatus repair combined with modified Hill technique for gastroesophageal reflux disease after sleeve gastrectomy at the Third People's Hospital of Chengdu from April 2023 to April 2024.

资料与方法
Data and Methods

一般资料
General Information

回顾性分析成都市第三人民医院2023年4月至2024年4月共11例袖状胃胃食管反流病患者，其中男性6例，平均年龄45±12.5岁，女性5例，平均年龄41±5.9岁，所有患者均因典型症状反酸、烧心入院，并伴长期口服并不能停用质子泵抑制剂，术前GERD评分均大于10分，胃食充盈超声造影提示胃食管反流来提示合并有胃食管反流，病程为12-69个月。术前通过超声或CT诊断考虑合并食管裂孔疝或纵膈胃上移9例，夜间反流呛醒5例，所有患者均为每日或隔日至少口服1次质子泵药物治疗，且在口服药物治疗时同时合并反流性食管炎，其中A级2例、B级5例、C级4例，(表1)。本研究经医院医学伦理委员会审核通过。
Retrospective analysis of 11 sleeve gastrectomy patients with gastroesophageal reflux disease (GERD) from April 2023 to April 2024 at Chengdu Third People's Hospital, including 6 males with an average age of 45±12.5 years and 5 females with an average age of 41±5.9 years. All patients were admitted due to typical symptoms of acid regurgitation and heartburn, accompanied by long-term oral medication and inability to discontinue proton pump inhibitors. Preoperative GERD scores were all greater than 10 points. Gastric esophageal reflux was suggested by gastroesophageal reflux ultrasound contrast, with a disease course of 12-69 months. Nine patients were considered to have hiatal hernia or mediastinal gastric upward displacement by ultrasound or CT before surgery, 5 patients were awakened by nocturnal reflux, and all patients took proton pump drugs orally at least once a day or every other day, and simultaneously had reflux esophagitis, including 2 cases of grade A, 5 cases of grade B, and 4 cases of grade C (Table 1). This study was approved by the hospital's medical ethics committee.

纳入标准：（1）不能停用质子泵抑制剂患者；(2)胃肠充盈超声造影明确存在胃食管反流；（2）患者自愿手术并签属同意书；（3）为袖状胃切除术后的胃食管反流患者行腹腔镜手术治疗，术中不能行胃底折叠术。
Inclusion criteria: (1) Patients unable to discontinue proton pump inhibitors; (2) Patients with definite gastroesophageal reflux demonstrated by gastrointestinal contrast ultrasound; (3) Patients willing to undergo surgery and sign informed consent; (4) Laparoscopic surgery for gastroesophageal reflux patients after sleeve gastrectomy, with no fundoplication procedure during the operation.

排除标准：（1）存在严重基础疾病不耐受手术治疗者；（2）行胃旁路患者；（3）采用内镜下治疗者；（4）同时采用胃肠吻合的双通道患者；（5）采用了胃底折叠术的患者。
Exclusion criteria: (1) Patients with severe underlying diseases intolerant to surgical treatment; (2) Patients undergoing gastric bypass surgery; (3) Patients receiving endoscopic treatment; (4) Patients undergoing biliopancreatic diversion with duodenal switch; (5) Patients who have had fundoplication.

观察指标：
Observation indicators:

患者一般资料和手术资料由病例系统进行收集；术后随访资料通过术后1月、3至6个月之间采用电话、微信联系，门诊或住院检查收集患者典型症状、有无夜间呛醒、胃肠充盈超声造影结果、术前每日口服质子泵抑制剂、吞咽情况。
Patient general information and surgical data are collected by the case system; postoperative follow-up data is collected through telephone and WeChat contact between 1 month and 3 to 6 months postoperatively, and outpatient or inpatient examinations collect typical symptoms, whether there is a night cough, gastrointestinal distension ultrasound contrast results, daily oral proton pump inhibitors before surgery, and swallowing status.

吞咽情况将1个月内按即定饮食流程进食无困难分无吞咽困难，有进食流质饮食困难需静脉补液者为吞咽困难，术后3个月仍不能恢复术前饮食为重度吞咽障碍。将质子泵抑制剂使用情况分为：完全停用即除其他疾病需使用质子泵抑制剂外不再使用该类药；好转是在原有用药基础上用药间隔时间延长或量降低为好转，无效是即同术前用药或用药频率及量的增加。典型症状有主要包括反酸、烧心；根据《中国胃食管反流病诊疗规范》[3]提出轻度症状为≥2d/周为标准，把典型症状≥2d/周分为有典型症状，反之为无典型症状；GERD评分以8分为基准，>8分为考虑胃食管反流病。将超声检查结果分为：未见反流即超声检查期间未见明显反流现像；好转即超提示仅某体位时存在反流，余无反流；无效即超声仍见明显反流。
Swallowing condition will be classified as normal if there is no difficulty in eating according to the predetermined dietary process within one month. Difficulty in eating liquid diet and the need for intravenous fluid replacement indicates dysphagia. Severe dysphagia is defined as the inability to recover to preoperative dietary intake after 3 months postoperatively. Proton pump inhibitor use is categorized as: complete discontinuation, except for other diseases requiring proton pump inhibitors, this class of drug is no longer used; improvement is defined as an extension of the interval or a reduction in dose based on the original medication; ineffective is the same as preoperative medication or an increase in frequency and dose of medication. Typical symptoms mainly include acid regurgitation and heartburn; according to the "China Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux Disease" [3], mild symptoms are defined as ≥2 days/week as the standard, typical symptoms are defined as ≥2 days/week, otherwise, there are no typical symptoms; GERD scoring is based on 8 points, >8 points is considered to have gastroesophageal reflux disease. Ultrasound examination results are categorized as: no reflux, indicating no significant reflux phenomenon during the ultrasound examination; improvement, indicating reflux only in certain body positions as suggested by ultrasound, no reflux otherwise; ineffective, indicating significant reflux is still visible on ultrasound.

表1 研究对像临床资料
Table 1 Clinical Data of Research Objects

治疗方法
Treatment methods

手术为同一医师进行手术。 手术步骤分为：分离粘连，游离显露食管裂孔和食管，关闭食管裂孔，Hill胃底固定。
The surgery was performed by the same physician. The surgical steps are: separation of adhesions, mobilization and exposure of the esophageal hiatus and esophagus, closure of the esophageal hiatus, and Hill fundoplication.

手术具本方法：五孔法，体位呈“大”字平卧位，头高脚低，右侧倾斜10^o。主刀位于患者右侧，脐上做10mm观察孔，分别于左右肋缘下锁骨中线及左右锁骨中线近脐平面分别立5mm、5mm、5mm、10mm；缝线进行悬吊左肝，暴露胃食管裂结合部，超声刀切开肝胃韧带，暴露右侧膈肌脚和胃后系膜，沿右侧膈肌角由右向左游离并向His角游离（图１）；再沿右侧食管裂孔处向左侧离断膈食管筋膜并完全松解食管裂孔（图２）；于胃体部中上段约3-5cm处向食管裂孔疝分解游离网膜与胃壁粘连并显露左侧食管裂孔（图３）；使用牵引条索进行牵拉食管，游离食管长约6-10cm，保障腹段食管3-5cm；缝合关闭食管裂孔并缝合食管肌层与食管裂孔的肌膜和肌肉即重建膈食管筋膜（需可容纳1.2cm支撑管经口腔由食管通过食管裂孔）（图４）；贲门上2cm至贲门处分别用不可吸收缝线缝合3针，分别于迷走神经前支左侧进针缝合食管肌层，向右侧连续缝合至迷走神经后支左侧（需注意避开迷走神经，迷走神经位于缝针外），再与膈肌角肌层和肌膜缝合固定（需可容纳1.2cm支撑管经口腔由食管通过食管裂孔）（图５）；残余胃底与左侧食管壁缝合抬高胃底约1-1.5cm（图６），缝合游离网膜与胃壁固定。
Surgical method: Five-port method, body position in a "big" letter supine position, head higher than feet, right side tilted 10 ^o . The surgeon is located on the right side of the patient, a 10mm observation incision is made above the umbilicus, and 5mm, 5mm, 5mm, and 10mm incisions are made respectively at the midclavicular line below the right and left ribs and near the umbilicus at the midclavicular line on the right and left sides; the suture is suspended to the left liver, exposing the junction of the esophagus and stomach, cutting the gastrohepatic ligament with a ultrasonic knife, exposing the right crural foot and the posterior mesentery of the stomach, freeing from right to left along the right crural angle and to the His angle (Figure 1); then along the right esophageal hiatus, the diaphragmophrenic fascia is transected to the left and completely released the esophageal hiatus (Figure 2); at the middle and upper segment of the gastric body, about 3-5cm from the esophageal hiatus, the omentum and the gastric wall are freed from the esophageal hiatus hernia and the left esophageal hiatus is exposed (Figure 3); the esophagus is pulled using traction strings, freeing it for about 6-10cm, ensuring a 3-5cm abdominal segment of the esophagus; the esophageal hiatus is sutured closed, and the esophageal muscle layer and the muscular membrane and muscle at the esophageal hiatus are sutured to reconstruct the diaphragmophrenic fascia (it needs to accommodate a 1.2cm support tube passing through the esophagus via the esophageal hiatus) (Figure 4); 3 sutures are made 2cm above the cardia to the cardia using non-absorbable sutures, the esophageal muscle layer is sutured from the left side of the vagus nerve anterior branch, and continuously sutured to the left side of the vagus nerve posterior branch to the right (attention must be taken to avoid the vagus nerve, which is located outside the suture needle), and then sutured and fixed with the muscle layer and muscular membrane at the crural angle (it needs to accommodate a 1.2cm support tube passing through the esophagus via the esophageal hiatus) (Figure 5); the remaining fundus of the stomach is sutured to the left esophageal wall, raising the fundus by about 1-1.5cm (Figure 6), and the omentum is sutured and fixed to the gastric wall.

图１ 图２
Figure 1 Figure 2

图３ 图４
Figure 3 Figure 4

图５ 图６
Figure 5 Figure 6

饮食指导 ：
Dietary Guidance:

术后第一天开始饮水总量约250-300ml,术后第二天给予肠内营养液+水约1000cm，术后第三天给予全流质饮食并复查腹部CT和超声出院。饮食由流质、半流质、软食到正常饮食过度大约需2周至3 个月，但正常饮食仍需少食多餐，严禁暴食暴饮和进食过快。
Postoperative day 1: Start with a total fluid intake of approximately 250-300ml. Postoperative day 2: Administer enteral nutrition fluid + water of about 1000cm. Postoperative day 3: Provide full liquid diet and re-examine abdominal CT and ultrasound for discharge. Transition from liquid, semi-liquid, soft food to normal diet takes about 2 weeks to 3 months, but normal diet still requires small meals and frequent eating, and is strictly prohibited to overeat or drink excessively and eat too fast.

统计学方法
Statistical Methods

统计学采用SPSS 25.0 统计软件。偏态分布采用中位数描述；正态分布采用计量资料均数±标准差表示，两组比较用t检查；计数资料采用百分比表示，两组比较用卡方检验；统计学差异为P＜0.05。
Statistics were analyzed using SPSS 25.0 software. Skewed distributions were described using medians; normal distributions were represented by mean ± standard deviation, with comparisons between two groups using t-test; count data were presented as percentages, with comparisons between two groups using chi-square test; statistical significance was defined as P < 0.05.

结果
Results

11例袖状胃切除术后胃食管反流病采用腹腔镜食管裂孔修补联合改良Hill术患者全部由腹腔镜完成，无中转开腹及改变术式。手术时间137±27.8min（85—180min），术中出血11.8±5.6ml（5-20ml）；术中余无其他脏器损伤；术前及术后均未留置胃管和尿管，术后未放置引流管；术后的平均住院时间3.7±0.6d（3-5d）（表2）。
11 cases of gastroesophageal reflux disease after sleeve gastrectomy were treated with laparoscopic esophageal hiatus repair combined with modified Hill procedure, all performed laparoscopically, without conversion to open surgery or change in surgical technique. The operation time was 137±27.8min (85—180min), intraoperative blood loss was 11.8±5.6ml (5-20ml); no other organ injuries occurred during surgery; no gastric tubes or urinary catheters were left in place preoperatively or postoperatively, and no drainage tubes were placed postoperatively; the average hospital stay after surgery was 3.7±0.6d (3-5d) (Table 2).

表2手术及并发症资料
Table 2 Surgical and Complication Data

注：脏器损伤中脏器包括：胸膜、胃、食管空透性损伤、脾、结肠、肝。
Note: In organ injuries, organs include pleura, stomach, esophageal perforation, spleen, colon, and liver.

将术后1个月、术后3-6个月随访资料分析比较。通过随访术后1月和3-6月随访均未发现明显吞咽困难和重度吞咽困难。在随访中1例患者术后3-6月后反流症状再次出现，但口服质子泵抑制剂用药间期延长，为每周一至两次用药。超声检查随访中发现术后1月有3例患者存在左侧位或右侧位时存在反流，术后3-6月2例为好转，1例无效；无效例是术后1月检查未见反流患者，术后3-6月复发，也为症状复发和使用质子泵抑制剂者患者。GERD评分在术后1月随访中所有患者均小于<8分，术后3-6月随访中1例患者为9分，即典型症状复发患者。所有患者食管裂孔疝或胃上移均缓解，无夜间呃咳发生，未额外补充维生素j微量元素，患者术后均感到满意。（表3、4）
Analysis and comparison of follow-up data at 1 month postoperatively and between 3-6 months postoperatively. No significant dysphagia or severe dysphagia was found in either the 1-month or 3-6-month follow-up. During the follow-up, 1 patient experienced a recurrence of reflux symptoms 3-6 months postoperatively, but the interval of proton pump inhibitor medication was extended to once or twice a week. Ultrasound follow-up examination found that 3 patients had reflux when in the left or right lateral position 1 month postoperatively, 2 improved at 3-6 months, and 1 was ineffective; the ineffective case was a patient who showed no reflux on the 1-month examination but recurred at 3-6 months, also with symptom recurrence and proton pump inhibitor use. The GERD score was less than 8 points for all patients in the 1-month follow-up, and 1 patient was 9 points in the 3-6-month follow-up, indicating a recurrence of typical symptoms. All patients had relief of esophageal hiatus hernia or gastric upward displacement, no nocturnal hiccups occurred, no additional vitamin J or trace elements were supplemented, and all patients were satisfied with the postoperative condition. (Tables 3, 4)

表3术后随访资料
Table 3 Postoperative Follow-up Data

表4术后随访资料
Table 4 Postoperative Follow-up Data

讨论
Discussion

减重手术可以使体重下降并降低腹腔内压力，所以在2021年Elzouki AN等人的一项综述中对近1万的减重术后患者研究中提出约63.4%的肥胖患者在术前胃食管反流症状在腹腔内压力的降低是可以得到缓解[4]。但更多的报告是在袖状胃切除术后胃反流病、反流性食管炎的发生是明显增加，2023年Coupaye M等的研究中提出袖状胃切除术后5年内新增发生食管炎的发病率为4.6%，术后质子泵抑制剂的使用率将增加40%左右[5]。本研究中11例患者其反流症状均比较重，在服用质子泵抑制剂的同时仍有5例存在患者夜间因反流呛醒。考虑为袖状胃切除术后，虽减重后可使腹内压降低，但仍不足抵消因袖状胃切除导到的His角的破坏、胃底切除、吊索纤维离断以及管型胃胃腔内壁不均导致压力不均而导致的反流的发生。
Bariatric surgery can cause weight loss and reduce intra-abdominal pressure, so in a 2021 review by Elzouki AN and others, it was proposed that approximately 63.4% of obese patients experienced relief of gastroesophageal reflux symptoms before surgery due to the reduction in intra-abdominal pressure [4]. However, more reports indicate that the occurrence of gastric reflux disease and reflux esophagitis is significantly increased after sleeve gastrectomy, with a study by Coupaye M and others in 2023 suggesting that the incidence of new esophagitis within 5 years after sleeve gastrectomy is 4.6%, and the use of proton pump inhibitors will increase by about 40% [5]. In this study, 11 patients all had relatively severe reflux symptoms, and 5 of them still experienced being woken up at night due to reflux despite taking proton pump inhibitors. Considering that although weight loss can reduce intra-abdominal pressure after sleeve gastrectomy, it is still not enough to offset the disruption of the His angle, resection of the gastric fundus, dissection of the suspensory fibers, and uneven wall of the tubular stomach lumen, which lead to uneven pressure and cause reflux.

早在1994年Aye RW等的一项研究中就提出Hill手术在胃食管反流病的中近期疗效达97%[6]；而在2011年Aye RW等针对Hill术后平均10年的随访研究中提出长期有效率在90%以上[7]，2018年Park Y等针对Hill术后平均19年的随访研究中提出长期有效率在85%以上[8]；本研究在典型症状上1个月内所有均缓解，完全缓解率为100%，术后3-6月有1例出现复发，其症状完全缓解率也达90.9%；在超声影像学提示反流方面，术后1月所有患者均得到改善，其完全缓解率为72.7%；而在3-6月其改善也达90.9%，完全缓解率仍维持72.7%；其中1例由术前1月好转转为完全缓解，考虑为手术后胃食管区局部水肿导致关闭不严，待水肿消退和局部瘢痕形成双重作用导致反流的消失。本研究其典型症状复发和药物的复用1例，均为同一患者，随访用药量也较术前减少，考虑为有好转，其有效率达到100%，完全停用药物也能达90%以上，所有食管裂孔疝和胃上移均得到改善，考虑与食管裂孔修补后，进一步可以维持胃食管瓣的正常形态；当胃食管瓣的形态异常与胃食管反流病的发生率密切呈正相关[9.10]，而复发1例患者术后未按要求进食，且常暴饮暴食，可能在早期修补未稳固，在暴饮暴食下导致的胃食管瓣的松驰有关。
As early as 1994, Aye RW et al. proposed that the short-term and intermediate-term efficacy of Hill surgery in gastroesophageal reflux disease reached 97% [6]; in 2011, Aye RW et al. reported that the long-term efficacy was over 90% in a follow-up study of an average of 10 years after Hill surgery [7], and in 2018, Park Y et al. suggested that the long-term efficacy was over 85% in a follow-up study of an average of 19 years after Hill surgery [8]; in this study, all typical symptoms were relieved within one month, with a complete relief rate of 100%, and one case of recurrence occurred between 3 to 6 months postoperatively, with a complete relief rate of 90.9%; in terms of reflux indicated by ultrasound imaging, all patients showed improvement one month postoperatively, with a complete relief rate of 72.7%; and between 3 to 6 months, the improvement reached 90.9%, with the complete relief rate still at 72.7%; in one case, improvement from one month before surgery to complete relief was considered, attributed to local edema in the gastroesophageal area causing incomplete closure, which was resolved with the regression of edema and the formation of local scars leading to the disappearance of reflux. In this study, one case of recurrence of typical symptoms and reuse of medication were both in the same patient, and the follow-up medication dosage was also reduced compared to before surgery, considered as an improvement, with an efficacy rate of 100%, and complete cessation of medication could also reach over 90%, with all hiatal hernias and upward migration of the stomach improved, considered related to the repair of the esophageal hiatus, which can further maintain the normal morphology of the gastroesophageal valve; when the morphology of the gastroesophageal valve is abnormally associated with the incidence of gastroesophageal reflux disease [9.10], and one patient who recurred postoperatively did not eat according to instructions and often overate, which may be related to the early repair not being stable under overeating, leading to relaxation of the gastroesophageal valve.

胃食管反流病是一种功能性疾病，主要影响是降低生活质量，极少因急症危及生命。而Hill手术是有创性操作，在1989年Low DE等就曾报告Hill手术后脾脏损伤需行脾切除的占8.3%、吞咽困难的发生率占6.3%，还有其他罕见的肺栓塞、心肌梗塞等。因其严重的并发症，往往让医务人员本身和患者都望而怯步[11]。而本研究中患者术后均无明显吞困难，考虑为术中给予支撑管进行支撑避免了胃食管结合部的过度狭窄；同时袖状胃切除术后因胃容量减少出现的单次饮食量少，以及手术后长期的饮食习惯影响有关系；另外本研究无合并脏器损伤，考虑袖状胃切除术后，通常已经游离离断了脾胃韧带，所以在手术过程中出现脾脏损伤的可能性小；另外改良Hill手术是先将食管裂孔周围进行游离，食管裂孔进行关闭，再将食管筋膜缝合后固定于膈肌角的膈肌上，通常游离范围不需要太大，并且不需要缝合于主动脉弓状韧带上，减少缝合时的误伤；改良后的Hill手术时间相对较短，且术中未按置尿管和引流管，术后能早期下床活动，能减少术后肺部感染等并发症的发生。
Gastroesophageal reflux disease is a functional disease, primarily affecting the quality of life, rarely posing a life-threatening emergency. The Hill procedure is an invasive operation, and in 1989, Low DE et al. reported that 8.3% of patients required splenectomy after the Hill procedure due to spleen injury, and the incidence of dysphagia was 6.3%, along with other rare complications such as pulmonary embolism and myocardial infarction. Due to its severe complications, it often makes both medical personnel and patients hesitant [11]. In this study, all patients had no significant dysphagia postoperatively, which is considered to be due to the use of a support tube during surgery to prevent excessive narrowing at the gastroesophageal junction; at the same time, the reduced single meal intake after sleeve gastrectomy due to the decreased stomach capacity, as well as the long-term influence of dietary habits after surgery, are related; in addition, there were no associated organ injuries in this study, considering that after sleeve gastrectomy, the gastro splenic ligament is usually freed and transected, so the possibility of spleen injury during the surgical process is low; in addition, the improved Hill procedure involves first freeing the area around the esophageal hiatus, closing the esophageal hiatus, and then suturing the esophageal fascia and fixing it to the diaphragm at the diaphragmatic angle, usually without the need for a large degree of dissection and without suturing to the aortic arch ligament, reducing the risk of accidental injury during suturing; the improved Hill procedure is relatively shorter in duration, and no urinary catheter or drainage tube is placed during surgery, allowing for early ambulation postoperatively, which can reduce the occurrence of postoperative pulmonary infections and other complications.

本研究缺乏大样本、多中心和长期随访数据，需要待后期进一步论证，但也为对袖状胃切除术后胃食管反流的治疗开避新的思路。
This study lacks large sample size, multi-center, and long-term follow-up data, which needs further verification in the later stage. However, it also opens up new ideas for the treatment of gastroesophageal reflux after sleeve gastrectomy.

参考文献
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