Kooij Cezanne D, de Groot Eline M, Goense Lucas, Kingma B Feike, Brenkman Hylke J F, Ruurda Jelle P, van Hillegersberg Richard
Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
Dis Esophagus. 2025 May 3;38(3). doi: 10.1093/dote/doaf041.
Hiatal herniation (HH) following esophagectomy can cause severe complications and affect functional outcomes. This study assessed whether prophylactic cruroplasty during robot-assisted minimally invasive esophagectomy (RAMIE) reduces HH incidence.
Patients undergoing curative RAMIE with cervical anastomosis for esophageal cancer at a high-volume center were included. Cruroplasty became routine in 2017 unless the hiatus was narrow. The primary outcome was HH incidence with versus without cruroplasty. Median follow-up was calculated using the reverse Kaplan-Meier method. Kaplan-Meier curves assessed HH-free survival and cumulative incidences up to 4 years, considering the time-dependent nature of HH. The log-rank test compared groups. Multivariable Cox regression evaluated the association between cruroplasty and HH, with hazard ratios (HR) and 95%-confidence interval (95%CI).
Between 2003 and 2023, 366 patients underwent RAMIE with cervical anastomosis. Median follow was 81 months (95%CI 71-91). In the cruroplasty group, 5 (5%) developed a HH (2 symptomatic, 3 asymptomatic), while 23 (9%) of patients without cruroplasty developed a HH (5 acute, 8 symptomatic, 10 asymptomatic). Most HHs were detected within 2 years (71%; n = 20). The 4-year cumulative incidence was 5.7% with cruroplasty and 11.1% without (P = 0.289). Imaging was performed in 77 of 101 patients (76%) with cruroplasty and 228 of 265 patients (86%) without cruroplasty. Cox regression revealed no significant association between cruroplasty and HH (HR 0.652, 95%CI 0.244-1.740).
Prophylactic cruroplasty may reduce HH in RAMIE with cervical anastomose, though it cannot always prevent HH. Further research is warranted to confirm these findings and evaluate its role in other types of esophagectomy.
食管切除术后裂孔疝（HH）可导致严重并发症并影响功能结局。本研究评估了机器人辅助微创食管切除术（RAMIE）期间预防性膈肌成形术是否能降低HH的发生率。
纳入在一家高容量中心接受根治性RAMIE并进行颈部吻合的食管癌患者。除非裂孔狭窄，否则膈肌成形术在2017年成为常规操作。主要结局是有无膈肌成形术的HH发生率。使用反向Kaplan-Meier方法计算中位随访时间。考虑到HH的时间依赖性，Kaplan-Meier曲线评估了长达4年的无HH生存期和累积发生率。采用对数秩检验比较组间差异。多变量Cox回归评估膈肌成形术与HH之间的关联，计算风险比（HR）和95%置信区间（95%CI）。
2003年至2023年期间，366例患者接受了RAMIE并进行颈部吻合。中位随访时间为81个月（95%CI 71-91）。在膈肌成形术组中，5例（5%）发生HH（2例有症状，3例无症状），而未进行膈肌成形术的患者中有23例（9%）发生HH（5例急性，8例有症状，10例无症状）。大多数HH在2年内被检测到（71%；n = 20）。膈肌成形术组4年累积发生率为5.7%，未进行膈肌成形术组为11.1%（P = 0.289）。101例接受膈肌成形术的患者中有77例（76%）进行了影像学检查，265例未进行膈肌成形术的患者中有228例（86%）进行了影像学检查。Cox回归显示膈肌成形术与HH之间无显著关联（HR 0.652，95%CI 0.244-1.740）。
预防性膈肌成形术可能会降低颈部吻合的RAMIE中HH的发生率，尽管它不能总是预防HH。有必要进行进一步研究以证实这些发现并评估其在其他类型食管切除术中的作用。
