Department of Surgery, Division of Endocrine & Minimally Invasive Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, 525 East 68th Street, K-836, New York, NY, 10065, USA.
Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA.
Surg Endosc. 2022 Sep;36(9):7008-7015. doi: 10.1007/s00464-022-09025-z. Epub 2022 Jan 31.
Hiatal hernia re-approximation during index anti-reflux surgery (ARS) contributes approximately 80% of overall change in distensibility index (DI) and, potentially, compliance of the gastroesophageal (GEJ), while sphincter augmentation contributes approximately 20%. Whether this is seen in re-operative ARS is unclear. We quantify the physiologic parameters of the GEJ at each step of robotic re-operative ARS and compare these to index ARS.
Robotic ARS with hiatal hernia repair was performed on 195 consecutive patients with pathologic reflux utilizing EndoFLIP™, of which 26 previously had ARS. Intra-operative GEJ measurements, including cross-sectional area (CSA), pressure, DI, and high-pressure zone (HPZ) length were collected pre-repair, post-diaphragmatic re-approximation, post-mesh placement, and post-lower-esophageal sphincter (LES) augmentation.
Both cohorts were similar by sex and BMI and underwent similar procedures. The re-operative cohort was older (60.6 ± 15.3 vs. 52.7 ± 16.2 years, p = 0.03), had more frequent pre-operative dysphagia (69.2% vs. 42.6%, p = 0.01) and esophageal dysmotility on barium swallow (75.0% vs. 35.0%, p < 0.001) but lower rates of hiatal hernia on endoscopy (30.8% vs. 68.7%, p < 0.001) compared to index procedures. Among the re-operative cohort, the CSA decreased by 34 (IQR - 80, - 15) mm and DI 1.1 (IQR - 2.4, - 0.6) mm/mmHg (both p < 0.001). Pressure increased by 11.2 (IQR 4.7, 14.9) mmHg and HPZ by 1.5 (1,2) cm (both p < 0.001). These changes were similar to those seen in index ARS. Diaphragmatic re-approximation contributed to a greater percentage of overall change to the GEJ than did the augmentation procedure, with 72% of the change in DI occurring during hiatal closure, similar to that seen during index ARS.
During re-operative ARS, dynamic intra-operative monitoring can quantify the effects of each operative step on GEJ physiologic parameters. Diaphragmatic re-approximation appears to have a greater effect on GEJ physiology than does LES-sphincter augmentation during both index and re-operative ARS.
在指数抗反流手术（ARS）中，食管裂孔疝的重新接近约占伸展指数（DI）总体变化的 80%，并可能影响胃食管交界处（GEJ）的顺应性，而括约肌增强约占 20%。在再次 ARS 中是否可以看到这种情况尚不清楚。我们在机器人再次 ARS 的每个步骤中量化 GEJ 的生理参数，并将其与指数 ARS 进行比较。
利用 EndoFLIP™对 195 例病理反流患者进行机器人 ARS 加食管裂孔疝修补术，其中 26 例患者曾进行过 ARS。术中测量 GEJ 指标，包括横截面积（CSA）、压力、DI 和高压区（HPZ）长度，分别在修复前、膈肌后重新接近、网片放置后和下食管括约肌（LES）增强后进行。
两个队列在性别和 BMI 方面相似，并且进行了相似的手术。再次 ARS 组年龄较大（60.6±15.3 岁 vs. 52.7±16.2 岁，p=0.03），术前吞咽困难（69.2% vs. 42.6%，p=0.01）和钡餐吞咽食管动力障碍更常见（75.0% vs. 35.0%，p<0.001），但内镜下食管裂孔疝发生率较低（30.8% vs. 68.7%，p<0.001）。在再次 ARS 组中，CSA 减少 34（IQR-80，-15）mm，DI 减少 1.1（IQR-2.4，-0.6）mm/mmHg（均 p<0.001）。压力增加 11.2（IQR 4.7，14.9）mmHg，HPZ 增加 1.5（1，2）cm（均 p<0.001）。这些变化与指数 ARS 中观察到的相似。膈肌的重新接近比 LES 括约肌增强对 GEJ 的影响更大，72%的 DI 变化发生在食管裂孔关闭期间，与指数 ARS 期间相似。
在再次 ARS 期间，动态术中监测可以定量评估每个手术步骤对 GEJ 生理参数的影响。膈肌的重新接近对 GEJ 生理学的影响似乎大于指数 ARS 和再次 ARS 期间的 LES 括约肌增强。
