Clinical Study Of Endoscopic Submucosal Dissection In The Treatment Of Large Hiatal Hernia With Refractory Gastroesophageal Reflux Disease

Objective: Hiatal hernia(HH)is very common in the general population,usually combined with gastroesophageal reflux disease(GERD).The coexistence of the two increases the difficulty of treatment and is challenging for endoscopy.Endoscopic submucosal dissection(ESD)was used in the treatment of large HH combined with refractory GERD in our center.We named it hiatal hernia-endoscopic submucosal dissection(HH-ESD).This study aims to explore the safety and effectiveness of this treatment.Methods: We conducted a prospective,single-arm,single-center clinical study.24 patients who met the inclusion and exclusion criteria in the Affiliated Hospital of Inner Mongolia Medical University and the Affiliated people’s Hospital of Inner Mongolia Medical University from December 2018 to August 2020 were selected for HH-ESD.To compare the changes of research indexes before and after treatment.Including gastroesophageal reflux disease-health related quality of life(GERD-HRQL),gastroesophageal reflux disease-questionnaire(GERD-Q),gastroscopy,upper gastrointestinal radiography,24-hour p H monitoring,esophageal high resolution manometry(HRM),gastroesophageal reflux index(GERI),and follow-up of intraoperative and postoperative complications and medication.Results: 6 months after HH-ESD,the GERD-Q and GERD-HRQL scores of all patients were significantly reduced.The GERD-Q score decreased from 15.00(13.00-16.00)before treatment to 6.00(6.00-7.00),P<0.001;GERD-HRQL score decreased from24.00(21.25-28.00)before treatment to 2.00(0.25-3.00),P<0.001.Gastroscopy showed that esophagitis significantly improved or even returned to normal in all cases(100%),and hernia sac shrank in 23 cases(95.83%).Upper gastrointestinal radiography showed that 21 cases(87.5%)had no gastroesophageal reflux,and hernia sac was significantly reduced in 22 patients(91.66%);Barium passed smoothly in all cases,and there was no barium retention or obstruction.24-hour p H monitoring: De Meester scores,percentage of total reflux time,reflux episodes,long reflux episodes,and maximum reflux time all decreased significantly,all P<0.001.Esophageal HRM: Lower esophageal sphincter resting pressure increased,P<0.001;HH size decreased significantly,P<0.001.GERI decreased from baseline(3.04±1.37)% to(1.66±1.05)%,P=0.061.19 patients(79.16%)stopped proton pump inhibitors completely.The incidence of delayed bleeding was4.16%,and the incidence of dysphagia was 33.33%.No serious adverse events such as massive bleeding and perforation occurred during and after operation,and no additional surgical treatment was performed.Conclusion: Endoscopic mucosal dissection for large hiatal hernia with refractory gastroesophageal reflux disease,namely HH-ESD,is a feasible method for the treatment of large HH complicated with refractory GERD.The short-term effect is considerable.