Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC, 28204, USA.
Surg Endosc. 2022 Feb;36(2):1650-1656. doi: 10.1007/s00464-021-08415-z. Epub 2021 Sep 1.
Elective repair versus watchful waiting remains controversial in paraesophageal hernia (PEH) patients. Generation of predictive factors to determine patients at greatest risk for emergent repair may prove helpful. The aim of this study was to evaluate patients undergoing elective versus emergent PEH repair and supplement this comparison with 3D volumetric analysis of hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) to determine risk factors for increased likelihood of emergent repair.
A retrospective review of a prospectively enrolled, single-center hernia database was performed on all patients undergoing elective and emergent PEH repairs. Patients with adequate preoperative computed tomography (CT) imaging were analyzed using volumetric analysis software.
Of the 376 PEH patients, 32 (8.5%) were emergent. Emergent patients had lower rates of preoperative heartburn (68.8%vs85.1%, p = 0.016) and regurgitation (21.9%vs40.2%, p = 0.04), with similar rates of other symptoms. Emergent patients more frequently had type IV PEHs (43.8%vs13.5%, p < 0.001). Volumetric analysis was performed on 201 patients, and emergent patients had a larger HSV (805.6 ± 483.5vs398.0 ± 353.1cm, p < 0.001) and HDA (41.7 ± 19.5vs26.5 ± 14.7 cm, p < 0.001). In multivariate analysis, HSV increase of 100cm (OR 1.17 CI 1.02-1.35, p = 0.022) was independently associated with greater likelihood of emergent repair. Post-operatively, emergent patients had increased length of stay, major complication rates, ICU utilization, reoperation, and mortality (all p < 0.05). Emergent group recurrence rates were higher and occurred faster secondary to increased use of gastropexy alone as treatment (p > 0.05). With a formal PEH repair, there was no difference in rate or timing of recurrence.
Emergent patients are more likely to suffer complications, require ICU care, have a higher mortality, and an increased likelihood of reoperation. A graduated increase in HSV increasingly predicts the need for an emergent operation. Those patients presenting electively with a large PEH may benefit from early elective surgery.
在食管裂孔疝（PEH）患者中，择期修复与密切观察等待仍然存在争议。生成预测因素以确定最有可能紧急修复的患者可能会有所帮助。本研究的目的是评估接受择期和紧急 PEH 修复的患者，并通过 3D 食管裂孔缺陷面积（HDA）和胸腔疝囊体积（HSV）的容积分析补充这一比较，以确定增加紧急修复可能性的危险因素。
对所有接受择期和紧急 PEH 修复的患者进行前瞻性入组、单中心疝数据库的回顾性研究。对有足够术前计算机断层扫描（CT）成像的患者使用容积分析软件进行分析。
在 376 例 PEH 患者中，32 例（8.5%）为紧急情况。紧急患者的术前烧心（68.8%对 85.1%，p=0.016）和反流（21.9%对 40.2%，p=0.04）发生率较低，其他症状发生率相似。紧急患者更常出现 4 型 PEH（43.8%对 13.5%，p<0.001）。对 201 例患者进行了容积分析，紧急患者的 HSV 更大（805.6±483.5vs398.0±353.1cm，p<0.001）和 HDA 更大（41.7±19.5vs26.5±14.7cm，p<0.001）。在多变量分析中，HSV 增加 100cm（OR 1.17，95%CI 1.02-1.35，p=0.022）与紧急修复的可能性增加独立相关。术后，紧急患者的住院时间延长、主要并发症发生率、ICU 使用率、再次手术和死亡率均较高（均 p<0.05）。紧急组的复发率更高，且由于单独使用胃固定术作为治疗方法的增加而更快发生（p>0.05）。对于正式的 PEH 修复，复发的发生率和时间没有差异。
紧急患者更有可能发生并发症、需要 ICU 护理、死亡率更高，并且更有可能再次手术。HSV 的逐渐增加越来越能预测紧急手术的需要。那些选择性就诊且 PEH 较大的患者可能受益于早期择期手术。
