Abstract
Objective
The aim of the study was to investigate the impact of the size of the esophageal hiatus on lower esophageal sphincter pressure (LESP) and acid reflux.
Methods
Patients with gastroesophageal reflux disease who underwent Nissen fundoplication in 2006–2008 were included. All underwent esophageal manometry and 22 had 24-h pH monitoring. The area of the esophageal hiatus was calculated from a photograph shot during surgery. A hiatal index was calculated via division of hiatal area with body mass index (BMI). Correlation and logistic regression analysis were performed.
Results
Twenty-eight patients (average age 44, 14 males) were enrolled. The mean BMI, LESP, DeMeester score, hiatal area, and hiatal index were 27 ± 3.9 kg/m2, 11.7 ± 6.6 mmHg, 43 ± 34, 3.83 ± 1.24 cm2, and 0.143 ± 0.048, respectively. There was a significant negative correlation between hiatal area, hiatal index and LESP (−0.513, p = 0.005, r = −0.439, p = 0.019 respectively). Additionally there was a negative correlation between hiatal area and total LES length (r = −0.508, p = 0.013) and a significant positive correlation between hiatal area, hiatal index, and DeMeester scores (0.452, p = 0.035, 0.537, p = 0.01, respectively). Height and hiatal area were significant factors in multiple linear regression.
Conclusions
The size of the esophageal hiatus significantly affects LESP and acid reflux, and hiatal index is a new value, which appears to reflect the amount of acid reflux. Total LES length is also shortened in patients with a large hiatus.
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References
Kahrilas PJ, Lin S, Chen J, Manka M. The effect of hiatus hernia on gastro-oesophageal pressure. Gut 1999;44:476–482.
Sontag SJ, Schnell TG, Miller TQ, Nemchausky B, Serlovsky R, O’Connell S, Chejfec G, Seidel UJ, Brand L. The importance of hiatal hernia in reflux esophagitis compared with lower esophageal sphincter pressure or smoking. J Clin Gastroenterol 1991;13:628–643.
van Herwaarden MA, Samsom M, Smout AJ. Excess gastroesophageal reflux in patients with hiatus hernia is caused by mechanisms other than transient LES relaxations. Gastroenterology 2000;119(6):1439–1446.
Costa MM, Pires-Neto MA. Anatomical investigation of the esophageal and aortic hiatuses: physiologic, clinical and surgical considerations. Anat Sci Int 2004;79(1):21–31.
Pandolfino JE, Kim H, Ghosh SK, Clarke JO, Zhang Q, Kahrilas PJ. High-resolution manometry of the EGJ: an analysis of crural diaphragm function in GERD. Am J Gastroenterol 2007;102(5):1056–1063.
Hill LD, Kozarek RA, Kraemer SJ, Aye RW, Mercer CD, Low DE, Pope CE 2nd. The gastroesophageal flap valve: in vitro and in vivo observations. Gastrointest Endosc 1996;44(5):541–547.
Seltman AK, Kahrilas PJ, Chang EY, Mori M, Hunter JG, Jobe BA. Endoscopic measurement of cardia circumference as an indicator of GERD. Gastrointestinal Endosc 2006;63:22–31.
Korn O, Csendes A, Burdiles P, Braghetto I, Stein HJ. Anatomic dilatation of the cardia and competence of the lower esophageal sphincter: a clinical and experimental study. J Gastrointest Surg 2000;4(4):398–406.
Mattioli S, D’Ovidio F, Pilotti V, Di Simone MP, Lugaresi ML, Bassi F, Brusori S. Hiatus hernia and intrathoracic migration of esophagogastric junction in gastroesophageal reflux disease. Dig Dis Sci 2003;48(9):1823–1831.
Pandolfino JE, Shi G, Curry J, Joehl RJ, Brasseur JG, Kahrilas PJ. Esophagogastric junction distensibility: a factor contributing to sphincter incompetence. Am J Physiol Gastrointest Liver Physiol 2002;282:G1052–G1058.
Pandolfino JE, Shi G, Trueworthy B, Kahrilas PJ. Esophagogastric junction opening during relaxation distinguishes nonhernia reflux patients, hernia patients, and normal subjects. Gastroenterology 2003;125(4):1018–1024.
Holloway RH. The anti-reflux barrier and mechanisms of gastro-oesophageal reflux. Baillieres Best Pract Res Clin Gastroenterol 2000;14(5):681–699.
Kahrilas PJ, Shi G, Manka M, Joehl RJ. Increased frequency of transient lower esophageal sphincter relaxation induced by gastric distention in reflux patients with hiatal hernia. Gastroenterology 2000;118(4):688–695.
Jones MP, Sloan SS, Rabine JC, Ebert CC, Huang CF, Kahrilas PJ. Hiatal hernia size is the dominant determinant of esophagitis presence and severity in gastroesophageal reflux disease. Am J Gastroenterol 2001;96(6):1711–1717.
Avidan B, Sonnenberg A, Schnell TG, Sontag SJ. Hiatal hernia and acid frequency predict presence and length of Barrett’s esophagus. Dig Dis Sci 2002;47(2):256–264.
Cameron AJ. Barrett’s esophagus: prevalence and size of hiatal hernia. Am J Gastroenterol 1999;94(8):2054–1059.
Fein M, Ritter MP, DeMeester TR, Oberg S, Peters JH, Hagen JA, Bremner CG. Role of the lower esophageal sphincter and hiatal hernia in the pathogenesis of gastroesophageal reflux disease. J Gastrointest Surg 1999;3(4):405–410.
Bredenoord AJ, Weusten BL, Carmagnola S, Smout AJ. Double-peaked high-pressure zone at the esophagogastric junction in controls and in patients with a hiatal hernia: a study using high-resolution manometry. Dig Dis Sci 2004;49(7–8):1128–1135.
Bredenoord AJ, Weusten BL, Timmer R, Smout AJ. Intermittent spatial separation of diaphragm and lower esophageal sphincter favors acidic and weakly acidic reflux. Gastroenterology 2006;130(2):334–340.
Moes MJ, Filly RA. The neonatal diaphragmatic crura are hypertrophied: a necessary preparation for the first breath? J Ultrasound Med 2003;22(7):715–718.
Granderath FA, Schweiger UM, Pointner R. Laparoscopic antireflux surgery: tailoring the hiatal closure to the size of hiatal surface area. Surg Endosc 2007;21(4):542–548.
Granderath FA, Schweiger UM, Kamolz T, Pointner R. Dysphagia after laparoscopic antireflux surgery: a problem of hiatal closure more than a problem of the wrap. Surg Endosc 2005;19(11):1439–1446.
Reardon PR. A modest proposal. Surg Endosc 2006;20(6):995.
Fourtanier G. A new method to calibrate the hiatus. Surg Endosc 2007;21(9):1674–1675.
Patti MG, Arcerito M, Feo CV, De Pinto M, Tong J, Gantert W, Tyrrell D, Way LW. An analysis of operations for gastroesophageal reflux disease: identifying the important technical elements. Arch Surg 1998;133(6):600–607.
Linke GR, Zerz A, Tutuian R, Marra F, Warschkow R, Müller-Stich BP, Borovicka J. Efficacy of laparoscopic mesh-augmented hiatoplasty in GERD and symptomatic hiatal hernia. Study using combined impedance–pH monitoring. J Gastrointest Surg 2008;12(5):816–821.
Müller-Stich BP, Linke GR, Borovicka J, Marra F, Warschkow R, Lange J, Mehrabi A, Köninger J, Gutt CN, Zerz A. Laparoscopic mesh-augmented hiatoplasty as a treatment of gastroesophageal reflux disease and hiatal hernias—preliminary clinical and functional results of a prospective case series. Am J Surg 2008;195(6):749–756.
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Batirel, H.F., Uygur-Bayramicli, O., Giral, A. et al. The Size of the Esophageal Hiatus in Gastroesophageal Reflux Pathophysiology: Outcome of Intraoperative Measurements. J Gastrointest Surg 14, 38–44 (2010). https://doi.org/10.1007/s11605-009-1047-8
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DOI: https://doi.org/10.1007/s11605-009-1047-8