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Society for Surgery of the Alimentary Tract

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Shahin Ayazi*, Ali H. Zaidi, Ping Zheng, Kristy Chovanec, Madison Salvitti, Ashten N. Omstead, Xinxin Shen, Yoshihiro Komatsu, Toshitaka Hoppo, Blair A. Jobe
Esophageal and Lung Institute, Allegheny Health Network, Pittsburgh, PA

Hiatal hernia (HH) results in deleterious anatomic changes at the level of the esophagogastric junction (EGJ) which may negatively impact proper deglutition and barrier function. To date, there has been no study, which has defined the manometric characteristics of the EGJ and esophageal body over the spectrum of hernia type and size. The current study defines the anatomic and physiologic impact of HH on the EGJ and esophagus using high-resolution impedance manometry (HRIM).

Material and Methods:
Patients were referred between 2013 and 2018 for objective evaluation of reflux. Those who completed HRIM, esophageal pH monitoring and an upper endoscopy were selected. Patients were divided into 4 groups based on HH status: no HH, small HH (<3cm), large HH (≥ 3cm) and paraesophageal hernia (PEH). Size and type of HH was determined at the time of upper endoscopy. Size of hernia was defined as the distance from the anatomic EGJ to the crural pinch. Patients with an intrathoracic EGJ and stomach with a paraesophageal component were defined as type III PEH. The HRIM features of the LES and esophageal body were compared between groups using the Kruskal Wallis test.

Of 496 patients [ 61% female, mean (SD) age: 54.0 (13.8), mean (SD) BMI: 29.0 (4.4)], there were 66 (13.3%) with no HH, 325 (65.5%) with small HH, 78 (15.7%) with large HH and 27 (5.4%) with a PEH. Patients with a large HH or PEH were older than those with no or small HH (p<0.0001). BMI was similar between groups (p=0.26). DeMeester score was higher in those with a large HH or PEH compared to the small or no HH groups (p<0.0001). Over the spectrum of HH size, there is increased deterioration of LES length, resting pressure and residual pressure (Table). Although there is not a decrease esophageal body contraction amplitude or distal contractile integral (DCI), there is a worsening of esophageal bolus clearance (p=0.0016).

With increasing HH size, there is anatomic deterioration of the EGJ barrier to reflux and an impairment of esophageal clearance which leads to prolonged distal esophageal contact times to refluxate as evidenced by a high DeMeester score. This condition leads to a vicious cycle and thus the observed progressive nature of this disease.

Comparison of the LES and esophageal body manometric characteristics based on the HH status
 No HHSmall HH
Large HH
(≥ 3cm)
PEHp value
LES overall length (cm)3.4 (0.8)3.0 (0.9)2.8 (1.0)2.4 (0.8)<.0001
LES resting pressure (mmHg)28.8 (13.6)22.6 (13.4)18.3 (14.4)18.5 (14.0)<.0001
LES residual pressure (mmHg)8.6 (5.5)7.4 (6.5)4.1 (6.2)2.7 (5.9)<.0001
Mean distal wave amplitude (mmHg)103.4 (46.4)89.1 (39.2)87.3 (42.8)85.4 (32.0)0.1479
Mean distal contractile integral ( (1896.5)1973.9 (1468.3)1933.9 (2059.9)1463.7 (803.6)0.1409
Incomplete bolus clearance (%)14.5 (25.2)21.4 (32.8)29.1 (36.7)45.2 (44.8)0.0016

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