Department of Surgery, The Pennsylvania State University, College of Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA.
JSLS. 2022 Oct-Dec;26(4). doi: 10.4293/JSLS.2022.00051.
Esophagogastric junction outflow obstruction (EGJOO) is attributed to primary/idiopathic causes or secondary/mechanical causes, including hiatal hernias (HH). While patients with HH and EGJOO (HH+EGJOO) may undergo HH repair without myotomy, it is unclear if an underlying motility disorder is missed by therapy which addresses only the secondary EGJOO cause. The goal of this study was to determine if HH repair alone is sufficient management for HH+EGJOO patients.
A retrospective review of patients who underwent HH repair between January 1, 2016 and January 31, 2020 was performed. Patients who underwent high-resolution esophageal manometry(HREM) within one year before HH repair were included. Patients with and without EGJOO on pre-operative HREM were compared.
Sixty-three patients were identified. Pre-operative HREM findings included: 43 (68.3%) normal, 13 (20.6%) EGJOO, 4 (6.3%) minor disorder or peristalsis, 2 (3.2%) achalasia, and 1 (1.6%) major disorder of peristalsis. No differences between patients with EGJOO or normal findings on pre-operative manometry were found in pre-operative demographics/risk factors, pre-operative symptoms, and pre-operative HREM, except higher integrated relaxation pressure in EGJOO patients. No differences were noted in length of stay, 30-day complications, long-term persistent symptoms, or recurrence with mean follow-up of 26-months. Of the 3 (23.1%) EGJOO patients with persistent symptoms, 2 underwent HREM demonstrating persistent EGJOO and none required endoscopic/surgical myotomy.
Most HH+EGJOO patients experienced symptom resolution following HH repair alone and none required additional intervention to address a missed primary motility disorder. Further study is required to determine optimal management of patients with persistent EGJOO following HH repair.
食管胃交界处流出梗阻（EGJOO）归因于原发性/特发性原因或继发性/机械性原因，包括食管裂孔疝（HH）。虽然 HH 和 EGJOO（HH+EGJOO）患者可能无需肌切开术即可进行 HH 修复，但尚不清楚仅针对继发性 EGJOO 病因进行治疗是否会错过潜在的动力障碍。本研究的目的是确定 HH 修复是否足以治疗 HH+EGJOO 患者。
对 2016 年 1 月 1 日至 2020 年 1 月 31 日期间接受 HH 修复的患者进行了回顾性分析。包括在 HH 修复前一年内接受高分辨率食管测压（HREM）的患者。比较术前 HREM 有和无 EGJOO 的患者。
共确定了 63 名患者。术前 HREM 检查结果包括：43 例（68.3%）正常，13 例（20.6%）EGJOO，4 例（6.3%）轻度障碍或蠕动，2 例（3.2%）贲门失弛缓症和 1 例（1.6%）严重蠕动障碍。术前 HREM 发现 EGJOO 或正常的患者在术前人口统计学/危险因素、术前症状和术前 HREM 方面没有差异，除了 EGJOO 患者的综合松弛压力较高。在住院时间、30 天并发症、长期持续症状或复发方面无差异，平均随访 26 个月。在 3 例（23.1%）持续存在症状的 EGJOO 患者中，2 例接受了 HREM 检查，结果显示持续存在 EGJOO，无一例需要内镜/手术肌切开术。
大多数 HH+EGJOO 患者在单独进行 HH 修复后症状得到缓解，且无需进一步干预以解决遗漏的原发性运动障碍。需要进一步研究以确定 HH 修复后持续存在 EGJOO 的患者的最佳治疗方法。
