Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Ospedale Galeazzi, Sant'Ambrogio, University of Milan, Via C. Belgioioso, 173, 20157, Milan, Italy.
Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, Milan, Italy.
Updates Surg. 2024 Nov;76(7):2675-2682. doi: 10.1007/s13304-024-02010-2. Epub 2024 Oct 5.
The optimal treatment for paraesophageal hiatus hernia (PEH) is controversial. While crural buttressing with mesh shows promises in reducing recurrences, the decision to use mesh during minimally invasive PEH repair is largely subjective. Due to these uncertainties, we conducted a survey to examine current clinical practices among surgeons and to assess which are the most important determinants in the decision-making process for mesh placement. Thirty-five multiple-choice Google Form-based survey on work-up, surgical techniques, and issues are considered in the decision-making process for mesh augmentation during minimally invasive PEH repair. Responses were graded on a 5-point Likert scale and analyzed using descriptive statistics. Consensus was defined as > 70% of participants agreed (agree or strongly agree) on a specific statement. Overall, 292 surgeons (86% from Europe) participated in the survey. The median age of participants was 42 years (range 29-69). The median number of PEH procedures was 25/year/center (range 5-400), with 67% of participants coming from high-volume centers (> 20 procedures/year). Consensus on use of mesh was reached for intraoperative findings of large (> 50% of intrathoracic stomach) PEH (74.3%), crural gap with > 4 cm distance between right and left crus (77.1%), and/or crural atrophy with < 0.5 cm thickness of one or both pillars (73%), and for redo surgery (71.9%). Further, consensus was reached in defining recurrence as a combination of refractory symptoms and anatomical/radiological evidence of > 2 cm hernia. This survey shows that large PEH, wide crural transverse diameter, fragile crura, and redo surgery are the most influential issues driving the decision for mesh-reinforced cruroplasty.
食管裂孔旁疝（PEH）的最佳治疗方法存在争议。虽然网片加强横膈脚在减少复发方面显示出前景，但在微创 PEH 修复中使用网片的决定在很大程度上是主观的。由于存在这些不确定性，我们进行了一项调查，以检查外科医生的当前临床实践，并评估在决定是否使用网片进行微创 PEH 修补时最重要的决定因素。该调查共包括 35 个基于谷歌表单的多项选择题，涵盖了工作流程、手术技术以及决策过程中考虑的与网片放置相关的问题。采用 5 分制 Likert 量表对答案进行评分，并进行描述性统计分析。共识定义为超过 70%的参与者对特定陈述表示同意（同意或非常同意）。共有 292 名外科医生（来自欧洲的占 86%）参与了这项调查。参与者的中位年龄为 42 岁（范围为 29-69 岁）。中位 PEH 手术数量为每年 25 例/中心（范围为 5-400 例），其中 67%的参与者来自高容量中心（每年手术量超过 20 例）。对于术中发现巨大（>50%的胸腔内胃）PEH（74.3%）、右左横膈脚之间的横径>4cm（77.1%）和/或横膈脚萎缩，厚度<0.5cm（73%），以及再次手术（71.9%），达成了使用网片的共识。此外，还达成共识，将复发定义为症状难治性和>2cm疝的解剖/放射学证据的组合。这项调查表明，巨大的 PEH、宽大的横膈脚横径、脆弱的横膈脚以及再次手术是决定是否进行网片加强横膈脚修补术的最主要因素。
