Outcomes after repair of the intrathoracic stomach: objective follow-up of up to 5 years

Patients report significant improvement in quality of life following hiatal hernia repair-despite recurrence

BACKGROUND

Hiatal hernia (HH) repairs have been associated with high recurrence rates. This study aimed to investigate if changes in patient's self-reported GERD health-related quality of life (HRQL) scores over time are associated with long-term surgical outcomes.

METHODS

Retrospective chart reviews were conducted on all patients who had laparoscopic or robotic HH repairs between 2018 and 2022 at a tertiary care center. Information was collected regarding initial BMI, endoscopic HH measurement, surgery, and pre- and post-operative HRQL scores. Repeat imaging at least a year following surgical repair was then evaluated for any evidence of recurrence. Paired t tests were used to compare pre- and post-operative HRQL scores. Wilcoxon ranked-sum tests were used to compare the HRQL scores between the recurrence cohort and non-recurrence cohorts at different time points.

RESULTS

A total of 126 patients underwent HH repairs and had pre- and post-operative HRQL scores. Mesh was used in 23 repairs (18.25%). 42 patients had recorded HH recurrences (33.3%), 35 had no evidence of recurrence (27.7%), and 49 patients (38.9%) had no follow-up imaging. The average pre-operative QOL score was 24.99 (SD ± 14.95) and significantly improved to 5.63 (SD ± 8.51) at 2-week post-op (p < 0.0001). That improvement was sustained at 1-year post-op (mean 7.86, SD ± 8.26, p < 0.0001). The average time between the initial operation and recurrence was 2.1 years (SD ± 1.10). Recurrence was significantly less likely with mesh repairs (p = 0.005). There was no significant difference in QOL scores at 2 weeks, 3 months, 6 months, or 1 year postoperatively between the cohorts (p = NS).

CONCLUSION

Patients had significant long-term improvement in their HRQL scores after surgical HH repair despite recurrences. The need to re-intervene in patients with HH recurrence should be based on their QOL scores and not necessarily based on established recurrence.

Hiatal Hernias Revisited-A Systematic Review of Definitions, Classifications, and Applications

INTRODUCTION

A hiatal hernia (HH) can be defined as a condition in which elements from the abdominal cavity herniate through the oesophageal hiatus in the mediastinum and, in the majority of cases, parts of the proximal stomach. Today, the role of HHs within the complex entity of gastroesophageal reflux disease (GERD) is very important with regard to its pathophysiology, severity, and therapeutic and prognostic options. Despite this, the application and stringent use of the worldwide accepted classification (Skinner and Belsey: Types I-IV) are lacking. The aim of this study was to carry out a systematic review of the clinical applications of HH classifications and scientific documentation over time, considering their value in diagnosis and treatment.

METHODS

Following the PRISMA concept, all abstracts published on pubmed.gov until 12/2023 (hiatal hernia) were reviewed, and those with a focus and clear description of the application of the current HH classification in the full-text version were analysed to determine the level of classification and its use within the therapeutic context.

RESULTS

In total, 9342 abstracts were screened. In 9199 of the abstracts, the reports had a different focus than HH, or the HH classification was not used or was incompletely applied. After further investigation, 60 papers were used for a detailed analysis, which included more than 12,000 patient datapoints. Among the 8904 patients, 83% had a Type I HH; 4% had Type II; 11% had Type III; and 1% had Type IV. Further subgroup analyses were performed. Overall, the precise application of the HH classification has been insufficient, considering that only 1% of all papers and only 54% of those with a special focus on HH have documented its use.

CONCLUSIONS

The application and documentation of a precise HH classification in clinical practice and scientific reports are decreasing, which should be rectified for the purpose of scientific comparability.

Impact of laparoscopic repair on type III/IV giant paraesophageal hernias: a single-center experience

PURPOSE

Giant paraesophageal hernia (GPEH) is a challenging problem for surgeons because of its high recurrence rate. This study was conducted to compare the outcomes in type IV vs. type III GPEHs after laparoscopic repair. Other outcomes included peri-operative morbidity and long-term quality of life.

METHODS

A retrospective analysis of 130 GPEH patients in a period between 2010 and 2019 underwent a tailored laparoscopic repair in our tertiary center with a minimum follow-up of 48 months. Operative steps included hernial sac excision, crural repair, relaxing incisions, and mesh cruroplasty with special indications.

RESULTS

The study enrolled 90 patients with type III and 40 patients with type IV GPEH. Type IV GPEH patients were older, more fragile, and scored worse on ASA classification, aside from having a more challenging surgical technique (wider crura, weaker muscles, increased need for release incisions, and mesh cruroplasty).Type IV GPEHs had a prolonged operative durations, and a higher conversion rate. Additionally, the same group showed increased morbidity, mortality, and re-operation rates. With a mean follow-up of 65 months (range 48-150 months), the incidence of recurrence was 20.7%, with an increased incidence in type IV GPEH (37.5% vs. 13.33% in type III GPEH). Type IV GPEH, low pre-operative albumin, larger crural defect, and low surgeon experience were significant risk factors for recurrence after laparoscopic repair of GPEH.

CONCLUSION

Type IV GPEH has a higher peri-operative morbidity and recurrence rate; so, a more tailored laparoscopic repair with a high surgeon experience is needed.

Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper

BACKGROUND

Diaphragmatic hernia (DH) presenting acutely can be a potentially life-threatening condition. Its management continues to be debatable.

METHODS

A bibliographic search using major databases was performed using the terms "emergency surgery" "diaphragmatic hernia," "traumatic diaphragmatic rupture" and "congenital diaphragmatic hernia." GRADE methodology was used to evaluate the evidence and give recommendations.

RESULTS

CT scan of the chest and abdomen is the diagnostic gold standard to evaluate complicated DH. Appropriate preoperative assessment and prompt surgical intervention are important for a clinical success. Complicated DH repair is best performed via the use of biological and bioabsorbable meshes which have proven to reduce recurrence. The laparoscopic approach is the preferred technique in hemodynamically stable patients without significant comorbidities because it facilitates early diagnosis of small diaphragmatic injuries from traumatic wounds in the thoraco-abdominal area and reduces postoperative complications. Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable. Damage Control Surgery is an option in the management of critical and unstable patients.

CONCLUSIONS

Complicated diaphragmatic hernia is a rare life-threatening condition. CT scan of the chest and abdomen is the gold standard for diagnosing the diaphragmatic hernia. Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias. Open repair is considered necessary in majority of unstable patients in whom Damage Control Surgery can be life-saving.

Laparoscopic large hiatus hernia repair with mesh reinforcement versus suture cruroplasty alone: a systematic review and meta-analysis

BACKGROUND

To compare the difference in outcomes in laparoscopic large hiatus hernia (LHH) repair using suture-based and mesh-based repair techniques.

METHODS

A systematic search of articles was conducted in PubMed, Medline and Embase using the PRISMA guidelines. Studies comparing recurrences and reoperations in those patients with large hiatal hernia repair (> 30% stomach in the chest, > 5 cm hiatal defect, hiatal surface area > 10 cm²) who had mesh vs no mesh were assessed quantitatively. The impact of mesh on significant intraoperative/postoperative surgical complications was qualitatively assessed.

RESULTS

Pooled data included six randomized controlled trials and thirteen observational studies with 1670 patients (824 with no mesh, 846 with mesh). There was a significant reduction in the total recurrence rate with mesh (OR 0.44, 95% CI 0.25-0.80, p = 0.007). Mesh use did not cause significant reduction in recurrences > 2 cm (OR 0.94, 95% CI 0.52-1.67, p = 0.83) or in reoperation rates (OR 0.64, 95% CI 0.39-1.07, p = 0.09). None of the specific meshes assessed were found to be superior in the reduction of recurrence or reoperation rates. Cases of mesh erosion with eventual foregut resection were noted and were associated with synthetic meshes only.

CONCLUSION

Mesh reinforcement seemed protective against total recurrence in LHH although this has to be interpreted with caution given the level of heterogeneity introduced by the inclusion of observational studies in the analysis. There was no significant reduction in large recurrences (> 2 cm) or reoperation rate. If the synthetic mesh is to be used patients need to be informed of the risk of mesh erosion.

Emergency surgery for hiatus hernias: does technique affect outcomes? A single-centre experience

BACKGROUND

Emergency surgery for a hiatus hernia is usually a high-risk procedure in acutely unwell patients. Common surgical techniques include reduction of the hernia, cruropexy then either fundoplication or gastropexy with a gastrostomy. This is an observational study in a tertiary referral centre for complicated hiatus hernias to compare recurrence rates between these two techniques.

METHODS

Eighty patients are included in this study, from October 2012 to November 2020. This is a retrospective review and analysis of their management and follow-up. Recurrence of the hiatus hernia that mandates surgical repair was the primary outcome of this study. Secondary outcomes include morbidity and mortality.

RESULTS

In total, 38% of the patients included in the study had fundoplication procedures, 53% had gastropexy, 6% had complete or partial resection of the stomach, 3% had fundoplication and gastropexy and one patient had neither (n = 30, 42, 5, 2,1, respectively). Eight patients had symptomatic recurrence of the hernia which required surgical repair. Three of these patients had acute recurrence and 5 after discharge. 50% had undergone fundoplication, 38% underwent gastropexy and 13% underwent a resection (n = 4, 3, 1) (p value = 0.5). 38% of patient had no complications and 30-day mortality was 7.5% CONCLUSION: To our knowledge, this is the largest single centre review of outcomes following emergency hiatus hernia repairs. Our results show that either fundoplication or gastropexy can be used safely to reduce the risk of recurrence in the emergency setting. Therefore, surgical technique can be tailored based on the patient characteristics and surgeon experience, without compromising the risk of recurrence or post-operative complications. Mortality and morbidity rates were in keeping with previous studies, which is lower than historically documented, with respiratory complications most prevalent. This study shows that emergency repair of hiatus hernias is a safe operation which is often a lifesaving procedure in elderly comorbid patients.

Is fundoplication necessary after paraesophageal hernia repair? A meta-analysis and systematic review

INTRODUCTION

Paraesophageal hernias are often asymptomatic, but when symptomatic they should be fixed laparoscopically. A cruroplasty of the diaphragmatic pillars is performed and a fundoplication is usually performed at the time. However, there are times, especially in emergency cases, where it is not always possible to perform a fundoplication. We hypothesized there would be no difference in outcomes whether or not a fundoplication is performed as part of a paraesophageal hernia repair.

METHODS

A literature review of available clinical databases was performed using PubMed, Clinical Key and Google Scholar. Our search terms were: "paraesophageal hernia" "paraesophageal hernia repair" "fundoplication" "emergency surgery" "no fundoplication" We excluded studies that were in languages other than English, abstracts and small case series.

RESULTS

Our search criteria yielded a total of 22 studies published between 1997 and 2020. There were a total of 8600 subjects enrolled into this study. The overall pooled prevalence of fundoplication were estimated as 69% (95% CI: 59%-78%). In patients who underwent fundoplication, the risk of gastroesophageal reflux disease (GERD) was reduced as compared to patients who did not undergo fundoplication (RR: 0.64, 95% CI: 0.40-1.04, p = 0.069, I2 = 47.2%). A similar trend was also observed in recurrence (RR: 0.53, 95% CI: 0.27-1.03, p = 0.061, I2 = 0.0%) and reoperations (RR: 0.25, 95% CI: 0.02-2.69, p = 0.25, I2 = 56.7%). However, patients who underwent fundoplication had an increased risk of dysphagia (RR: 1.68, 95% CI: 0.59-4.81, p = 0.83, I2 = 42%).

CONCLUSIONS

There is a higher rate of recurrence of gastroesophageal reflux disease, recurrence of hernia and reoperation when no fundoplication is performed during a paraesophageal hernia repair but a lower risk of dysphagia, but none of these reached statistical significance.(Comment 1) Paraesophageal hernia repair with fundoplication should be performed, but it is acceptable to not do it in certain situations.

Primary laparoscopic fundoplication in selected patients with gastroesophageal reflux disease

BACKGROUND

Despite proton pump inhibitors being a powerful therapeutic tool, laparoscopic fundoplication (LF) has proven successful in the treatment of gastroesophageal reflux disease (GERD), through mechanical augmentation of a weak antireflux barrier and the advantages of minimally invasive access. A critical patient selection for LF, based on thorough preoperative assessment, is important for the management of GERD-patients. The purpose of this study is to provide an overview on the management of GERD-patients treated by primary LF in a specialized center and to illustrate the possible outcome after several years.

METHODS

Patients were selected after going through diagnostic workup consisting of patient's history and physical examination, upper gastrointestinal endoscopy, assessment of gastrointestinal Quality of Life Index, screening for somatoform disorders, functional assessment by esophageal manometry, (impedance)-24-hour-pH-monitoring, and selective radiographic studies. The indication for LF was based on EAES-guidelines. Either a floppy and short Nissen fundoplication was performed or a posterior Toupet-hemifundoplication was chosen. A long-term follow-up assessment was attempted after surgery.

RESULTS

In total, n = 1131 patients were evaluated (603 males; 528 females; mean age; 48.3 years; and mean body mass index: 27). The mean duration between onset of symptoms and surgery was 8 years. Nissen: n = 873, Toupet: n = 258; conversion rateerativ: 0.5%; morbidity 4%, mortality: 1 (1131). Mean follow-up (n = 898; 79%): 5.6 years; pre/post-op results: esophagitis: 66%/12.1%; Gastrointestinal Quality of Life Index: median: 92/119; daily proton pump inhibitors-intake after surgery: 8%; and operative revisions 4.3%.

CONCLUSIONS

In conclusion, our data show that careful patient selection for laparoscopic fundoplication and well-established technical concepts of mechanical sphincter augmentation can provide satisfying results in the majority of patients with severe GERD.

OUP accepted manuscript

Background

Fundoplication is an essential step in para-oesophageal hernia (POH) repair, but which type minimizes postoperative mechanical complications is controversial.

Methods

This was a randomized, double-blind clinical trial conducted between May 2009 and October 2018. Patients with symptomatic POH were allocated to either a total (Nissen) or a posterior partial (Toupet) fundoplication after hernia reduction and crural repair. The primary outcome was dysphagia (Ogilvie dysphagia scores) at 6 months postoperatively. Secondary outcomes were peri- and postoperative complications, swallowing difficulties assessed by the Dakkak dysphagia score, gastro-oesophageal reflux, quality of life (QoL), and radiologically confirmed hernia recurrence.

Results

A total of 70 patients were randomized to a Nissen (n = 32) or a Toupet (n = 38) fundoplication. Compared with baseline, Ogilvie dysphagia scores were stable at the 3- and 6-month follow-up in the Nissen group (P = 0.075 and 0.084 respectively) but significantly improved in the Toupet group (from baseline mean (s.d.): 1.4 (1.1) to 0.5 ( 0.8) at 3 months, and 0.5 (0.6) at 6 months; P = 0.003 and P = 0.001 respectively). At 6 months, Dakkak dysphagia scores were significantly higher in the Nissen group than in the Toupet group (mean (s.d.): 10.4 (7.9) versus 5.1 (7.2); P = 0.003). QoL scores improved throughout the follow-up. However, at 3 and 6 months postoperatively, the absolute median improvement (⍙) from preoperative values in the mental component scores of the Short Form-36 QoL questionnaire was significantly higher in the Toupet group (median (i.q.r.): 7.1 (−0.6 to 15.2) versus 1.0 (−5.4 to 3.3) at 3 months, and 11.2 (1.4 to 18.3) versus 0.4 (−9.4 to 7.5) at 6 months; (P = 0.010 and 0.003 respectively)). At 6 months, radiologically confirmed POH recurrence occurred in 11 of 24 patients (46 per cent) of the Nissen group and in 15 of 32 patients (47 per cent) of the Toupet group (P = 1.001).

Conclusions

A partial posterior wrap (Toupet fundoplication) showed reduced obstructive complications and improved QoL compared with a total (Nissen) fundoplication following POH repair.

Registration number: NCT04436159 (http://www.clinicaltrials.gov)

Minimally invasive surgery for large hiatal hernia

The majority of large hiatal hernias are paraesophageal hiatal hernias (PEH). Once prolapse of the stomach to the chest cavity reaches a high degree, it is called an intrathoracic stomach. More than 25 years have elapsed since laparoscopic surgery was carried out as minimally invasive surgery for PEH. The feasibility and safety thereof has nearly been established. PEH may cause serious complications such as strangulation and perforation. The outcome of elective repair of PEH is better than emergent repair, so we should carry out elective repair as much as possible. Although not a major clinical problem, following PEH repair the rate of anatomical recurrence increases with age. In order to reduce the recurrence rate, mesh reinforcement by crural repair has been widely performed. Although this improves the short-term outcomes, the long-term outcomes are unclear. For PEH repair, fundoplication and gastropexy are believed desirable. We should select the procedure associated with a lower incidence of dysphagia and so on following surgery. While relaxing incision is useful for primary tension-free closure, it has not contributed to improvement in the recurrence rate.

Who gets a PEG? An analysis of simultaneous PEG placement during elective laparoscopic paraesophageal hernia repair

INTRODUCTION

Percutaneous Endoscopic Gastrostomy (PEG) is an infrequent adjunct in elective paraesophageal hernia repair (PEHR). Guidelines denote that PEG "may facilitate postoperative care in selected patients." Though there is sparse literature defining which patients may benefit. The purpose of this study is to determine factors associated with simultaneous PEG placement during PEHR and their subsequent outcomes.

METHODS

The NSQIP database was queried from 2011 to 2016 for patients undergoing elective laparoscopic PEHR. Cases were excluded if PEHR or fundoplasty was not the primary procedure, a concomitant bariatric procedure was performed, or if the primary surgeon was not a general or cardiothoracic surgeon. Groups were Propensity Score Matched for age, BMI, and ASA Class.

RESULTS

15700 patients were identified, 371 who underwent simultaneous PEG placement (2.4%). Non-PEG patients were matched at a 5:1 ratio, producing 1855 controls. PEG patients had higher rates of pre-operative dyspnea (OR 1.45, p = 0.0110), pre-operative weight loss (OR 2.87, p = 0.0001), and lower pre-operative albumin (3.92 vs. 4.01, p = 0.0129). PEG patients had more intra-operative contamination (mean Wound Classification 1.54 vs. 1.38, p < 0.0001) and longer case durations (170 vs. 148 min, p < 0.0001). PEG patients had longer lengths of stay (3.4 vs. 2.5 days, p = 0.0001), rates of superficial SSI (OR 5.82, p = 0.0012), peri-operative transfusions (OR 2.68, p = 0.0197), and pulmonary emboli (OR 3.61, p = 0.0359).

CONCLUSION

Patients undergoing simultaneous PEG during PEHR are more likely to have respiratory symptoms, markers of malnutrition, and intra-operative factors indicative of more technically challenging cases. These patients have longer hospitalizations, higher rates of superficial SSI, and more pulmonary emboli.

[Hiatus hernia : Standards and controversies in diagnostics and treatment]

A hiatus hernia is defined as a transdiaphragmatic protrusion/migration of the intrabdominal contents through the esophageal hiatus of the diaphragm. The classification of hiatus hernias is based on anatomical morphological differentiation (types I-IV). The leading symptoms and psychological stress vary with respect to the symptoms, e. g. reflux and compression symptoms. Gastroscopy and multichannel intraluminal impedance pH measurement are obligatory preoperative functional diagnostics. A distinction is made between frequent type I hernia (antireflux surgery), symptomatic paraesophageal, thoracic and mixed hernia types (II-IV). Surgical indications exist in symptomatic type II-IV hernias. Hiatal mesh augmentation reduces recurrences. The complication potential of synthetic meshes must be taken into account. Biological implants show no advantages.

Paraesophageal Hernia and Reflux Prevention: Is One Fundoplication Better than the Other?

BACKGROUND

The management of paraesophageal hernia (PEH) is one of the most debated in surgery. Trends regarding indications, approach (open, laparoscopic, thoracoscopic), sac excision, mesh placement, and routine performance of fundoplication have changed over time. Today, most surgeons tend to perform a laparoscopic PEH repair that entails the excision of the sac, liberal use of a mesh to buttress the hiatus, and the addition of an anti-reflux procedure. Nevertheless, very little has been written on which type of fundoplication should be performed in these patients. Therefore, the goal of our study was to provide an evidence-based overview of which type of fundoplication should be performed during a PEH repair and the role of preoperative function tests in the decision-making METHODS: We searched the MEDLINE, Cochran, PubMed, Google Scholar, and Embase databases for papers published between 1996 and 2016 pertaining to the surgical treatment of PEH. We hand-searched the bibliographies of included studies and we excluded all reviews and case reports. We selected clinical studies and technical reports. We only considered papers stating rationales for the type of fundoplication performed.

RESULTS

Our search yielded 24 articles: 17 clinical studies and 7 technical reports. In five of the clinical studies, a fundoplication was added only to patients with reflux symptoms. In all clinical studies, the most performed procedure was a total fundoplication (Nissen or Nissen-Rossetti), whereas a partial fundoplication (Toupet more frequently than Dor) or no fundoplication was reserved to those with impaired esophageal motility. All seven technical reports recommended a tailored approach and suggested adding a partial fundoplication (mainly Toupet) when the manometric findings showed esophageal dismotility.

CONCLUSION

The argument of whether or not a fundoplication should be added to a PEH repair in patients without evidence of reflux still persists. However, this review highlights that, when a fundoplication is performed, a tailored approach based on preoperative function tests is almost always preferred.

Primary paraesophageal hernia repair with Gore® Bio-A® tissue reinforcement: long-term outcomes and association of BMI and recurrence

BACKGROUND

Laparoscopic repair remains the gold-standard treatment for paraesophageal hernia (PEH). We analyzed long-term symptomatic outcomes and surgical reintervention rates after primary PEH repair with onlay synthetic bioabsorbable mesh (W. L. Gore & Associates, Inc., Flagstaff, AZ) and examined body mass index (BMI) as a possible risk factor for poor outcomes and for recurrence.

METHODS

We queried a prospectively maintained database to identify patients who underwent laparoscopic primary PEH repair with onlay patch of a bioprosthetic absorbable mesh (Bio-A® Gore®) between 05/28/2009 and 12/31/2013. Electronic health records were accessed to record demographic and operative data and were reviewed up to the present to identify any repeat procedures. Patients were grouped according to preoperative BMI (A: BMI < 25; B: BMI = 25-29.9; C: BMI = 30-34.9; D: BMI ≥ 35). Patients completed standardized satisfaction and symptom surveys.

RESULTS

In total, 399 patients were included. Most patients (n = 261; 65.4%) were women. Mean age was 59.6 ± 13.4 years; mean BMI was 29.9 ± 5.0 kg/m². The patients were grouped as follows: A, 53 patients (13.3%); B, 166 (41.6%); C, 115 (28.8%); D: 65 (16.3%). Four procedures (1.0%) were converted from laparoscopy to open procedures. All patients underwent an antireflux procedure (225 Nissen, 170 Toupet, 4 Dor). A mean follow-up of 44.7 ± 22.8 months was available for 305 patients (76.4%). 24/305 patients (7.9%) underwent reoperation, and the number of reoperations did not differ among groups (P = 0.64). Long-term symptomatic outcomes were available for 217/305 patients (71.1%) at a mean follow-up of 54.0 ± 13.1  months; no significant difference was observed among groups. 194/217 patients (89.4%) reported good to excellent satisfaction, with no significant differences among the groups.

CONCLUSIONS

Laparoscopic primary PEH repair with onlay Bio-A® mesh is a safe and feasible procedure with excellent long-term patient-centered outcomes and acceptable symptomatic recurrence rate. BMI does not appear to be related to the need for surgical reintervention.

Thinking About Hiatal Hernia Recurrence After Laparoscopic Repair: When Should It Be Considered a True Recurrence? A Different Point of View

Background:

High rates of recurrence after laparoscopic hiatal hernia repair have been published. Most of these recurrences are asymptomatic and only diagnosed by endoscopic or radiologic studies. The definition of hiatal hernia recurrence is still under discussion.

Objective:

This study aimed to define a true hiatal hernia recurrence using a score and classification criteria considering the presence of symptoms and size of the recurrence.

Patients and Methods:

A total of 153 patients with giant hiatal hernia larger than 10 cm in diameter underwent an operation using a laparoscopic approach. Of these patients, 129 had a complete follow-up (3–5 years) after surgery, and they were the only ones included in this study. The IT system of our hospital was our database for data registration. A score and classification were designed for definition of a “true” hiatal hernia recurrence, based on postoperative symptoms and the presence or not of a hiatal hernia in both radiologic and endoscopic evaluations.

Results:

Hiatal hernia recurrence based on endoscopic and/or radiologic hiatal hernia was found in 55 patients (42.6%), and only 28 of them (50.9%) had recurrent symptoms. Applying the score and proposed classification, no recurrence was considered in 18 patients (13.9%). Symptomatic and true recurrence were considered in 22.9% of patients (29 patients). Reoperation was needed for 7 patients (5.4%) because of symptomatic and radiologic recurrence.

Conclusions:

Postoperative symptoms, endoscopic findings, or radiologic findings are important for the definition of the type of recurrence and for the indication of appropriate treatment. The proposed score and classification are useful in order to specify the hiatal hernia recurrence and treatment.

Long-term clinical outcomes after intrathoracic stomach surgery: a decade of longitudinal follow-up

BACKGROUND

A subset of patients with large paraesophageal hernias have more than 75% of the stomach herniated above the diaphragm; such cases are referred to as intrathoracic stomach (ITS). Herein, we report longitudinal symptomatic outcomes over a decade after surgical ITS repair in a large patient cohort.

METHODS

Patients who underwent surgical treatment for ITS from 01/2004 to 05/2016 were studied. Preoperative and follow-up data were prospectively collected. Patients completed a standardized symptom questionnaire 1 year postoperatively and at 2-year intervals thereafter.

RESULTS

In total, 235 patients were reviewed. The mean age was 70.0 ± 11.6 years; 174 patients (74.0%) were women. Surgical procedures included 7 transthoracic repairs and 228 transabdominal repairs (222 laparoscopic, 2 open, 4 laparoscopic-to-open conversions). Anti-reflux procedures were performed in 173 patients (73.6%). 33 patients (14.0%) had mesh reinforcement of hiatal closure; 11 (4.7%) underwent Collis gastroplasty. Follow-up symptom questionnaires at 1, 3, 5, 7, 9, and 11 years were available for 81, 48, 47, 30, 33, and 38% of patients, respectively. Significant and lasting symptom improvement was reported at all follow-up time points. Mean satisfaction scores of 9.3, 9.1, 9.3, 9.0, 9.5, and 9.8 on a 1-10 scale were recorded at the aforementioned intervals.

CONCLUSIONS

Long-term clinical outcomes confirm that laparoscopic ITS repair is safe and durable, and is associated with a high degree of patient satisfaction and symptom resolution.

Subjective outcome after laparoscopic hiatal hernia repair for intrathoracic stomach

PURPOSE

For decades, an intrathoracic stomach (ITS) has been a definite indication for surgery due to the perceived risk of an acute volvulus with perforation, gangrene, or hemorrhage. At the present time, elective laparoscopic repair is the first choice for treatment of ITS. There is a lack of evidence in the long-term quality of life after a hiatal hernia repair for an intrathoracic stomach.

METHODS

A retrospective analysis was performed on all patients undergoing a hiatal hernia repair for an intrathoracic stomach between January 2004 and January 2015. Additionally, to a hiatal closure, the patients received an antireflux procedure. Outcome measures included patient characteristics, operative details, complications, and postoperative morbidity and mortality. All patients were sent a quality of life questionnaire to assess long-term quality of life and patient satisfaction. A higher quality of life score represents a better quality of life.

RESULTS

Eighty-six patients underwent laparoscopic repair for ITS, from which, one patient died during surgery. Eighty-five patients were contacted and 81 completed the questionnaire, resulting in a response rate of 95.3 %. At a median follow-up of 2.7 years (range 0.1-9.6), the mean quality of life score was 13.5 (standard deviation 2.8). The mean overall satisfaction was 8.4. There were four recurrences: three in the first 12 days after surgery and one in 2.4 years.

CONCLUSIONS

Very good results in patient satisfaction and symptom reduction were achieved after a median follow-up of 2.7 years in this laparoscopic repair of the intrathoracic stomach single center experience study. The symptomatic recurrence rate was very low.

Contemporary management of paraesophaegeal hernias: establishing a European expert consensus

BACKGROUND

The surgical treatment of paraesophageal hernias remains a challenge due to the lack of consensus regarding principles of operative treatment. The objectives of this study were to achieve consensus on key topics through expert opinion using a Delphi methodology.

METHODS

A Delphi survey combined with a face-to-face meeting was conducted. A panel of European experts in foregut surgery from high-volume centres generated items in the first survey round. In subsequent rounds, the panel rated agreement with statements on a 5-point Likert-type scale. Internal consistency (consensus) was predefined as Cronbach's α > .80. Items that >70 % of the panel either rated as irrelevant/unimportant, or relevant/important were selected as consensus items, while topics that did not reach this cut-off were termed "undecided/controversial".

RESULTS

Three survey rounds were completed: 19 experts from 10 countries completed round one, 18 continued through rounds two and three. Internal consistency was high in rounds two and three (α > .90). Fifty-eight additional/revised items derived from comments and free-text entries were included in round three. In total, 118 items were rated; consensus agreement was achieved for 70 of these. Examples of consensus topics are the relevance of the disease profile for assessing surgical urgency and complexity, the role of clinical history as the mainstay of patient follow-up, indications for revision surgery, and training and credentialing recommendations. Topics with the most "undecided/controversial" items were follow-up, postoperative care and surgical technique.

CONCLUSIONS

This Delphi study achieved expert consensus on key topics in the operative management of paraesophageal hernias, providing an overview of the current opinion among European foregut surgeons. Moreover, areas with substantial variability in opinions were identified reflecting the current lack of empirical evidence and opportunities for future research.

Novel combined VATS/laparoscopic approach for giant and complicated paraesophageal hernia repair: description of technique and early results

BACKGROUND

The laparoscopic approach for repair of giant and/or recurrent paraesophageal hernias (PEH) is challenging, due to limited access to the dissection of the hernia sac into the proximal mediastinum and esophageal mobilization through the diaphragmatic hiatus. An esophageal lengthening procedure is often necessary, due to the difficulty in obtaining adequate intra-abdominal esophageal length. We, therefore, developed a VATS and laparoscopic technique, which allows for safe and extensive thoracic dissection and intra-abdominal gastric fixation and cruroplasty, yet preserving the benefits of minimally invasive surgery.

METHODS

We use a standard VATS approach. The hernia sac, optimally visualized, is dissected posteriorly from the thoracic aorta, inferiorly from its diaphragmatic attachments, anteriorly from the pericardium, and laterally from the mediastinal pleura. The esophagus is completely mobilized up to the aortic arch, and the anterior vagus nerve is released from its bronchial branches. The hernia sac is then opened, dissected, and completely removed. The hernia content is then reduced into the abdomen laparoscopically, the short gastric vessels are divided and the gastric fundus is completely mobilized. The hiatus is closed with interrupted sutures, and the cruroplasty is buttressed with a biological mesh. A floppy Nissen or a partial fundoplication and a gastropexy are done for reflux control and gastric fixation.

RESULTS

From January 2012 to January 2014, we treated 18 patients (7 with type III PEH and 11 with type IV) with the above-described procedure. Six patients had previous history of antireflux surgery. We performed a planned laparotomy instead of laparoscopy in two patients, who needed concurrent repair of complex incisional hernias. We did not need esophageal lengthening procedures, nor experienced damages to thoracic structures in any patient.

CONCLUSIONS

Our newly developed surgical approach has proven to be safe and feasible. This technique represents a good option for treatment of giant and complicated PEH.

Long-term outcome and quality of life after laparoscopic treatment of large paraesophageal hernia

BACKGROUND

Laparoscopy has been widely used for surgical repair of large paraesophageal hernias (PEHs). The technique, however, entails substantial technical difficulties, such as repositioning the stomach in the abdominal cavity, sac excision, closure of the hiatal gap, and fundoplication. Knowledge of the long-term outcome (>10 years) is scarce. The aim of this article was to evaluate the long-term results of this approach, primarily the anatomic hernia recurrence rate and the impact of the repair on quality of life.

METHODS

We identified all patients who underwent laparoscopic repair for PEH between November 1997 and March 2007 and who had a minimum follow-up of 48 months. In March 2011, all available patients were scheduled for an interview, and a radiologic examination with barium swallow was performed. During the interview the patients were asked about the existence/persistence of symptoms. An objective score test, the gastrointestinal quality of life index (GIQLI), was also administered.

RESULTS

A total of 77 patients were identified: 17 men (22 %) and 60 women (78 %). The mean age at the time of fundoplication was 64 years (range 24-87 years) and at the review time 73 years (range 34-96 years). The amount of stomach contained within the PEH sac was <50 % in 39 patients (50 %), >50 % in 31 (40 %), and 100 % (intrathoracic stomach) in 7 (9.5 %). A 360º PTFe mesh was used to reinforce the repair in six cases and a polyethylene mesh in three. In May 2011, 55 of the 77 patients were available for interview (71 %), and the mean follow-up was 107 months (range 48-160 months). Altogether, 43 patients (66 %) were asymptomatic, and 12 (21 %) reported symptoms that included dysphagia in 7 patients, heartburn in 3, belching in 1, and chest pain in 1. Esophagography in 43 patients (78 %) revealed recurrence in 20 (46 %). All recurrences were small sliding hernias (<3 cm long). In all, 37 patients (67 %) answered the GIQLI questionnaire. The mean GIQLI score was 111 (range 59-137; normal 147). Patients with objective anatomic recurrence had a quality of life index of 110 (range 89-132) versus 122 in the nonrecurrent hernia group (range 77-138, p < 0.01). Mesh was used to buttress the esophageal hiatus in nine patients. One patient died during the follow-up period. Five of the remaining eight patients (62 %) developed dysphagia, a mesh-related symptom. Three patients required reoperation because of mesh-related complications. Esophagography revealed recurrence in four (50 %) of the eight patients. GIQLI scores were similar in patients with recurrence (126, range 134-119) and without it (111, range 133-186) (p > 0.05).

CONCLUSIONS

Long-term follow-up (up to 160 months) in our study showed that laparoscopic PEH repair is clinically efficacious but is associated with small anatomic recurrences in ≤50 % of patients. Further studies are needed to identify the anatomic, pathologic, and physiological factors that may impair outcome, allowing the procedure to be tailored to each patient.

Reoperative intervention in patients with mesh at the hiatus is associated with high incidence of esophageal resection--a single-center experience

BACKGROUND

Mesh hiatoplasty is a widely debated topic among foregut surgeons. While short-term outcomes tout decreased recurrence rates, an increase in mesh-related complications has been reported. The aim of this study is to present a single-center experience with reoperative intervention in patients with previous mesh at the hiatus.

METHODS

After institutional review board approval, a prospectively maintained database was retrospectively queried to identify patients who underwent reoperative intervention between 2003 and spring of 2013 and had mesh placed at a previous hiatal hernia procedure. Patient charts were reviewed and data variables collected.

RESULTS

Twenty-six patients (mean age of 56.7 ± 18.3; 19 females) who underwent 27 procedures met the inclusion criteria. Synthetic mesh was placed in 15 (56 %) procedures, while the remaining 12 had biologic mesh. The mean interval between reoperative intervention and previous surgery was 33 months. Dysphagia (56 %) was the most common presentation, while three patients had mesh erosion. Recurrent hiatus hernia (2 to 7 cm) was noted in 19 (70 %) patients. Eight patients (30 %) underwent redo fundoplication, six patients (22 %) were converted to Roux-en-Y gastrojejunostomy, two patients (7.4 %) underwent distal esophagectomy with esophagojejunostomy, five patients (19 %) had subtotal esophagectomy with gastric pull-up, and one patient underwent substernal gastric pull-up for esophageal bypass with interval esophagectomy. The mean operative time was 252 ± 71.7 min, and the median blood loss was 150 ml (range, 50-1,650 ml). There was no postoperative mortality.

CONCLUSION

Reoperative intervention in patients with mesh at the hiatus is associated with a high need for esophageal resection. More than two thirds of the patients also had a recurrent hiatal hernia.

The choice of primary repair or mesh repair for paraesophageal hernia: a decision analysis based on utility scores

BACKGROUND

Controversy exists on the use of mesh in the repair of paraesophageal hernias (PEH). This debate centers around the type of mesh used, its value in preventing recurrence, its short- and long-term complications, and the consequences of those complications compared with primary repair. Decision analysis is a method to account for the important aspects of a clinical decision. The purpose of this study was to determine whether or not the addition of mesh would be superior in PEH repair.

METHODS

A decision analysis model of the choice between primary repair and mesh repair of a PEH was constructed. The essential features of the decision were the rate of perioperative complications, PEH recurrence rate, reoperation rate after recurrence, rate of symptomatic recurrence, and type of outcome after reoperation. The literature was reviewed to obtain data for the decision analysis and the average rates used in the baseline analysis. A utility score was used as the outcome measure, with a perfect outcome receiving a score of 100 and death 0. Sensitivity analysis was used to determine if changing the rates of recurrence or reoperation changed the dominant treatment.

RESULTS

Using the baseline analysis, mesh repair was slightly superior to primary repair (utility score 99.59 vs 99.12, respectively). However, if recurrence rates were similar, primary repair would be slightly superior; whereas if reoperation rates were similar, mesh repair would be superior. Using sensitivity analysis, there are combinations of recurrence rates and reoperation rates that would make one repair superior to the other. However, these differences are relatively small.

CONCLUSIONS

Depending on what the decision-maker accepts as the recurrence and reoperation rates for these types of repair, either mesh or primary repair may be the treatment of choice. However, the differences between the two are small, and, perhaps, clinically inconsequential.

Efficacy and feasibility of laparoscopic redo fundoplication

BACKGROUND

Nearly 15% of patients who undergo anti-reflux surgery report recurrent symptoms on long-term follow-up and may be candidates for redo anti-reflux surgery (redo-ARS). In the last 10 years, several studies have evaluated the feasibility and short-term results of redo-ARS. The purpose of the present study was to critically review our experience with 102 redo fundoplications with short- to medium-term follow-up and special emphasis on subjective outcomes for redo-ARS.

METHODS

A retrospective chart analysis was done on consecutive 102 redo fundoplications performed between December 2003 and March 2008. The patients were divided into two groups, the open group (group A) and the laparoscopic (group B). Subjective symptom analysis was performed on an annual basis using a standard questionnaire.

RESULTS

There was no significant difference in mean age, body mass index (BMI), or time since first surgery between the two groups. Significant differences were noted between operative time, estimated blood loss, and median hospital stay between the two groups. A total of 16 patients were found to have short esophagus and underwent Collis gastroplasty. Complications included 11 hollow viscus injuries seen in group A and 13 such injuries in group B. There was significant improvement in all symptom scores in the two groups, along with a significant decrease in the use of acid suppression therapy. In the open group 58% of patients rated their satisfaction as excellent compared to 90% in the laparoscopic group.

CONCLUSIONS

This study clearly establishes the safety and efficacy of redo laparoscopic anti-reflux surgery with excellent outcomes after short- to medium-term follow-up.