INTRODUCTION The esophagogastric junction (EGJ) is a complex anti-reflux barrier whose integrity relies on both the intrinsic lower esophageal sphincter (LES) and extrinsic crural diaphragm. During hiatal hernia repair, it is unclear whether the crural closure or the fundoplication is more important to restore the anti-reflux barrier. The objective of this study is to analyze changes in LES minimum diameter (Dmin) and distensibility index (DI) using the endoluminal functional lumen imaging probe (FLIP) during hiatal hernia repair. METHODS Following implementation of a standardized operative FLIP protocol, all data were collected prospectively and entered into a quality database. This data were reviewed retrospectively for all patients undergoing hiatal hernia repair. FLIP measurements were collected prior to hernia dissection, after hernia reduction, after cruroplasty, and after fundoplication. Additionally, subjective assessment of the tightness of crural closure was rated by the primary surgeon on a scale of 1 to 5, 1 being the loosest and 5 being the tightest. RESULTS Between August 2018 and February 2020, 97 hiatal hernia repairs were performed by a single surgeon. FLIP measurements collected using a 40-mL volume fill without pneumoperitoneum demonstrated a significant decrease in LES Dmin (13.84 ± 2.59 to 10.27 ± 2.09) and DI (6.81 ± 3.03 to 2.85 ± 1.23 mm2/mmHg) after crural closure (both p < 0.0001). Following fundoplication, there was a small, but also statistically significant, increase in both Dmin and DI (both p < 0.0001). Additionally, subjective assessment of crural tightness after cruroplasty correlated well with DI (r = - 0.466, p < 0.001) and all patients with a crural tightness rating ≥ 4.5 (N = 13) had a DI < 2.0 mm2/mmHg. CONCLUSION Cruroplasty results in a significant decrease in LES distensibility and may be more important than fundoplication in restoring EGJ competency. Additionally, subjective estimation of crural tightness correlates well with objective FLIP evaluation, suggesting surgeon assessment of cruroplasty is reliable.

中文翻译：

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小腿闭合，而不是胃底折叠术，导致下食管括约肌的扩张性显着降低。

引言 食管胃交界处 (EGJ) 是一个复杂的抗反流屏障，其完整性依赖于内在的下食管括约肌 (LES) 和外在的小腿隔膜。在食管裂孔疝修补术中，尚不清楚小腿闭合和胃底折叠术哪个对恢复抗反流屏障更重要。本研究的目的是使用腔内功能腔成像探头 (FLIP) 分析食管裂孔疝修复期间 LES 最小直径 (Dmin) 和膨胀指数 (DI) 的变化。方法 在实施标准化手术 FLIP 协议后，前瞻性收集所有数据并输入质量数据库。对所有接受食管裂孔疝修补术的患者的数据进行了回顾性审查。FLIP 测量值是在疝气解剖之前收集的，疝气复位后、脚趾成形术后和胃底折叠术后。此外，小腿闭合松紧度的主观评估由主治外科医生按照 1 到 5 的等级进行评分，1 表示最松，5 表示最紧。结果 2018 年 8 月至 2020 年 2 月期间，一名外科医生进行了 97 次食管裂孔疝修补术。使用无气腹的 40 mL 体积填充收集的 FLIP 测量结果表明，在脚部闭合后，LES Dmin（13.84 ± 2.59 至 10.27 ± 2.09）和 DI（6.81 ± 3.03 至 2.85 ± 1.23 mm2/mmHg）显着降低（均 p < 0.0001） ). 胃底折叠术后，Dmin 和 DI 均有小幅但具有统计学意义的增加（均 p < 0.0001）。此外，小腿成形术后小腿紧绷度的主观评估与 DI 密切相关 (r = - 0.466, p < 0. 001) 并且所有脚部紧度等级 ≥ 4.5 (N = 13) 的患者的 DI < 2.0 mm2/mmHg。结论 Croplasty 导致 LES 扩张性显着降低，并且在恢复 EGJ 能力方面可能比胃底折叠术更重要。此外，小腿松紧度的主观评估与 FLIP 的客观评估密切相关，表明外科医生对小腿成形术的评估是可靠的。