Allograft dermal matrix hiatoplasty during laparoscopic primary fundoplication, paraesophageal hernia repair, and reoperation for failed hiatal hernia repair
Allograft dermal matrix hiatoplasty during laparoscopic primary fundoplication, paraesophageal hernia repair, and reoperation for failed hiatal hernia repair
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DOI：
10.1007/s00464-012-2700-y
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发表时间：
2013-06-01
影响因子：
3.1
通讯作者：
Freeman, Katherine D.
中科院分区：
文献类型：
--
作者：
Bell, Reginald C. W.;Fearon, Jacqueline;Freeman, Katherine D.
裂孔修补失败是腹腔镜食道旁疝修补术的死因，也是一期胃底折叠术和裂孔二次手术失败的主要原因。生物假体提供了加强修复的前景，而不存在与永久性假体相关的风险。使用同种异体移植物(无细胞真皮基质)嵌体的腹腔镜裂孔疝修补术的安全性和相对有效性的回顾评估。有症状性失败的患者接受了内窥镜或放射学评估裂孔状态。在2007年1月至2011年3月期间，连续450例接受腹腔镜同种异体裂孔疝修补术的患者中，有252例获得了超过6个月的随访。无侵蚀、狭窄或持续性吞咽困难。在需要再次手术的病例中，粘连是最小的。裂孔修补失败率在中位18个月(6~51个月)时差异有统计学意义(p<；0.005)：A组(一期胃底折叠术加轴型疝千分之2 cm)为3.7%，B组(一期胃底折叠术并轴型疝2~5 cm)为7.1%，G组(巨大/食道旁)为8.8%，R组(二次手术)为23.4%。此外，与其他组(462-489天)相比，R组的平均失败时间(247天)明显缩短。在18个月的中位随访期内，使用同种异体植骨加固裂孔是安全的。尽管有同种异体移植，再次手术的失败率明显高于其他组，失败的时间比其他组短，这表明初次修复需要最大的关注，在再次手术中可能需要额外的技术。与接受食道旁裂孔疝修补术的患者相比，轴向小于2厘米的患者复发率相同，应给予类似的治疗。
Hiatal repair failure is the nemesis of laparoscopic paraesophageal hernia repair as well as the major cause of failure of primary fundoplication and reoperation on the hiatus. Biologic prosthetics offer the promise of reinforcing the repair without risks associated with permanent prosthetics.Retrospective evaluation of safety and relative efficacy of laparoscopic hiatal hernia repair using an allograft (acellular dermal matrix) onlay. Patients with symptomatic failures underwent endoscopic or radiographic assessment of hiatal status.Greater than 6-month follow-up was available for 252 of 450 consecutive patients undergoing laparoscopic allograft-reinforced hiatal hernia repair between January 2007 and March 2011. No erosions, strictures, or persisting dysphagia were encountered. Adhesions were minimal in cases where reoperation was required. Failure of the hiatal repair at median 18 months (6-51 months) was significantly (p < 0.005) different between groups: group A (primary fundoplication with axial hernia a parts per thousand currency sign 2 cm), 3.7 %; group B (primary fundoplication with axial hernia 2-5 cm), 7.1 %; group G (giant/paraesophageal), 8.8 %; group R (reoperative), 23.4 %. Additionally, mean time to failure was significantly shorter in group R (247 days) compared with the other groups (462-489 days).Use of allograft reinforcement to the hiatus is safe at 18 months median follow-up. Reoperations had a significantly higher failure rate and shorter time to failure than the other groups despite allograft, suggesting that primary repairs require utmost attention and that additional techniques may be needed in reoperations. Patients with hiatal hernias > 2 cm axially had a recurrence rate equal to that of patients undergoing paraesophageal hiatal hernia repair, and should be treated similarly.