Feinberg School of Medicine, Northwestern Quality Improvement, Research and Education in Surgery, Northwestern University, Chicago, IL, USA.
Department of Surgery, Feinberg School of Medicine, Northwestern University, 633N St Clair St, 20th Floor, Chicago, IL, 60611, USA.
Surg Endosc. 2024 Sep;38(9):5017-5022. doi: 10.1007/s00464-024-11048-7. Epub 2024 Jul 12.
Hiatal hernia (HH) is estimated to affect between 20 and 50% of patients undergoing bariatric surgery. However, there is no consensus regarding the preoperative assessment and intraoperative repair of HH. The aim of this study was to evaluate the variation in surgeon assessment and repair of HH during bariatric surgery across a multi-hospital healthcare system.
A retrospective cohort analysis was conducted using data obtained from the metabolic and bariatric accreditation quality improvement program (MBSAQIP) and institutional medical records. All adult patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were included. Preoperative assessment of HH was defined as either EGD or upper GI/Esophagram (UGI) within one year of surgery. Surgeons were evaluated individually and by hospital. Chi-square analysis and ANOVA were performed.
From January 2018 to February 2023, 3,487 bariatric surgeries were performed across 4 hospitals and 11 surgeons (2481 SG and 1006 RYGB). HH were concurrently repaired during 24% of operations. The rate of HH repair in SG was 25 and 22% in RYGB (p = 0.06). Preoperatively, 41% of patients underwent EGD and 23% had an UGI. HH was diagnosed in 22% of EGDs. Patients who underwent preoperative EGD had higher rates of HH repair than those without a preop EGD (33% vs. 17%; p < 0.001). The rate of preoperative EGD utilization by surgeon varied significantly from 3 to 92% (p < 0.001) as did HH repair rates between surgeons (range 8-57%; p < 0.001). Even among patients with a preoperatively diagnosed HH, the repair rate ranged 20-91% between individual surgeons (p < 0.001).
Within a healthcare system there was significant heterogeneity in approach to assessment and repair of HH during bariatric surgery. This appears to be mediated by multiple factors, including utilization of preoperative studies, individual surgeon differences, and differences between hospitals.
据估计，在接受减重手术的患者中，有 20%至 50%患有食管裂孔疝（HH）。然而，对于 HH 的术前评估和术中修复，目前尚无共识。本研究旨在评估在多医院医疗保健系统中，外科医生在减重手术中对 HH 的评估和修复的变化。
使用代谢和减重手术认证质量改进计划（MBSAQIP）和机构病历中获得的数据，进行回顾性队列分析。所有接受腹腔镜袖状胃切除术（SG）或 Roux-en-Y 胃旁路术（RYGB）的成年患者均纳入研究。HH 的术前评估定义为手术前一年内经内镜检查（EGD）或上消化道/食管造影（UGI）。对每位外科医生和每个医院进行了 χ2 分析和 ANOVA。
从 2018 年 1 月至 2023 年 2 月，在 4 家医院和 11 名外科医生中进行了 3487 例减重手术（2481 例 SG 和 1006 例 RYGB）。HH 在 24%的手术中同时修复。SG 中 HH 修复率为 25%，RYGB 中为 22%（p=0.06）。术前，41%的患者行 EGD 检查，23%的患者行 UGI 检查。22%的 EGD 检查诊断为 HH。行术前 EGD 的患者 HH 修复率高于未行 EGD 的患者（33%比 17%；p<0.001）。外科医生行术前 EGD 检查的利用率差异显著（范围 3%至 92%；p<0.001），外科医生之间的 HH 修复率也存在显著差异（范围 8%至 57%；p<0.001）。即使在术前诊断为 HH 的患者中，不同外科医生之间的修复率也在 20%至 91%之间（p<0.001）。
在医疗保健系统内，在减重手术中对 HH 的评估和修复方法存在显著的异质性。这似乎是由多种因素介导的，包括术前研究的使用、外科医生个体差异以及医院之间的差异。
