Departments of Internal Medicine.
Thoracic and Cardiovascular Surgery.
J Clin Gastroenterol. 2020 Jul;54(6):e56-e62. doi: 10.1097/MCG.0000000000001316.
The shortened esophagus is poorly defined and is determined intraoperatively, as there exists no objective test to identify a shortened esophagus before surgical hiatal hernia repair. We devised a unique manometric esophageal length to height (MELH) ratio to define the presence of a shortened esophagus and examined the role of esophageal length in hiatal hernia recurrence.
A retrospective review identified 254 patients with hiatal hernia who underwent preoperative esophageal manometry and either an open hernia repair with Collis gastroplasty and fundoplication (with Collis) or laparoscopic repair and fundoplication without Collis gastroplasty (without Collis) from 2005-2016. The MELH ratio was calculated by measuring the upper to lower esophageal sphincter distance divided by the patient's height.
Of 245 patients, 157 underwent repair with Collis, while 97 underwent repair without Collis. The Collis group had a shorter manometric esophageal length (20.2 vs. 22.4 cm, P<0.001) and lower MELH (0.12 vs. 0.13, P<0.001). The Collis group had fewer hernia recurrences (18% vs. 55%, log-rank P<0.001) and fewer reoperations for recurrence (0% vs. 10%, log-rank P<0.001) at 5 years. A 33% decrease in risk of hernia recurrence was seen for every 0.01 U increment in MELH ratio (hazard ratio: 0.67; 95% confidence interval: 0.55-0.83, P<0.001) while repair without Collis (hazard ratio: 6.1; 95% confidence interval: 3.2-11.7, P<0.001) was associated with increased risk of hernia recurrence.
MELH ratio is an objective predictor of a shortened esophagus preoperatively. Lower MELH is associated with increased risk of recurrence and the risk associated with shortened esophagus can be mitigated with an esophageal lengthening procedure such as Collis gastroplasty.
短食管的定义不明确，需要在术中确定，因为在手术治疗食管裂孔疝修复前，没有客观的测试来识别短食管。我们设计了一种独特的测压食管长度与身高比（MELH）来定义短食管的存在，并研究了食管长度在食管裂孔疝复发中的作用。
回顾性分析了 2005 年至 2016 年间 254 例接受食管测压和开腹疝修补术（Collis 胃底折叠术和胃食管瓣成形术，Collis 组）或腹腔镜疝修补术和胃食管瓣成形术（无 Collis 胃底折叠术，无 Collis 组）的食管裂孔疝患者。MELH 比值通过测量食管上括约肌到下食管括约肌的距离除以患者的身高来计算。
在 245 例患者中，157 例接受 Collis 修补术，97 例接受无 Collis 修补术。Collis 组的食管测压长度更短（20.2 厘米 vs. 22.4 厘米，P<0.001），MELH 比值更低（0.12 比 0.13，P<0.001）。Collis 组疝复发率较低（18% vs. 55%，对数秩检验 P<0.001），复发后再手术率较低（0% vs. 10%，对数秩检验 P<0.001）。MELH 比值每增加 0.01 U，疝复发风险降低 33%（风险比：0.67；95%置信区间：0.55-0.83，P<0.001），而无 Collis 修补术（风险比：6.1；95%置信区间：3.2-11.7，P<0.001）与疝复发风险增加相关。
MELH 比值是术前预测短食管的客观指标。较低的 MELH 与复发风险增加相关，而 Collis 胃底折叠术等食管延长术可降低短食管相关风险。
