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Hiatushernie und Rezidive

Die Achillessehne der Antirefluxchirurgie?

Hiatus hernia and recurrence

The Achilles heel of antireflux surgery?

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Zusammenfassung

Trotz guter Langzeitergebnisse der laparoskopischen Antirefluxchirurgie kommt es bei bis zu 10% der Patienten postoperativ zu Komplikationen und/oder neuen oder wieder auftretenden Symptomen der gastroösophagealen Refluxkrankheit. Die diesen Symptomen zugrunde liegenden morphologischen Veränderungen sind im Wesentlichen 2 Problemzonen zuzuordnen: Einerseits der Manschette selbst, andererseits der Art des Zwerchfellverschlusses. Der Verschluss des Hiatus oesophageus stellt einen immer zentraleren Punkt in der Chirurgie der gastroösophagealen Refluxkrankheit dar und rückt damit auch immer mehr in den Mittelpunkt des chirurgischen Interesses. Anhand der Rezidivraten nach laparoskopischer Antirefluxchirurgie wie auch der publizierten Rezidivraten nach „Hiatushernienchirurgie“ versucht die vorliegende Arbeit die Problemzone Hiatushernie zu skizzieren und mögliche Lösungsansätze anzudenken. Dazu wurde die eigene Patientenklientel von 1201 primär laparoskopischen Fundoplikatios und 240 laparoskopischen Re-Fundoplikatios hinsichtlich morphologischer Fehlerursachen, postoperativer Symptome und den daraus resultierenden jeweiligen klinischen Konsequenzen analysiert. Die häufigste morphologische Fehlerursache der zwischen 1993 und 2007 durchgeführten 240 laparoskopischen Re-Fundoplikatios nach vorher fehlgeschlagener offener oder laparoskopischer Fundoplikatio an dieser Abteilung war ein Hiatushernienrezidiv mit konsekutiver intrathorakaler Migration der Antirefluxmanschette, in dieser Arbeit als „slipped Nissen“ bezeichnet. Dagegen sind die in der Zeit der offenen Chirurgie typischen Probleme wie Manschettenlösung oder Teleskopphänomen, beide ausschließlich die Manschette betreffend, in der Ära der laparoskopischen Antirefluxchirurgie heute nahezu eine Rarität. Auch bei wiederholten laparoskopischen Re-Eingriffen ist der Problembereich ausschließlich am Hiatus zu suchen.

Mit der Auseinandersetzung der Problemzone „Hiatus oesophageus“ wird auch klar, dass es bislang keine für Chirurgen relevante Formen oder Größeneinteilung bzw. Definition der Bruchpforte selbst gibt. Diese fehlende Vergleichbarkeit der Bruchpfortengröße ist ein zentrales Problem aller bisherigen Publikationen. Für eine erfolgreiche Antirefluxoperation stellen die Optimierung und Standardisierung des Hiatusverschlusses eventuell auch durch Einsatz prothetischer Verschlusstechniken einen zentralen Faktor dar, bedarf jedoch weiterer eingehender wissenschaftlicher Aufarbeitung in den kommenden Jahren.

Abstract

Long-term studies show good postoperative results after laparoscopic antireflux surgery, but still approximately 10% of patients suffer from new or recurrent symptoms of gastroesophageal reflux disease. In the majority of cases the symptoms are caused by morphological changes of the fundic wrap or are related to the hiatal closure. Closure of the esophageal hiatus is therefore becoming more and more the key point of antireflux surgery. The aim of this study was to show the problems caused by the esophageal hiatus and to offer possible solutions. Therefore 1,201 laparoscopic antireflux procedures and 240 refundoplications performed in our department between 1993 and 2007 were analyzed with respect to morphologic reasons for failures and the corresponding symptoms. The most common morphological reason for complications after surgery was failure of the hiatal closure with consecutive intrathoracic migration of the fundic wrap, the so-called slipped Nissen. In the past the typical problems after open antireflux surgery were either that the wrap was too loose, a breakdown of the wrap or a so-called telescope phenomenon, all caused by failure of the fundic wrap and now a rarity since laparoscopic surgery. Even after repeated laparoscopic refundoplications the main problem was always the hiatus. This shows the importance of the crural closure and the necessity of a specific definition of size and form of the hiatus.

The aim of this study was to initiate a discussion leading to a new definition of the hiatus with the focus on the “hiatal surface area” for a better basis for comparison of the published results of antireflux or hiatal surgery.

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Authors and Affiliations

  1. Abteilung für Allgemeinchirurgie, A.ö. Krankenhaus Zell am See, A-5700, Zell am See, Österreich

    R. Pointner

  2. Klinik für Allgemein-, Viszeral- und minimalinvasive Chirurgie, Krankenhaus Neuwerk, Mönchengladbach, Mönchengladbach, Deutschland

    F.A. Granderath

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  2. F.A. Granderath
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Correspondence to R. Pointner.

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Pointner, R., Granderath, F. Hiatushernie und Rezidive. Chirurg 79, 974–981 (2008). https://doi.org/10.1007/s00104-008-1496-8

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