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首页> 外文期刊>Surgical Endoscopy >How high is too high? Extensive mediastinal dissection in patients with hiatal hernia repair
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How high is too high? Extensive mediastinal dissection in patients with hiatal hernia repair

机译：太高了多少？ 患有海拔疝修复患者的广泛纵隔解剖

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Background Approximately 10% of patients receiving anti-reflux procedures present with shortened esophagus. Collis gastroplasty (CG) is the current gold standard for esophageal lengthening, but mediastinal esophageal mobilization without gastroplasty may be an alternative approach. This study assesses preoperative and intraoperative hernia characteristics and mediastinal dissection impact in patients with large hiatal hernia repair (HHR). Methods A single-institution, prospectively collected database was reviewed for adults who underwent laparoscopic HHR with mesh and anti-reflux surgery between 2005 and 2016, hernia >= 5 cm. Preoperative hernia and follow-up were assessed using upper endoscopy and barium swallow. Intraoperative hernia characteristics were collected from the operative note. Esophageal symptom scores were collected pre- and postoperatively. Analyses were conducted using SPSS v26.0. Results Among 662 patients who had anti-reflux surgery in this period, a total of 205 patients who underwent HHR with mesh met the inclusion criteria and were included in study. Mean age was 61.7 +/- 13.6 years, and majority of patients were female and Caucasian. Mean BMI was 29.9 +/- 6.0 kg/m(2). Median hernia size was 6.5 cm [5.0-12.0 cm], and intra-thoracic stomach had a prevalence of 21.9%. Analysis of preoperative barium swallow revealed an average of elevated gastroesophageal junction above the diaphragm of 4.10 +/- 1.67 cm. Radiographically, average hernia size was 6.34 +/- 1.93 cm and 6.38 +/- 1.92 cm in the anterior-posterior and obliquus view, respectively. Median follow-up time was 2.7 years [1-9 years]. Esophageal symptoms improved in all patients (p < 0.05). 45% of patients had radiographic recurrence, but only four presented symptomatic or were on PPI. Conclusions CG has been the standard for ensuring adequate esophageal length prior to anti-reflux surgery. Our results support that CG is unnecessary in the majority of cases, and extensive mediastinal dissection was successfully used instead of CG with durable, long-term outcomes. Extended mediastinal dissection may mitigate CG risks in patients requiring additional intra-abdominal esophagus.
机译：背景：大约10%接受抗反流手术的患者出现食管缩短。Collis胃成形术（CG）是目前食管延长的金标准，但不进行胃成形术的纵隔食管松动术可能是一种替代方法。本研究评估了大裂孔疝修补术（HHR）患者术前和术中的疝特征以及纵隔剥离的影响。方法对2005年至2016年间接受腹腔镜HHR加补片和抗反流手术、疝气>=5cm的成年人进行前瞻性研究。术前疝气和随访通过上内镜和钡剂吞咽进行评估。从手术记录中收集术中疝的特征。术前和术后收集食管症状评分。使用SPSS v26进行分析。结果在662名在此期间接受抗反流手术的患者中，共有205名接受HHR和mesh的患者符合纳入标准，并被纳入研究。平均年龄为61.7+/-13.6岁，大多数患者为女性和白种人。平均BMI为29.9+/-6.0 kg/m（2）。疝气的中位数为6.5厘米[5.0-12.0厘米]，胸腔内胃的患病率为21.9%。术前吞钡分析显示，膈以上胃食管交界处平均升高4.10+/-1.67厘米。放射学检查，前后位和斜视位的平均疝大小分别为6.34+/-1.93 cm和6.38+/-1.92 cm。中位随访时间为2.7年[1-9年]。所有患者的食管症状均有改善（p<0.05）。45%的患者有影像学复发，但只有4例出现症状或正在进行PPI。结论CG是抗反流手术前保证食管长度的标准。我们的结果支持在大多数病例中CG是不必要的，并且广泛的纵隔剥离成功地替代了CG，具有持久、长期的结果。对于需要额外腹腔内食管的患者，扩大纵隔剥离可能会降低CG风险。

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