Use of intraoperative distensibility index with EndoFLIP™ is independently associated with hiatal hernia recurrence after fundoplication.

BACKGROUND: Intraoperative impedance planimetry (EndoFLIP™) provides real-time data that assists hiatal hernia (HH) repairs with fundoplication. An ideal range for the distensibility index (DI) during fundoplication has been previously established to help guide surgeons in performing these cases and is correlated with improved postoperative patient-reported outcomes. However, the correlation between DI and hiatal hernia recurrence remains unknown. This study evaluated the association between final intraoperative DI and postoperative HH recurrence. METHODS: Patients undergoing HH repair with fundoplication (2013-2022) were identified from our prospectively maintained institutional database. Patients were stratified by initial HH and fundoplication types. DI was recorded after fundoplication, with the abdomen desufflated, via an 8-cm catheter (EF-325 30 or 40 mL fills) or 16-cm catheter (EF-322 60 mL fill). Outcomes included HH recurrence, 30-day complications, emergency department (ED) visits, reinterventions. RESULTS: A total of 457 patients were included, of whom 79 (17.3%) developed postoperative HH recurrence. ROC analysis identified an optimal DI cutoff of 3.7 mm2/mmHg (AUC = 0.54), and optimal Dmin cutoff at 11.7 mm (AUC = 0.55). Among patients who developed recurrence, 40.5% had a final DI ≥ 3.7 mm2/mmHg, compared to 28.0% of those without recurrence (p = 0.028). There were no significant differences in 30-day mortality, complication rates, ED visits, or readmissions between recurrence and nonrecurrence groups. Postoperative re-intervention was significantly more frequent in the recurrence group (20.3 vs 4.8%, p < 0.001). On multivariable analysis, a final DI ≥3.7 mm2/mmHg (OR 1.82, 95% CI 1.09-3.05, p = 0.022), and Dmin (OR 1.79, 95% CI 1.08-2.99, p = 0.025) were independently associated with HH recurrence. CONCLUSION: Final intraoperative DI ≥ 3.7 mm2/mmHg and Dmin ≥ 11.7 mm are independently associated with hiatal hernia recurrence following HH repair with fundoplication. An elevated DI or Dmin after fundoplication should prompt intraoperative reassessment of the repair.