Progression of Hiatal Hernias
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RESEARCH COMMUNICATION
Progression of Hiatal Hernias Máté Csucska 1 & Balázs Kovács 1 & Takahiro Masuda 1,2 & Deepika Razia 1 & Ross M. Bremner 1 & Sumeet K. Mittal 1,2 Received: 23 May 2020 / Accepted: 15 September 2020 # 2020 The Society for Surgery of the Alimentary Tract
Keywords Hiatal hernia . Intrathoracic stomach . Laparoscopic antireflux surgery
The term hiatal hernia refers to the migration of the stomach or other abdominal viscera through the esophageal hiatus into the thoracic cavity. Hiatal hernias play an integral role in pathophysiology of GERD and are likely to enlarge over time; however, the mechanisms of this progression are not fully understood. Surgical repair of a hiatal hernia is the Achilles heel of anti-reflux surgery, and high recurrence rates have been reported after PEH.1 Similar to groin hernia surgery, an important consideration of hiatal hernia repair is the size of the defect, rather than the contents of the hernia sac. Using the method introduced by Granderath et al.,2 we evaluated these parameters in our patients and compared them with the patients’ age and height. After IRB approval, we queried our esophageal surgery database to identify patients who had intraoperative hiatus measurements taken and recorded between January 2017 and May 2020. For this study, we included patients who underwent primary surgery for GERD and/or PEH by a single surgeon (SKM). The surgical technique has been described elsewhere in detail.2 After hiatus dissection and mediastinal mobilization are completed, a laparoscopic ruler is used to measure and photograph the hiatus dimensions (Fig. 1a). The size of the hiatus defect, termed the hiatal surface area (HSA), was measured intraoperatively using the formula first introduced by Granderath et al.2 (Fig. 1b).
* Sumeet K. Mittal [email protected] 1
Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, 500 W. Thomas Rd., Ste. 500, Phoenix, AZ 85013, USA
2
Creighton University School of Medicine – Phoenix Regional Campus, Phoenix, AZ, USA
Eighty-four patients met the inclusion criteria during the study period. The mean age was 65.68 ± 11.93 years. Sixtythree patients (75.0%) were women, and the mean body mass index was 28.79 ± 5.21 kg/m2. The mean transverse dimension was 2.72 ± 0.98 cm, and the mean anteroposterior dimension was 4.44 ± 0.76 cm. The mean HSA was 4.9 ± 1.9 cm2. Patient age showed significant positive correlation with the transverse dimension (rs = 0.42, p < 0.001) and the HSA (rs = 0.45, p < 0.001), but lacked the correlation with crus length (rs = 0.07, p = 0.51). The crus length, however, had significant correlation with the patients’ height (rs = 0.3, p = 0.006; Fig. 2). Our study shows that the height of the pie-shaped hiatus defect (i.e., the anteroposterior dimension [AP]) is associated with the patient’s height and remains unchanged with age. On the other hand, the width of the crural defect (i.e., the transverse dimension [T]) increases with age, as does the hiatus defect surface area. These findings
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