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Theresa N. Wang*1, Bryan W. An2, Tina X. Wang2, Patrick J. Sweigert1, Tarik Yuce1, Gokulakrishnan Balasubramanian1, Kelly Haisley1, Kyle A. Perry1
1The Ohio State University Wexner Medical Center, Columbus, OH; 2The Ohio State University College of Medicine, Columbus, OH

Introduction: Short esophageal length has been proposed as a risk factor for paraesophageal hernia (PEH) recurrence. We sought to investigate the relationship between pre-operative manometric measurements of esophageal length or a calculated manometric esophageal length to height ratio (MELH) and recurrence in primary PEH repair. We hypothesized that intraoperative high mediastinal esophageal mobilization is sufficient to gain adequate intraabdominal esophageal length for PEH repair, and pre-operative shortened esophageal length does not increase the risk of recurrence.

Methods: Patients who underwent elective PEH repair between 2015 and 2022 at a university-based hospital were identified. Patients who had prior esophageal or gastric surgery or did not have pre-operative manometry were excluded. Patient demographics, operative details, pre-operative manometric esophageal length, and radiographic or symptomatic PEH recurrence were recorded in an IRB-approved database. The MELH was calculated as manometric esophageal length divided by height in cm. Descriptive statistics and logistic regression were used to analyze the data. Data are presented as mean±SD or median [IQR] and p-values of <0.05 were considered statistically significant.

Of the 160 patients (mean age 66.4±8.9 years, 78.8% female) who underwent elective PEH repair during the study period, 30.6% (n=49) had a PEH recurrence. Amongst those with recurrences, 32.7% (n=16) were symptomatic and 67.3% (n=33) were radiographic. Radiographic recurrence was found in 36.3% (n=91) of patients who had interval imaging for any reason. A total of 7.5% (n=12) of patients required a reoperation for recurrence. With a median follow-up of 20.0 [2.2, 39.1] months, the median time to recurrence was 10.1 [4.4, 21.7] months. All patients underwent a high mediastinal mobilization to achieve intraabdominal esophageal length of at least 2-3cm; no patients underwent esophageal lengthening gastroplasty. Average manometric esophageal length was 19.7±2.7cm (range: 12.1-28.1cm). Average MELH was 0.119±0.014 (range 0.079-0.152). Neither manometric esophageal length nor MELH was associated with radiographic or symptomatic PEH recurrence (Table 1), and neither manometric esophageal length nor MELH correlated to time to recurrence (p>0.05).

Pre-operative manometric esophageal length and manometric esophageal length to height ratio are not correlated with either symptomatic or radiographic paraesophageal hernia recurrence in elective, primary paraesophageal hernia repair. In addition, incidentally identified recurrence is very common and occurs in over a third of patients who have interval imaging. Our findings suggest that high mediastinal esophageal mobilization achieving adequate intraabdominal esophagus is sufficient to overcome short esophageal length found on pre-operative manometry.

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