探讨临床应用补片治疗食管裂孔疝（HH）术后复发的因素。

回顾性分析2010年11月至2021年5月于上海长征医院甲乳疝外科行补片加固食管裂孔疝修补术15例患者的术后复发情况。HH复发的主观指标主要依据改良Visick评分系统，客观指标包括术后半年随访时的胃镜、上消化道钡餐、上腹部CT和高分辨食管测压和24 h pH监测。症状性复发者首先经影像学检查评估有无客观证据，存在症状反复但无明确解剖复发证据者，需经食管测压和24 h pH监测有无抗反流屏障功能的损害和病理性反流，必要时结合阻抗检查评价反流与症状的相关性。

15例患者复发时间距初次手术时间6~121个月，中位时间28个月。其中小HH（Ⅰ~Ⅱ型）4例，巨大HH（Ⅲ~Ⅳ型）11例。使用的3种类型补片的数量为4层SIS 5例，6层SIS 8例，复合补片2例。再发胃灼热、胃内容物反流等症状者10例，均为生物补片病例；以吞咽困难为主要表现3例（2例为复合补片）。症状与检查结果不对应者4例（26.66%）。术后上腹部CT提示HH复发2例，但无明显GERD症状反复；自述GERD症状再现，但无明确影像学HH复发证据，食管测压和pH-阻抗监测未见病理性反流2例，均有轻度焦虑。再次手术探查4例，其中合成补片1例，生物补片3例，术前评估均提示有不同程度的HH复发。切取补片所在部位活检1例（合成补片），见显著胶原蛋白沉积和包裹的合成纤维组织。

应用补片治疗HH术后复发，重点分析其与解剖结构改变的相关性是决定再手术与否的关键。

To analyze the factors of clinical application of mesh in the treatment of postoperative recurrence of esophageal hiatal hernia.

A retrospective analysis was performed of 15 patients who used mesh-reinforced esophageal hiatus hernia (HH) repairs and had recurrence of HH after surgery from November 2010 to May 2021 in the Department of Thyroid Breast Hernia of Shanghai Changzheng Hospital. The subjective indicators are mainly based on the modified Visick scoring system. The objective indicators include gastroscopy, upper gastrointestinal barium meal, upper abdominal CT and high-resolution esophageal pressure measurement and 24-hour pH monitoring during the six months postoperative follow-up. Patients with symptomatic recurrence should first be assessed by imaging examinations for objective evidence. For those with recurrent symptoms but no clear evidence of anatomical recurrence, esophageal pressure measurement and 24-hour pH monitoring for impairment of the anti-reflux barrier function and pathological reflux are required. Impedance examination was required to evaluate the correlation between reflux and symptoms if necessary.

The recurrence time of 15 patients was 6-121 months after the initial operation, with a median time of 28 months. Among them, 4 cases were small HH (type Ⅰ-Ⅱ) and 11 cases were huge HH (type Ⅲ-Ⅳ). The number of 3 types of meshes used was 5 cases of 4-layer SIS, 8 cases of 6-layer SIS, and 2 cases of composite mesh. There were 10 cases of recurrent fever and gastric reflux, all of which used biological mesh; 3 cases had dysphagia as the main manifestation (2 cases of them used composite mesh). 4 cases had symptoms that did not correspond to the examination results, accounting for 26.66%. Two patients' postoperative upper abdominal CT showed HH recurrence, but with no obvious recurrence of GERD symptoms; 2 patients reported recurrence of GERD symptoms, but with no clear evidence of HH recurrence on imaging, and with no pathological reflux in esophageal pressure measurement and pH-impedance monitoring. Psychological evaluation of these 2 patients suggests mild anxiety. 4 cases underwent re-operation exploration, including 1 case with synthetic mesh and 3 cases with biological mesh. The preoperative evaluation showed different degrees of HH recurrence. A biopsy was taken from the site where the mesh (synthetic mesh) was located. Synthetic fibrous tissue with significant collagen deposition and encapsulation was seen.

In terms of the application of mesh in the treatment of postoperative recurrence of esophageal hiatal hernia, the analysis of its correlation with changes in anatomical structure is the key to deciding whether to have reoperation or not.