| Objective: To investigate the esophageal dynamic characteristics of patients with hiatal hernia and the mechanism of esophageal motility in patients with both hiatal hernia and reflux symptoms.To evaluate the influence of hiatal hernia repair combined with fundoplication on esophageal motility.Methods: A total of 73 patients diagnosed with hiatal hernia by gastroscopy or highresolution esophageal manometry(HREM)in the First Affiliated Hospital of Dalian Medical University from April 2021 to December 2022 were collected in the disease group.Ten healthy volunteers who underwent high resolution esophageal manometry were included in the healthy control group.Patients in the disease group were divided into Gerd Q≥8 group(53 cases)and Gerd Q < 8 group(20 cases)according to Gerd Q score.According to the size of hernia sac,there were 30 patients in the small hernia group(2-3cm)and 27 patients in the large hernia group(≥3cm);combined with reflux monitoring indexes,13 patients were divided into GERD+ small hernia group and 10 patients into GERD+ large hernia group.10 patients in the disease group who underwent surgical treatment and completed return visit in 3 months after surgery were included in the surgical observation group for preoperative and postoperative comparison.Baseline data were comparable in all groups.The clinical information about the subjects were recorded,including general data such as gender,BMI,and clinical symptoms;Gerd Q score;HREM indexes: maximum separation distance between LES and CD、LESP、UESP、LES length、DCI、MRS-DCI、MRS-DCI /DCI、EGJ-CI、ineffective swallow ratio and proximal and distal esophagus DCI,etc.Reflux monitoring indexes:acid exposure time,De Meester score and acid reflux times、weak acid reflux times、total reflux times under impedance monitoring;endoscopic indexes:prevalence of esophagitis、GEFV classification of cardia and prevalence of Barrett’s mucosa.Results:1.The Gerd Q score and ineffective swallow ratio of the disease group were significantly higher than those of the healthy control group,and LES length,LESP,DCI,MRS-DCI and EGJ-CI were significantly lower than those of the healthy control group,the differences were statistically significant(P < 0.05).There was no significant difference in UESP and MRS-DCI/DCI between the two groups.The abnormal LESP rate in the disease group was significantly higher than that in the healthy control group(84.9% VS 30.0%).2.The MRS-DCI in the Gerd Q≥8 group was significantly less than that in the Gerd Q< 8 group(P = 0.011).There were no statistic difference in other HREM indexes,such as maximum separation distance between LES and CD,LES length,UESP,LESP,DCI,MRS-DCI/DCI,EGJ-CI and ineffective swallow ratio,and reflux monitoring indexes,such as acid exposure time,De Meester score,reflux times,etc.and endoscopic indexes such as the prevalence of esophagitis,abnormal GEFV classification and the prevalence of Barrett’s mucosa between the two groups(P > 0.05).3.The prevalence of Barrett’s mucosa in the small hernia group was higher than that in the large hernia group(P = 0.015).There were no significant differences in Gerd Q score,HREM indexes such as LES length,UESP,LESP,DCI,MRS-DCI,MRSDCI/DCI,EGJ-CI and ineffective swallow ratio,and reflux monitoring indexes,such as acid exposure time,De Meester score,acid reflux times,weak acid reflux times,total reflux times,and the prevalence of endoscopic esophagitis between the two groups(P >0.05).The acid reflux times and total reflux times in GERD+ small hernia group were significantly lower than those in GERD+ large hernia group(P < 0.05).There were no significant differences in the LES length,UESP,LESP,DCI,MRS-DCI,MRSDCI/DCI,EGJ-CI,ineffective swallow ratio and acid exposure time,De Meester score,weak acid reflux times between groups(P > 0.05).4.The DCI of proximal esophagus and distal esophagus in the disease group were significantly lower than those in the healthy control group(P < 0.05).There was no statistical difference in DCI between Gerd Q≥8 group and Gerd Q < 8 group,and between small hernia group and large hernia group(P > 0.05).5.The preoperative Gerd Q score was significantly higher than that after operation(P<0.001),and the MRS-DCI was significantly lower than that after operation(P =0.026).There was no significant difference in the maximum separation distance between LES and CD,LESP,MRS-DCI/DCI,EGJ-CI before and after operation,but all of them showed an improvement trend.There was no statistic difference in the length of LES,UESP,4s IRP,DCI and ineffective swallow ratio before and after operation(P >0.05).Preoperative endoscopy showed mild esophagitis in 3 patients and Barrett mucosa in 1 patient,all of which returned to normal after operation.The symptoms of reflux and heartburn were significantly improved in 10 patients(100%)at 3 months after operation,and all of them stopped taking acid-inhibitory drugs.The satisfaction of operation in all patients was above 80%.4 patients(40.0%)had dysphagia symptoms in the postoperative period,which were mostly induced by eating too fast or eating solid food,and the symptom could be improved by changing their dietary habits(such as having more meals a day but less food at each,eating liquid diet or semi-liquid diet,and chewing carefully and swallowing slowly,etc.).No patients had endoscopic dilation or re-operation.Conclusion:1.The patients with hiatus hernia had abnormal esophageal motility,which was manifested as the impaired anti-reflux barrier,low pressure in the EGJ region,and the hypoactive peristalsis of the esophageal body.This dynamic abnormality accumulated the entire esophagus.2.The esophageal reserve function of patients with hiatal hernia was worse than that of healthy people.The esophageal reserve function of patients with reflux symptoms was worse than that of patients without reflux symptoms.The degradation of esophageal reserve function may be one of the dynamic mechanisms in patients with hiatal hernia complicated with reflux-like symptoms.3.The Gerd Q score had certain limitations in the diagnosis of gastroesophageal reflux disease,and it cannot assess the severity of the disease in patients with hiatal hernia and reflux-like symptoms.4.There was no clear correlation between the size of hernia sac and the severity of esophageal motility abnormality in hiatal hernia patients.However,for patients with hiatal hernia complicated with GERD,regurgitation,especially acid regurgitation,was more frequent in patients with large hernia sac.5.Laparoscopic hiatal hernia repair combined with fundoplication can repair the anatomical structure of EGJ,strengthen the anti-reflux barrier,improve the esophageal reserve function and esophageal body peristalsis function.The most common postoperative complication was dysphagia,which could be relieved by changing dietary habits.Serious complications were rare. |
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