Magnetic sphincter augmentation (MSA) in patients with hiatal hernia: clinical outcome and patterns of recurrence
Magnetic sphincter augmentation (MSA) in patients with hiatal hernia: clinical outcome and patterns of recurrence
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DOI：
10.1007/s00464-019-06950-4
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发表时间：
2020-04-01
影响因子：
3.1
通讯作者：
Jobe, Blair A.
中科院分区：
文献类型：
--
作者：
Ayazi, Shahin;Chowdhury, Nobel;Jobe, Blair A.
前言：磁化括约肌增强术(MSA)是治疗胃食道反流病的有效方法。在早期的研究中，裂孔疝(HH)和Gt；=3厘米的患者被排除在植入的考虑范围之外，最初FDA认为在这种情况下使用它是“预防”的。这种早期的方法导致了一些外科医生对向HH患者提供这种治疗方法的犹豫不决。这项研究旨在评估HH状态对MSA预后的影响，并报告MSA后HH的复发率。方法和程序这是对2013年6月至2017年8月期间接受MSA的患者的前瞻性收集的数据的回顾。收集了基线的临床和客观数据。根据HH状态将患者分为四组：无HH组、小HH组(<3 cm)、大HH组(<3 cm)和食道旁疝(PEH)组。比较两组患者满意度、GERD-HRQL和RSI数据、脱离PPI、术后需要扩张、住院时间、90天再住院率、需要取出装置和HH复发。结果350例患者中，女性占60%，平均年龄为53.5岁(13.8岁)。无HH 65例(18.6%)，小HH 205例(58.6%)，大HH 58例(16.6%)，PEH 22例(6.2%)。平均随访13.6(10.4)个月，两组的结果满意率相似(86%、87.9%、92.2%和93.8%，p=0.72)。GERD-HRQL临床总分改善情况也是如此(79.1%、77.8%、82%和87.5%，p=0.77)。四组患者术后吞咽困难发生率(p=0.33)和术后无PPI发生率(p=0.96)相似。HH或PEH较大的患者住院时间较长，且仅PEH患者的90天再住院率较高(p=0.0004)。不同组间的扩张需要无差异(p=0.13)。四组患者中取出装置的需求(总体为5%)相似(p=0.28)。所有组的HH复发率加在一起为10%，240名患者中只有7名(2.9%)需要再次手术；这些患者中的大多数在指标性手术时接受了微创剥离手术(不修补腹股沟)。HH复发率与术前HH大小呈正相关(0%、10.1%、16.6%和20%，p=0.032)。结论在最大的MSA植入系列中，我们证明MSA植入后的良好结果和高满意度与HH的存在或大小无关。尽管大HH和PEH患者的腹股沟复发率较高，但术后内窥镜干预和装置取出的比率与无HH或小HH的患者相似。应放弃对MSA的最小解剖入路。
Introduction Magnetic sphincter augmentation (MSA) is an effective treatment for patients with gastroesophageal reflux disease. In early studies, patients with a hiatal hernia (HH) >= 3 cm were excluded from consideration for implantation and initially the FDA considered its use as "precautionary" in this context. This early approach has led to an attitude of hesitance among some surgeons to offer this therapy to patients with HH. This study was designed to evaluate the impact of HH status on the outcome of MSA and to report the rate of HH recurrence after MSA. Methods and procedures This is a retrospective review of prospectively collected data of patients who underwent MSA between June 2013 and August 2017. Baseline clinical and objective data were collected. Patients were divided into four groups based on HH status: no HH, small HH (< 3 cm), large HH (>= 3 cm), and paraesophageal hernia (PEH). Patient satisfaction, GERD-HRQL and RSI data, freedom from PPI, need for postoperative dilation, length of hospitalization, 90-day readmission rate, need for device removal, and HH recurrence was compared between groups. Results There were 350 patients [60% female, mean (SD) age: 53.5 (13.8)] who underwent MSA. There were 65 (18.6%) with no HH, 205 (58.6%) with small HH (< 3 cm), 58 (16.6%) with large HH (>= 3 cm) and 22 (6.2%) with PEH. At a mean follow-up of 13.6 (10.4) months, the rate of outcome satisfaction was similar between the groups (86%, 87.9%, 92.2% and 93.8%, p = 0.72). This was also true for GERD-HRQL total score clinical improvement (79.1%, 77.8%, 82% and 87.5%, p = 0.77). The rate of postoperative dysphagia (p = 0.33) and freedom from PPIs (p = 0.96) were similar among the four groups. Duration of hospitalization was higher among those with a large HH or PEH, and only PEH patients had a higher 90-day readmission rate (p = 0.0004). There was no difference between the need for dilation among groups (p = 0.13). The need for device removal (5% overall) was similar between the four groups (p = 0.28). HH recurrence was 10% in all groups combined, and only 7 of 240 (2.9%) patients required reoperation; the majority of these patients underwent a minimal dissection approach (no hernia repair) at the index operation. The incidence of recurrent HH increased in direct correlation with the preoperative HH size (0%, 10.1%, 16.6 and 20%, p = 0.032). Conclusion In the largest series of MSA implantation, we demonstrate that the excellent outcomes and high degree of satisfaction after MSA are independent of the presence or size of HH. Despite higher rates of hernia recurrence in large HH and PEH patients, the rates of postoperative endoscopic intervention, and device removal is similar to those with no or small HH. The minimal dissection approach to MSA should be abandoned.