Laparoscopic paraesophageal hernia repair: defining long-term clinical and anatomic outcomes

Patient reported outcomes and decision regret scores in redo-paraesophageal hernia repair

INTRODUCTION

Recurrent paraesophageal hernia (PEH) repair presents significant technical challenges, with limited data weighing the benefit to the operative risk. This study aims to describe our experience with recurrent PEH repair, including long-term surgical and patient reported outcomes (PROs).

METHODS

We conducted a retrospective review of recurrent PEH repairs from June 2018-March 2023 using our institutional database. A blinded review of post-operative imaging was conducted to assess for recurrence. Quality of life (QOL) and decision regret were measured using the GERD Health-Related Quality-of-Life (GERD-HRQL) questionnaire and Decision Regret Scale (DRS) at maximum follow up.

RESULTS

Eighty-eight patients underwent recurrent PEH repair at our institution for PEH, classified as type II (13.6%), type III (72.7%) and type IV (13.6%). There was significant heterogeneity in operative techniques used: one-third of patients had mesh placed at the hiatus, 11.4% had a Collis gastroplasty, and one-third of patients underwent fundoplication. Intraoperative complications included gastric (5.7%), esophageal (2.3%), vascular (1.1%) and pulmonary (1.1%) injuries. Follow up was available for 73 patients with median follow up of 35.2 months. Of patients with radiographic follow up, 20 (35.7%) had a radiographic recurrence: 12 (21.4%) were 2-5 cm and 8 (14.3%) were > 5 cm. Patients reporting PROs (53 patients; 60.2%) reported low symptom severity (mean GERD-HRQL 13.1 ± 12) and low decision regret (mean DRS 13.3 ± 19.4) with 75.5% scoring in the lowest quartile (DRS < 25). Radiographic recurrence was associated with worse QOL (p < 0.05), but no significant difference in decision regret (p = 0.125).

CONCLUSION

We found significant heterogeneity amongst recurrent PEH repair techniques with continued high recurrence rate during follow up. Radiographic recurrence was correlated with worse QOL, yet patients reported low symptom severity and low decision regret, suggesting continued value in these challenging operations. Future studies should aim to identify more effective techniques to reduce recurrence rates in this patient population.

Surgical strategies for recurrent hiatal hernia: three-point fundoplication fixation

BACKGROUND

The management of a recurrent (symptomatic) hiatal hernia remains controversial. This study aimed to review the outcomes of patients who underwent recurrent repair of hiatal hernias.

METHODS

Thirteen patients who underwent recurrent hiatal hernia repairs at our hospital between 2018 and 2024 were reviewed retrospectively. The postoperative outcomes and complications of these patients were investigated.

RESULTS

Thirteen patients were included in this study. The median time of reoperation from the previous hiatal hernia repair was 3 years (IQR, 2.5-5). Patients with a history of only one repair accounted for 76.9%, whereas those with two repairs accounted for 23.1%. All reoperations were completed laparoscopically. No deaths or readmissions during the 30-day postoperative period were recorded at an average of 30.5 ± 20.9 (6-68) months of follow-up. No other complications or symptoms were recorded, and oral medication was discontinued in eleven (84.6%) patients. The average GERD-Q score was 6.7 ± 1.3 postoperatively, whereas it was 10.4 ± 3.0 preoperatively.

CONCLUSION

We present several surgical strategies for addressing the recurrence of hiatal hernias. The key is not only to accurately close the hernia ring but also to fix the fundoplication to reduce the impact on the tissue around the hiatus to reduce the incidence of recurrence. Our three-point fixation technique showed promising effects in preventing recurrence but needs further study.

CLINICAL TRIAL NUMBER

ChiCTR2100049995.

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.

Lessons learned from revision procedures: a case series pleading for reinforcement of the anterior hiatus in recurrent hiatal hernia

BACKGROUND

Hiatal Hernia (HH) is a common structural defect of the diaphragm. Laparoscopic repair with suturing of the hiatal pillars followed by fundoplication has become standard practice. In an attempt to lower HH recurrence rates, mesh reinforcement, commonly located at the posterior site of the esophageal hiatus, has been used. However, effectiveness of posterior mesh augmentation is still up to debate. There is a lack of understanding of the mechanism of recurrence requiring further investigation. We investigated the anatomic location of HH recurrences in an attempt to assess why HH recurrence rates remain high despite various attempts with mesh reinforcement.

METHODS

A retrospective case series of prospectively collected data from patients with hiatal hernia repair between 2012 and 2020 was performed. In total, 54 patients with a recurrent hiatal hernia operation were included in the study. Video clips from the revision procedure were analyzed by a surgical registrar and senior surgeon to assess the anatomic location of recurrent HH. For the assessment, the esophageal hiatus was divided into four equal quadrants. Additionally, patient demographics, hiatal hernia characteristics, and operation details were collected and analyzed.

RESULTS

54 patients were included. The median time between primary repair and revision procedure was 25 months (IQR 13-95, range 0-250). The left-anterior quadrant was involved in 43 patients (80%), the right-anterior quadrant in 21 patients (39%), the left-posterior quadrant in 21 patients (39%), and the right-posterior quadrant in 10 patients (19%).

CONCLUSION

In this study, hiatal hernia recurrences occured most commonly at the left-anterior quadrant of the hiatus, however, posterior recurrences were not uncommon. Based on our results, we hypothesize that both posterior and anterior hiatal reinforcement might be a suitable solution to lower the recurrence rate of hiatal hernia. A randomized controlled trial using a circular, bio-absorbable mesh has been initiated to test our hypothesis.

Malpractice claims after antireflux surgery and paraesophageal hernia repair: a population-based analysis

BACKGROUND

The complication rate of modern antireflux surgery or paraesophageal hernia repair is unknown, and previous estimates have been extrapolated from institutional cohorts.

METHODS

A population-based retrospective cohort study of patient injury cases involving antireflux surgery and paraesophageal hernia repair from the Finnish National Patient Injury Centre (PIC) register between Jan 2010 and Dec 2020. Additionally, the baseline data of all the patients who underwent antireflux and paraesophageal hernia operations between Jan 2010 and Dec 2018 were collected from the Finnish national care register.

RESULTS

During the study period, 5734 operations were performed, and the mean age of the patients was 54.9 ± 14.7 years, with 59.3% (n = 3402) being women. Out of all operations, 341 (5.9%) were revision antireflux or paraesophageal hernia repair procedures. Antireflux surgery was the primary operation for 79.9% (n = 4384) of patients, and paraesophageal hernia repair was the primary operation for 20.1% (n = 1101) of patients. A total of 92.5% (5302) of all the operations were laparoscopic. From 2010 to 2020, 60 patient injury claims were identified, with half (50.0%) of the claims being related to paraesophageal hernia repair. One of the claims was made due to an injury that resulted in a patient's death (1.7%). The mean Comprehensive Complication Index scores were 35.9 (± 20.7) and 47.6 (± 20.8) (p = 0.033) for antireflux surgery and paraesophageal hernia repair, respectively. Eleven (18.3%) of the claims pertained to redo surgery.

CONCLUSIONS

The rate of antireflux surgery has diminished and the rate of paraesophageal hernia repair has risen in Finland during the era of minimally invasive surgery. Claims to the PIC remain rare, but claims regarding paraesophageal hernia repairs and redo surgery are overrepresented. Additionally, paraesophageal hernia repair is associated with more serious complications.

EAES Multidisciplinary Rapid Guideline: systematic review, meta-analysis, GRADE assessment and evidence-informed recommendations on the surgical management of paraesophageal hernias

BACKGROUND

New evidence has emerged since latest guidelines on the management of paraesophageal hernia, and guideline development methodology has evolved. Members of the European Association for Endoscopic Surgery have prioritized the management of paraesophageal hernia to be addressed by pertinent recommendations.

OBJECTIVE

To develop evidence-informed clinical practice recommendations on paraesophageal hernias, through evidence synthesis and a structured evidence-to-decision framework by an interdisciplinary panel of stakeholders.

METHODS

We performed three systematic reviews, and we summarized and appraised the certainty of the evidence using the GRADE methodology. A panel of general and upper gastrointestinal surgeons, gastroenterologists and a patient advocate discussed the evidence in the context of benefits and harms, the certainty of the evidence, acceptability, feasibility, equity, cost and use of resources, moderated by a Guidelines International Network-certified master guideline developer and chair. We developed the recommendations in a consensus meeting, followed by a modified Delphi survey.

RESULTS

The panel suggests surgery over conservative management for asymptomatic/minimally symptomatic paraesophageal hernias (conditional recommendation), and recommends conservative management over surgery for asymptomatic/minimally symptomatic paraesophageal hernias in frail patients (strong recommendation). Further, the panel suggests mesh over sutures for hiatal closure in paraesophageal hernia repair, fundoplication over gastropexy in elective paraesophageal hernia repair, and gastropexy over fundoplication in patients who have cardiopulmonary instability and require emergency paraesophageal hernia repair (conditional recommendation). A strong recommendation means that the proposed course of action is appropriate for the vast majority of patients. A conditional recommendation means that most patients would opt for the proposed course of action, and joint decision-making of the surgeon and the patient is required. Accompanying evidence summaries and evidence-to-decision frameworks should be read when using the recommendations. This guideline applies to adult patients with moderate to large paraesophageal hernias type II to IV with at least 50% of the stomach herniated to the thoracic cavity. The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/j7q7Gn .

CONCLUSION

An interdisciplinary panel provides recommendations on key topics on the management of paraesophageal hernias using highest methodological standards and following a transparent process.

GUIDELINE REGISTRATION NUMBER

PREPARE-2023CN018.

Surgical Repair of Large Hiatal Hernias: Insight from a High-Volume Center

BACKGROUND

Laparoscopic-assisted hiatal hernia (HH) repair is safe and effective; however, it is unclear whether hernia size affects perioperative outcomes and whether a watch-and-wait strategy is appropriate for patients with asymptomatic large HHs. We aimed to investigate these issues.

METHODS

After IRB approval, we queried our prospectively maintained database for patients who underwent primary laparoscopic HH repair at our center between August 2016 and December 2019. All procedures were performed by a single surgeon (SKM). According to the intraoperative findings, HHs were divided into four groups: small (S-HH), medium (M-HH), large (L-HH), or giant (G-HH) when the percentage of herniated stomach was 0% (sliding), < 50%, 50-75%, or > 75%, respectively. Perioperative and mid-term outcomes were analyzed.

RESULTS

A total of 170 patients were grouped: S-HH (n = 46), M-HH (n = 69), L-HH (n = 20), and G-HH (n = 35) with mean age of 58.5.6 ± 11.0, 61.9 ± 11.3, 70.7 ± 10.3, and 72.6 ± 9.7 years (p < 0.001), respectively. Compared to M-HH patients, L-HH patients had significantly longer hospital stays (mean 2.8 ± 3.2 vs 1.4 ± 0.91 days; p = 0.001) and more postoperative complications (6/20 [30.0%] vs 3/69 [4.3%]; OR 6.9, 95% CI 5.4-8.4, p < 0.001). At a mean follow-up time of 43.1 ± 25.0 and 43.5 ± 21.6 months for the combined S/M-HH and L/G-HH groups, GERD-Health-Related Quality of Life scores were comparable (S/M-HH: 6.5 ± 10.9 vs L/G-HH: 7.1 ± 11.3; p = 0.63). There was no perioperative mortality.

CONCLUSIONS

HHs likely grow with age, reflecting their progressive nature. Laparoscopic L-HH repair was associated with higher morbidity than M-HH repair. Thus, patients with M-HH, even if less symptomatic, should be evaluated by a foregut surgeon. Regardless of HH size, good mid- and long-term quality of life outcomes can be achieved.

Robotic Primary and Revisional Hiatal Hernia Repair is Safe and Associated with Favorable Perioperative Outcomes: A Single Institution Experience

Background: Robotic hiatal hernia (HH) repair has been demonstrated to be feasible and safe. Recent conflicting reports have emerged on the higher incidence of perioperative complications with robotic HH repair when compared with laparoscopic repair. Materials and Methods: A retrospective review of a prospective database at an academic medical center for all robotic HH repairs performed by a high-volume foregut surgeon from 2018 to 2021 was performed. Outcome measures included operative time, estimated blood loss (EBL), length of stay (LOS), conversion rate, need for esophageal lengthening procedure, intra- and perioperative complications, and 30-day in-hospital mortality. Results: One hundred four patients were included in the analysis. Fifteen percent of patients had a type I HH, 2% had a type II, 73% had a type III, and 10% had a type IV HH. Eighty-four percent of cases were primary and 16% were revisional. Fifty-four percent of patients had mesh placed and 4.4% had an esophageal lengthening procedure. Mean EBL was 15 mL and mean operative time was 151 minutes. Median LOS was 2 days (interquartile range 1-2 days). There were zero conversions. Intraoperative complication rate was 1% and 30-day complication rate was 4%. The 30-day in-hospital mortality was zero. Conclusion: In this retrospective analysis of 114 consecutive robotic HH repairs performed, with 83% type III or IV HHs and 16% revisional hiatal cases, our results demonstrate favorable perioperative outcomes, with lower EBL, shorter LOS, lower complication rate, zero conversions, and comparable operative times compared with historical laparoscopic data.

Evolution of biomimetic ECM scaffolds from decellularized tissue matrix for tissue engineering: A comprehensive review

Tissue engineering is essentially a technique for imitating nature. Natural tissues are made up of three parts: extracellular matrix (ECM), signaling systems, and cells. Therefore, biomimetic ECM scaffold is one of the best candidates for tissue engineering scaffolds. Among the many scaffold materials of biomimetic ECM structure, decellularized ECM scaffolds (dECMs) obtained from natural ECM after acellular treatment stand out because of their inherent natural components and microenvironment. First, an overview of the family of dECMs is provided. The principle, mechanism, advances, and shortfalls of various decellularization technologies, including physical, chemical, and biochemical methods are then critically discussed. Subsequently, a comprehensive review is provided on recent advances in the versatile applications of dECMs including but not limited to decellularized small intestinal submucosa, dermal matrix, amniotic matrix, tendon, vessel, bladder, heart valves. And detailed examples are also drawn from scientific research and practical work. Furthermore, we outline the underlying development directions of dECMs from the perspective that tissue engineering scaffolds play an important role as an important foothold and fulcrum at the intersection of materials and medicine. As scaffolds that have already found diverse applications, dECMs will continue to present both challenges and exciting opportunities for regenerative medicine and tissue engineering.

Preoperative esophageal testing predicts postoperative reflux status in sleeve gastrectomy patients

BACKGROUND

Patients who undergo vertical sleeve gastrectomy (VSG) are at risk of postoperative GERD. The reasons are multifactorial, but half of conversions to Roux-en Y gastric bypass are for intractable GERD. Our institution routinely performs preoperative pH and high-resolution manometry studies to aid in operative decision making. We hypothesize that abnormal pH studies in concert with ineffective esophageal motility would lead to higher rates of postoperative reflux after VSG.

METHODS

A single institution retrospective review was conducted of adult patients who underwent preoperative pH and manometry testing and VSG between 2015 and 2021. Patients filled out a symptom questionnaire at the time of testing. Postoperative reflux was defined by patient-reported symptoms at 1-year follow-up. Univariate logistic regression was used to examine the relationship between esophageal tests and postoperative reflux. The Lui method was used to determine the cutpoint for pH and manometric variables maximizing sensitivity and specificity for postoperative reflux.

RESULTS

Of 291 patients who underwent VSG, 66 (22.7%) had a named motility disorder and 67 (23%) had an abnormal DeMeester score. Preoperatively, reflux was reported by 122 patients (41.9%), of those, 69 (56.6%) had resolution. Preoperative pH and manometric abnormalities, and BMI reduction did not predict postoperative reflux status (p = ns). In a subgroup analysis of patients with an abnormal preoperative pH study, the Lui cutpoint to predict postoperative reflux was a DeMeester greater than 24.8. Postoperative reflux symptoms rates above and below this point were 41.9% versus 17.1%, respectively (p = 0.03).

CONCLUSION

While manometry abnormalities did not predict postoperative reflux symptoms, GERD burden did. Patients with a mildly elevated DeMeester score had a low risk of postoperative reflux compared to patients with a more abnormal DeMeester score. A preoperative pH study may help guide operative decision-making and lead to better counseling of patients of their risk for reflux after VSG.

Novel "starburst" mesh configuration for paraesophageal and recurrent hiatal hernia repair: comparison with keyhole mesh configuration

BACKGROUND

Controversy exists over the use of mesh, its type and configuration in repair of hiatal hernia. We have used biological mesh for large or recurrent hiatal hernias. We have developed a mesh configuration to better enhance the tensile strength of the hiatus by folding the mesh over the edge of the hiatus-entitled the "starburst" configuration. We report our experience with the starburst configuration, comparing it to our results with the keyhole configuration.

METHODS

Medical records of all patients undergoing either the keyhole or starburst mesh configuration hiatal hernia repair were reviewed between 2017 and 2021. Data gathered included age, sex, type of hernia (sliding, paraesophageal, or recurrent), fundoplication type (none, Nissen, Toupet, Dor, Collis-Nissen, Collis-Toupet, or magnetic sphincter augmentation [MSA]), 30-day complications, and long-term outcomes (hiatal hernia recurrence, reflux-symptom recurrence, dysphagia, dilations, reoperations).

RESULTS

From 7/2017 to 8/2019, 51 cases using the keyhole mesh were completed. Sliding hiatal hernia comprised 4%, paraesophageal hernia (PEH) 64% and recurrent hiatal hernia (RHH) 34% of cases. Distribution of fundoplication type: 2% none, 41% Nissen, 41% Toupet, 8% Dor, 2% Collis-Nissen, and 6% Collis-Toupet. 30-day complication rate 31%. Long-term outcomes: recurrent hiatal hernia 16%, dysphagia 12%, dysphagia requiring dilation(s) 10%, recurrent GERD symptoms 4%, and reoperation 14%. From 10/2020 to 8/2021, 58 cases using the starburst configuration were completed. PEH comprised 60% and RHH 40%. Distribution of fundoplication type: 10% none, 40% Nissen, 43% Toupet, 5% MSA, 2% Collis-Toupet. 30-day complication rate 16%. Long-term outcomes: recurrent hiatal hernia 19%, dysphagia 14%, dilations 5%, recurrent GERD symptoms 9%, and reoperations 3%.

CONCLUSION

The starburst mesh configuration compares favorably with the keyhole configuration with respect to postoperative dysphagia, need for esophageal dilation, and GERD symptom recurrence, with similar recurrence rates. We are continuing to further refine this technique and study the long-term outcomes.

Surgical treatment of large and complicated hiatal hernias with the new resorbable mesh with hydrogel barrier (Phasix™ ST): a preliminary study

Evaluation of the efficacy and safety of the new monofilament fully resorbable mesh with hydrogel barrier (Phasix™ ST), for large and complex hiatal hernia repair. Between December 2017 and December 2020, 60 patients with large or complicated hiatal hernia were treated (40 robotic and 20 laparoscopic procedures). The mesh was placed after primary closure of the hiatal defect, in an onlay fashion around the esophagus, followed by 360^o fundoplication. Follow-up at 3, 6, 12, 18, 24 months from intervention included clinical evaluation and upper GI endoscopy. In cases of recurrence, radiologic survey and manometry were utilized. There were no conversions to open repair or significant postoperative incidents. Over a median follow-up of 21 months (range 3-36), no recurrences or mesh related complications were observed. From our early experience, Phasix™ ST mesh seems to be safe and effective for the reinforcement of crural defects in large and complex hiatal hernia.

Management of Recurrent Paraesophageal Hernia

Introduction: Recurrent paraesophageal hernias (rPEH) represent a clinical and surgical challenge. Even with a relatively high incidence, most of them are minimally symptomatic, and the need for reoperation is low. For those patients who are candidates for surgery, laparoscopic revision is a feasible and safe technique although there are other treatment options available. Methods: This article provides an overview of the definition, mechanisms of recurrence, epidemiology, clinical presentation, and indications for treatment of rPEH, as well as an overview of the surgical management options and a description of the technical principles of the repair and/or resection. Results: Surgeons should consider multiple factors when deciding the appropriate treatment of patients with rPEH, and all of them require a complete and comprehensive evaluation. The surgical options need to be individualized and include a redo PEH repair and revisional fundoplication, a partial or total gastrectomy with Roux-en-Y reconstruction, or an esophagectomy. There are key steps during the surgical repair that contribute to a successful operation and also auxiliary techniques that can improve postoperative outcomes. After laparoscopic redo most patients have improvement of their symptoms and an acceptable rate of perioperative complications when they are performed by experienced foregut surgeons. In obese patients with rPEH, bariatric surgery can be the best treatment option. Conclusions: Laparoscopic reoperative management should be considered in symptomatic patients who are not controlled with maximal nonoperative therapy, after a thorough work-up and appropriate counseling. In cases with multiple hernia repairs, it is important to consider alternative operations.

Quantifying physiologic parameters of the gastroesophageal junction during re-operative anti-reflux surgery

BACKGROUND

Hiatal hernia re-approximation during index anti-reflux surgery (ARS) contributes approximately 80% of overall change in distensibility index (DI) and, potentially, compliance of the gastroesophageal (GEJ), while sphincter augmentation contributes approximately 20%. Whether this is seen in re-operative ARS is unclear. We quantify the physiologic parameters of the GEJ at each step of robotic re-operative ARS and compare these to index ARS.

METHODS

Robotic ARS with hiatal hernia repair was performed on 195 consecutive patients with pathologic reflux utilizing EndoFLIP™, of which 26 previously had ARS. Intra-operative GEJ measurements, including cross-sectional area (CSA), pressure, DI, and high-pressure zone (HPZ) length were collected pre-repair, post-diaphragmatic re-approximation, post-mesh placement, and post-lower-esophageal sphincter (LES) augmentation.

RESULTS

Both cohorts were similar by sex and BMI and underwent similar procedures. The re-operative cohort was older (60.6 ± 15.3 vs. 52.7 ± 16.2 years, p = 0.03), had more frequent pre-operative dysphagia (69.2% vs. 42.6%, p = 0.01) and esophageal dysmotility on barium swallow (75.0% vs. 35.0%, p < 0.001) but lower rates of hiatal hernia on endoscopy (30.8% vs. 68.7%, p < 0.001) compared to index procedures. Among the re-operative cohort, the CSA decreased by 34 (IQR - 80, - 15) mm2 and DI 1.1 (IQR - 2.4, - 0.6) mm2/mmHg (both p < 0.001). Pressure increased by 11.2 (IQR 4.7, 14.9) mmHg and HPZ by 1.5 (1,2) cm (both p < 0.001). These changes were similar to those seen in index ARS. Diaphragmatic re-approximation contributed to a greater percentage of overall change to the GEJ than did the augmentation procedure, with 72% of the change in DI occurring during hiatal closure, similar to that seen during index ARS.

CONCLUSIONS

During re-operative ARS, dynamic intra-operative monitoring can quantify the effects of each operative step on GEJ physiologic parameters. Diaphragmatic re-approximation appears to have a greater effect on GEJ physiology than does LES-sphincter augmentation during both index and re-operative ARS.

Mesh Versus No Mesh for Cruroplasty

This review describes the evolution of hiatal hernia repair for the past several decades: From the use of a primary tissue repair only, the subsequent inclusion of synthetic mesh and its complications, to current day indications for mesh use. We will highlight the recent research in biologic and composite meshes as well as the ongoing limitations in studying their efficacy. Finally, we will describe our institutional indications and surgical technique practices in the utilization of biologic mesh.

Comparing anterior gastropexy to no anterior gastropexy for paraesophageal hernia repair: a study protocol for a randomized control trial

BACKGROUND

More than half of patients undergoing paraesophageal hernia repair (PEHR) will have radiographic hernia recurrence at 5 years after surgery. Gastropexy is a relatively low-risk intervention that may decrease recurrence rates, but it has not been studied in a prospective manner. Our study aims to evaluate the effect of anterior gastropexy on recurrence rates after PEHR, compared to no anterior gastropexy.

METHODS

This is a two-armed, single-blinded, registry-based, randomized controlled trial comparing anterior gastropexy to no anterior gastropexy in PEHR. Adult patients (≥18 years) with a symptomatic paraesophageal hernia measuring at least 5 cm in height on computed tomography, upper gastrointestinal series, or endoscopy undergoing elective minimally invasive repair are eligible for recruitment. Patients will be blinded to their arm of the trial. All patients will undergo laparoscopic or robotic PEHR, where some operative techniques (crural closure techniques and fundoplication use or avoidance) are left to the discretion of the operating surgeon. During the operation, after closure of the diaphragmatic crura, participants are randomized to receive either no anterior gastropexy (control arm) or anterior gastropexy (treatment arm). Two hundred forty participants will be recruited and followed for 1 year after surgery. The primary outcome is radiographic PEH recurrence at 1 year. Secondary outcomes are symptoms of gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular, and pulmonary symptoms as well as patient satisfaction in the immediate postoperative period and at 1-year follow-up. Outcome assessors will be blinded to the patients' intervention.

DISCUSSION

This randomized controlled trial will examine the effect of anterior gastropexy on radiographic PEH recurrence and patient-reported outcomes. Anterior gastropexy has a theoretical benefit of decreasing PEH recurrence; however, this has not been proven beyond a suggestion of effectiveness in retrospective series. If anterior gastropexy reduces recurrence rates, it would likely become a routine component of surgical PEH management. If it does not reduce PEH recurrence, it will likely be abandoned.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04007952 . Registered on July 5, 2019.

Medium-term safety and efficacy profile of paraesophageal hernia repair with Phasix-ST® mesh: a single-institution experience

BACKGROUND

Hernia recurrence after laparoscopic repair is a perplexing problem. In an effort to reduce anatomical and clinical recurrences, different type of meshes have been used to bolster the esophageal hiatus.

OBJECTIVE

The aim of this study was to assess safety, medium-term efficacy, and quality of life improvement after laparoscopic repair of hiatal hernia reinforced with a biosynthetic absorbable mesh (Phasix-ST^®).

METHODS

Observational single-center retrospective single-arm cohort study (November 2015-February 2021). We included all adult patients (> 18 years old) who underwent laparoscopic paraesophageal hernia repair with Phasix-ST^® mesh and Toupet fundoplication.

RESULTS

Sixty-eight patients were included. The median postoperative stay was 3.2 days (range 2-9) and the postoperative complication rate was 11.7%. The median follow-up time was 27 months (range 1-53). No mesh-related complications were detected. Hernia recurrence was diagnosed in six patients (8.8%). The recurrence-free probability at 34 months was 0.89 (95% CI 0.807-0.988) while at 60 months was 0.86 (95% CI 0.76-0.97). Hernia recurrences were mostly observed between 21 and 36 months after the operation. None of the patients required surgical revision and all were managed with PPI. Postoperative dysphagia requiring endoscopic balloon dilatation occurred in 2.9% of patients. Compared to baseline, both the GERD-HRQL (15.2 ± 6.2 vs. 3.2 ± 3.1; p = 0.026) and all SF-36 items were significantly improved (p < 0.001).

CONCLUSIONS

Laparoscopic crura augmentation with Phasix-ST^® mesh combined with a Toupet fundoplication is safe and seems effective in the medium-term follow-up. Phasix-ST^® crural reinforcement resulted in low hernia recurrence rate with a sustained symptoms and quality of life improvement.

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)

Anatomic location and mechanism of hiatal hernia recurrence: a video-based assessment

INTRODUCTION

Hiatal hernia recurrence following surgical repair is common. We sought to define the most common anatomic location and mechanism for hiatal failure to inform technical strategies to decrease recurrence rates.

METHODS

Retrospective chart review and video analysis were performed for all recurrent hiatal hernia operations performed by a single surgeon between January 2013 and April 2020. Hiatal recurrences were defined by anatomic quadrants. Recurrences on both left and right on either the anterior or posterior portion of the hiatus were simply classified as 'anterior' or 'posterior', respectively. Three or more quadrants were defined as circumferential. Mechanism of recurrence was defined as disruption of the previous repair or dilation of the hiatus.

RESULTS

There were 130 patients to meet criteria. Median time to reoperation from previous hiatal repair was 60 months (IQR19.5-132). First-time recurrent repairs accounted for 74%, second time 18%, and three or more previous repairs for 8% of analyzed procedures. Mesh had been placed at the hiatus in a previous operation in 16%. All reoperative cases were completed laparoscopically. Video analysis revealed anterior recurrences were most common (67%), followed by circumferential (29%). There were two with left-anterior recurrence (1.5%), two posterior recurrence (1.5%), and one right-sided recurrence. The mechanism of recurrence was dilation in 74% and disruption in 26%. Disruption as a mechanism was most common in circumferential hiatal failures. Neither the prior number of hiatal surgeries nor the presence of mesh at the time of reoperation correlated with anatomic recurrence location or mechanism. Reoperations in patients with hiatal disruption occurred after a shorter interval when compared to hiatal dilation.

CONCLUSION

The most common location and mechanism for hiatal hernia recurrence is anterior dilation of the hiatus. Outcomes following techniques designed to reinforce the anterior hiatus and perhaps to prevent hiatal dilation should be explored.

Decellularization of Small Intestinal Submucosa

Small intestinal submucosa (SIS) is the most studied extracellular matrix (ECM) for repair and regeneration of different organs and tissues. Promising results of SIS-ECM as a vascular graft, led scientists to examine its applicability for repairing other tissues. Overall results indicated that SIS grafts induce tissue regeneration and remodeling to almost native condition. Investigating immunomodulatory effects of SIS is another interesting field of research. SIS can be utilized in different forms for multiple clinical and experimental studies. The aim of this chapter is to investigate the decellularization process of SIS and its common clinical application.

Minimally Invasive Paraesophageal Hernia Repair in the Elderly: Is Age Really Just a Number?

Introduction: Paraesophageal hernias readily affect the elderly with a median age of presentation between 65 and 75 years. Laparoscopic paraesophageal hernia repair (PEHR) is a technically challenging operation with potential for dire complications. Advanced age and medical comorbidities may heighten perioperative risk and limit surgical candidacy, potentially refusing patients an opportunity toward symptom resolution. Given the increased prevalence in the elderly and associated surgical risks, we aim to assess age as an independent risk factor for perioperative morbidity and mortality after PEHR. Methods: A retrospective analysis using a prospectively maintained database assessed patients undergoing PEHR from 2007 to 2018. Patients were stratified by age: Group A (age <65 years), Group B (65≤ age <80 years), and Group C (age ≥80 years). Patient demographics, preoperative symptoms, postoperative outcomes, and mortality rate were analyzed. Barium esophagram was performed on symptomatic postsurgical patients. Recurrence was confirmed radiologically. Results: In total, 143 patients underwent laparoscopic (94.4%) or robotic-assisted (5.6%) PEHR. Average age per group was Group A (n = 49) 55.4 years (standard deviation [SD] ±8.91), Group B (n = 76) 71.4 years (SD ±4.40), and Group C (n = 17) 84.1 (years) (SD ±3.37). Group C had significantly higher rates of nonelective surgery (P = .018), preoperative weight loss (P = .014), hypertension (P = .031), ischemic heart disease (P = .001), and cancer (P = .039); preoperative body mass index was significantly lower (P = .048). Charlson comorbidity index differences between groups were significant (2.00 versus 3.61 versus 5.28, P < .001). Median follow-up was 426 days (6-3199). Symptom improvement was seen in 78.3% of patients. Recurrence and reoperation rates were not significantly different between groups. No differences were seen in mortality, length of stay, or postoperative complications between groups. Conclusions: PEHR in elderly patients proved to be safe and effective. Avoidance of emergent intervention may be achieved through a judicious elective approach to this anatomic problem. Symptom resolution and quality-of-life improvement can be safely achieved with surgical repair in this patient population, demonstrating that age is truly just a number for PEHR.

Proton Pump Inhibitor Use After Hiatal Hernia Repair: Inhibitor of Recurrent Symptoms and Potential Revisional Surgery

BACKGROUND

Hiatal hernia recurrence after hiatal hernia repair (HHR) is often underdiagnosed and underreported but may present with recurrent gastroesophageal reflux disease (GERD) symptoms. Because of their availability, proton pump inhibitor (PPI) use is common and may mask patients who would benefit from revisional surgery, which has been shown to improve symptoms and quality of life.

METHODS

A retrospective analysis was performed to evaluate recurrence patterns of patients who underwent HHR, specifically for the indication of GERD, from 2007 to 2015 at a single Veterans Administration Medical Center. Clinicopathologic parameters were reviewed for association with hiatal hernia recurrence, including postoperative PPI use.

RESULTS

Sixty-four patients were identified with a median follow-up time of 57.8 mo. Thirty-eight patients developed an anatomic recurrence, which did not demonstrate any associated factors on univariate analysis. Seventy percent of patients remained or were restarted on PPI after their initial surgery. For patients with a documented recurrence, the median time to start a PPI was 224 d, but the time to identify recurrence on imaging or endoscopy was 712.5 d. Eleven (39.3%) patients had a reintervention for anatomic recurrence, of which all had developed recurrent symptoms of GERD.

CONCLUSIONS

Most patients who developed recurrent hiatal hernia were restarted on PPI without workup for their symptoms. The time of initiation of PPI was much earlier than the time of identification of a recurrent hiatal hernia. The use of PPIs in patients whom have undergone HHR may delay proper workup to identify recurrent hiatal hernia amenable to surgical repair and should be reserved until patients develop recurrent symptoms and have at least begun a diagnostic workup to rule out an anatomic cause for the recurrent symptoms.

Robotic Approach to Paraesophageal Hernia Repair Results in Low Long-Term Recurrence Rate and Beneficial Patient-Centered Outcomes

BACKGROUND

Little is known regarding important long-term outcomes after robotic paraesophageal hernia (PEH) repairs, such as symptom relief and recurrence rates. The aim of this study was to evaluate the long-term clinical outcomes in a large series of patients undergoing robotic PEH repair.

STUDY DESIGN

This prospective, IRB-approved study analyzed adult patients who underwent robotic PEH repair, from 2010 to 2014, at a high-volume tertiary academic medical center. Detailed information on patient characteristics, perioperative factors, and long-term patient-reported outcomes for up to 5 years postoperatively were collected. Objective long-term outcomes included radiographic evidence of PEH recurrence at 1, 3, and 5 years postoperatively.

RESULTS

A total of 233 patients underwent robotic PEH repair during the study period-70% were primary, 30% were revisional. Seventy-eight percent of patients (181) had a type III PEH, 21% (49) had a type IV, and 1% (3) had a type II. At 5 years postoperatively, 62% of patients (145 of 233) were available for follow-up, with a radiographic recurrence rate of 9% (13 of 145). Additionally, there was a significant improvement in the GERD-HRQL score at 5 years postoperatively (preoperative: 25.6 ± 8.7, 5-year postoperative, 4.5 ± 1.7, p < 0.01, 95% CI 19.7 to 22.5).

CONCLUSIONS

This study represents one of the largest longitudinal robotic foregut surgical databases to date. Our results demonstrate that robotic PEH repair with an experienced surgical team is a safe and effective alternative to laparoscopic repair, with excellent long-term outcomes, including a very low recurrence rate.

Hiatal hernia repair: prevention of mesh erosion and migration into the esophagogastric junction

Background:

Erosion and migration into the esophagogastric lumen after laparoscopic hiatal hernia repair with mesh placement has been published.

Aim:

To present surgical maneuvers that seek to diminish the risk of this complication.

Method:

We suggest mobilizing the hernia sac from the mediastinum and taking it down to the abdominal position with its blood supply intact in order to rotate it behind and around the abdominal esophagus. The purpose is to cover the on-lay mesh placed in “U” fashion to reinforce the crus suture.

Results:

We have performed laparoscopic hiatal hernia repair in 173 patients (total group). Early postoperative complications were observed in 35 patients (27.1%) and one patient died (0.7%) due to a massive lung thromboembolism. One hundred twenty-nine patients were followed-up for a mean of 41+28months. Mesh placement was performed in 79 of these patients. The remnant sac was rotated behind the esophagus in order to cover the mesh surface. In this group, late complications were observed in five patients (2.9%). We have not observed mesh erosion or migration to the esophagogastric lumen.

Conclusion:

The proposed technique should be useful for preventing erosion and migration into the esophagus.

Evolution From the U-shaped to Keyhole-shaped Mesh Configuration in the Repair of Paraesophageal and Recurrent Hiatal Hernia

BACKGROUND

Paraesophageal hernia (PEH) and recurrent hiatal hernia (RHH) are prone to recurrences. One adjunct used to reduce recurrences is mesh reinforcement. The optimal configuration is yet to be determined. We present our evolution from the U-shaped to the keyhole pattern.

METHODS

All patients undergoing PEH/RHH repair with mesh between 2013 and 2019 were reviewed for demographic information, perioperative/intraoperative details, postoperative complications, and recurrences.

RESULTS

Of patients undergoing PEH/RHH repair between 2013 and 2019, 138 were repaired using mesh. Of these, 88 were repaired using the U-shaped configuration and 50 using the keyhole configuration. The U-shaped configuration was used for PEH in 72% and RHH in 28%, while the keyhole configuration was used for PEH in 66% and RHH in 34%. Thirty patients suffered postoperative complications, although there was no difference between the groups. Overall, 28 patients in the U-shaped configuration group (31.8%) had a recurrence of their hiatal hernia identified, compared with 7 patients (14.6%) in the keyhole group (P=0.039). The median time to last follow-up was 21 months (range: 1 to 85) in the U-shaped group and 8 months (range: 1 to 23) in the keyhole group. There was no difference in median time to recurrence, postoperative dysphagia, dilations, or strictures.

CONCLUSIONS

The keyhole pattern mesh was not associated with a higher complication rate compared with the U-shape pattern. Although this study was not a direct comparison between the configurations, it does suggest that the keyhole pattern may lead to fewer recurrences.

Long-Term Outcomes Following Laparoscopic Repair of Large Hiatus Hernias Performed by Trainees Versus Consultant Surgeons

BACKGROUND

The laparoscopic approach is the preferred method for repair of large hiatus hernias but can be technically challenging. Training surgeons need experience as the primary operator to gain competency in this operation. However, learning the procedure should not compromise the functional long-term outcome for patients. The aim of this study was to determine whether any difference in long-term outcomes exists for patients having a laparoscopic large hiatus hernia repair performed by a trainee versus a consultant surgeon.

METHODS

A total of 648 suitable patients who had undergone laparoscopic repair of a large hiatus hernia were identified from a prospective database. Cases were divided into two groups based on whether the primary operator was a trainee or a consultant surgeon. Demographics, perioperative data, revisions and patient-reported clinical outcomes via standardised questionnaires were compared.

RESULTS

There were no statistically significant differences in the clinical outcomes for patients undergoing laparoscopic repair of a large hiatus hernia performed by a trainee versus a consultant surgeon, with comparable patient-reported outcomes for heartburn, dysphagia, and overall satisfaction with the outcome following surgery. Median operative time was approximately 20 min longer for trainees (p = <0.0001). Revisional surgery rates were similar for the two groups.

CONCLUSIONS

Patients operated on by trainees have equivalent long-term clinical outcomes to patients operated on by consultant surgeons. For these patients, surgery can be safely performed by supervised trainees.

Reparación laparoscópica de hernia hiatal gigante

Introducción. La reparación laparoscópica es el estándar de tratamiento en hernia hiatal gigante. Sin embargo, a pesar de su baja morbilidad, la tasa de recurrencia sigue siendo alta. Nuestro objetivo fue describir los resultados de la reparación laparoscópica de hernia hiatal gigante, independientemente de la técnica de cruroplastia empleada. Métodos. Se llevó a cabo un estudio retrospectivo de pacientes llevados a reparación laparoscópica de hernia hiatal gigante en el periodo 2009-2017. Se analizaron los datos demográficos, la técnica quirúrgica, las complicaciones y la estancia hospitalaria. Se revisaron los resultados de la endoscopia, la radiografía de vías digestivas altas y la escala de síntomas GERD-HRQOL, obtenidos luego de un año de cirugía. Resultados. Se incluyeron 44 pacientes con un tamaño promedio de la hernia de 7 cm. Se practicó cruroplastia con sutura simple en 36,4 %, sutura más refuerzo con politetrafluoroetileno (PTFE) o dacrón, en 59,1 %, y se usó malla en 4,5 %. Hubo 12 complicaciones, la estancia hospitalaria promedio fue de 3,5 días y no hubo mortalidad. Se encontró recurrencia endoscópica o radiológica en 6/20 pacientes, todas pequeñas y asintomáticas. En 23 pacientes, la escala GERD-HRQOL reportó un valor promedio de 7,7 y 78 % de satisfacción. Solo un paciente requirió cirugía de revisión. Conclusión. El método preferido de reparación laparoscópica de la hernia hiatal gigante es la cruroplastia sin malla, técnica asociada a baja morbilidad y adecuado control de los síntomas. La tasa de recurrencia es similar a la reportada en la literatura. Se requieren estudios prospectivos con seguimiento completo a largo plazo para validar estos resultados.

Anatomic Observation of Recurrent Hiatal Hernia: Recurrence or Disease Progression?

BACKGROUND

Recurrence after hiatal hernia repair is common. The causes are uncertain. Our observation is the site of recurrence is primarily the nonsutured or nonreinforced anterior-left lateral portion of the hiatus. Our aim was to assess the distribution of hiatal hernia recurrence location as a basis for developing a theory of recurrence.

METHODS

Consecutive patients who underwent repair of recurrent hiatal hernias from March 2012 to December 2019 were reviewed. Data collected included age, sex, date of operation, location of hiatal hernia recurrence, operative approach, method of hiatal hernia repair, fundoplication performed, need for gastrectomy, and additional procedures.

RESULTS

One hundred and eight consecutive patients were studied. The distribution of recurrence locations was as follows: anterior 67%, posterior 12%, and circumferential 21%. Foreshortened esophagus was a contributing factor in 12%. Median time from the original repair to recurrence was 1.5 years (interquartile range 0.9 to 3.75 years) for posterior recurrences, 2.75 years (interquartile range 1.15 to 8.5 years) for circumferential recurrences, and 3.25 years (interquartile range 1.38 to 10 years) for anterior recurrences. Recurrences were repaired in a variety of techniques, depending on the clinical circumstances.

CONCLUSIONS

Hiatal hernia recurrences due to failure of the crural closure were less common, but early, recurrences. The majority of recurrences were due to stretching of the hiatus anterior and to the left of the esophagus. We theorize that the pathophysiology of late hiatal hernia recurrence is widening of the anterior and left lateral portion of the hiatus secondary to repeated stress from differential pressures that eventually overcomes the tensile strength of the hiatus.

Robotic voluminous paraesophageal hernia repair: a case report and review of the literature

Background

The treatment for sliding esophageal hernia with mild gastroesophageal reflux is usually conservative, but surgical treatment is recommended for refractory sliding esophageal hernia, paraesophageal hernia liable to prolapse, or paraesophageal hernia with ulceration and/or stenosis. Robotic surgery overcomes laparoscopic pitfalls by providing steady-state three-dimensional visualization, augmented dexterity with endo-wrist movements, and superior ergonomics for the surgeon.

Case presentation

To investigate robotic paraesophageal hernia repair, a literature search was conducted using PubMed with the following key words: mini invasive surgery, robotic surgery, hiatal hernia, and Nissen fundoplication. We present the case of a 44-year-old Italian woman with a 20-year history of gastroesophageal reflux disease refractory to medical treatment, who underwent robotic Nissen fundoplication. In our center, we use the da Vinci® Xi™ Surgical System, which is an advanced tool for minimally invasive surgery.

Conclusions

Various reports published in the literature suggested that the robot-assisted approach was effective and was associated with very low postoperative morbidity and was accompanied by satisfactory symptomatic and anatomical radiological outcomes during a follow-up period.

The robotic approach to paraesophageal repair is safe and effective with low complication rates. With increased experience, the operative time, length of stay, and complications decrease without compromising surgical principles.

Large paraesophageal hernia in elderly patients: Two case reports of laparoscopic posterior cruroplasty and anterior gastropexy

BACKGROUND

Paraesophageal hernia (PEH) is a rare form of hiatal hernia, which commonly occurs in elderly people. Although asymptomatic, it can be associated with severe life-threatening complications, such as gastric volvulus. Surgical treatment is reserved for symptomatic patients. Herein, we present two cases of complicated PEH that were treated with laparoscopic posterior cruroplasty and anterior gastropexy.

CASE SUMMARY

An 88-year old woman presented with epigastric pain, hematemesis and food intolerance for the last two days. Physical exam revealed mild abdominal distention. Chest X-ray showed a left thoracic opacity, and barium swallow images showed a mixed type III PEH. Abdominal CT-scan images confirmed the diagnosis of incomplete gastric volvulus. The patient underwent a laparoscopic hernia reduction with sac excision, posterior cruroplasty and anterior gastropexy with continuous barbed suturing. The postoperative course was uneventful, and follow-up showed complete resolution of her symptoms. A 91-year old patient was admitted for dyspnea and fever, with vomiting and food intolerance for the last 7 days. Physical exam revealed absent sounds on both lungs. Chest X-ray showed a large left opacity. CT-scan images revealed a giant PEH with complete gastric volvulus. The patient underwent emergency laparoscopic hernia reduction and sac excision, with re-inforced posterior cruroplasty, and anterior gastropexy with continuous barbed suturing. There were no surgical complications, but the patient died on the 4^th day postoperatively due to respiratory failure.

CONCLUSION

Early laparoscopic posterior cruroplasty and anterior gastropexy is a safe and effective surgical alternative for elderly patients with comorbidities, presenting with symptomatic PEH.

Hiatal Surface Area's CT scan measurement is useful in hiatal hernia's treatment of bariatric patients

INTRODUCTION

Hiatal surface area (HSA) measurement has been recently proposed as useful tool for tailored treatment of hiatal defects. Multidetector CT scan (MDCT) of the hiatal area was shown to be useful in hiatal hernia (HH) management.

PURPOSE

MDCT preoperative HSA measurements validation as a useful method in the surgical repair decision making process of hiatal defects in candidates to antireflux ± bariatric surgery.

MATERIAL AND METHODS

Twenty-five obese patients (group A), candidates to laparoscopic cruroplasty ± bariatric surgery, were prospectively evaluated preoperatively and after one year, using an original MDCT algorithm, compared with intraoperative HSA measurement. Twelve non-obese (group B) and 12 obese patients (group C), without GERD or HH, were used as control groups.

RESULTS

Median preoperative HSA was 7.9 cm², (interquartile IQR 5.97-9.80) while intraoperative median HSA was 6 cm² (6-9.5), p = .84. Postoperative median HSA was 3.8 cm² (3.21-4.8), showing the efficacy of cruroplasty, comparable with HSA calculated in the control groups (3.98 for B and 3.69 cm² for C, p = .8547). No statistically significant difference between MDCT preoperative measurement and intraoperative findings was observed.

CONCLUSIONS

Preliminary results demonstrate MDCT scan HSA measurements as a valid, non-invasive method to predict intraoperative findings. It allows the HSA monitoring in order to correlate the symptoms onset and failure of cruroplasty.

Paraesophageal Hernia: To Mesh or Not to Mesh? The Controversy Continues

Introduction: Paraesophageal hernias represent 5%-10% of all primary hiatal hernias and are becoming increasingly more common with the aging of the population. Surgical treatment includes closure of the wide hiatal gap. Achieving tension-free closure is difficult, and several studies have reported lower recurrence rates with the use of mesh reinforcement. The use of this technique, however, is controversial. Objective and Materials and Methods: Narrative revision of the literature revising: (1) evidence-based surgery and clinical studies, (2) what the experts say (Delphi), (3) complications of mesh, and (4) long-term results of laparoscopic treatment impact on the quality of life. Results: Consensus about the type of mesh continues to be elusive, and we clearly need a higher level of evidence to address the controversy. Conclusion: Mesh reinforcement can effectively reduce the hernia recurrence rate. Mesh-associated complications are few, but because they are serious, most experts recommend mesh use only in specific circumstances, particularly those in relation to the size of the hiatal defect and the quality of the crura.

Common Tenets in Repair of Primary Paraesophageal Hernias: Reducing Tension and Maximizing Length

Tension-free repair remains the most important principle of surgical management of giant paraesophageal hernias. The axial tension is relieved by generous circumferential mobilization of the esophagus in the mediastinum to the level of subcarina. An esophageal lengthening procedure may be necessary for a true short esophagus. The radial tension is managed by mobilizing the left and right diaphragmatic crus. Adjunctive procedures such as pleurotomy or diaphragmatic relaxation incisions may be needed to further reduce the tension on the repair.

Comparison of Dor and Nissen fundoplication after laparoscopic paraesophageal hernia repair

BACKGROUND

Fundoplication is performed routinely during laparoscopic repairs of a paraesophageal hernia, but the degree of fundoplication remains controversial. The purpose of this study is to assess postoperative dysphagia and reflux after a Dor versus a Nissen fundoplication in patients undergoing laparoscopic repair of giant paraesophageal hernias.

METHODS

We performed a retrospective cohort study of all patients undergoing laparoscopic repair of giant paraesophageal hernias with Nissen or Dor fundoplication between January 2012 and December 2017 at a high-volume center, excluding revisional and emergency cases. Primary outcomes were reflux and dysphagia at 1 and 6 months. Severe dysphagia was defined as intolerance to liquids. Balanced cohorts were created using coarsened exact matching.

RESULTS

A total of 106 patients were included, and 87 were matched (Dor = 48, Nissen = 58). Baseline characteristics were well balanced between matched groups. Mean follow-up duration was 17.7 months (standard deviation 16.4). The incidence of severe dysphagia at 1 month was less in the Dor group (0 of 48 vs 8 of 58, P = .02) with similar reflux symptoms. There was no difference in severe dysphagia and reflux symptoms at 6 months and at the latest visit.

CONCLUSION

Dor fundoplication is associated with less severe, early postoperative dysphagia. Future studies assessing the relative importance of dysphagia and reflux on quality of life should be conducted to tailor the operative technique and optimize patient satisfaction.

Laparoscopic anti-reflux procedures with hepatic shoulder technique in the surgical management of large hiatal hernias and paraesophageal hernias: a follow-up study

BACKGROUND

Numerous techniques have been historically proposed in the management of gastroesophageal reflux and paraesophageal hernias (PEH). A follow-up study (Quilici et al. in Surg Endosc 23(11):2620-2623, 2009) to a novel laparoscopic approach introduced in 2009 and performed in 49 patients is presented.

METHODS

All procedures were performed via laparoscopy. Thirty-two patients underwent a Nissen Fundoplication, eleven a reduction of the PEH with a Nissen fundoplication, two without a fundoplication, and four with a Collis-Nissen fundoplication. In all patients, the left hepatic lobe was freed, repositioned, and anchored under and inferior to the gastroesophageal junction, propping the gastroesophageal junction anteriorly. This maneuver entirely covers and closes the diaphragmatic defect.

RESULTS

At the time of laparoscopy, several patients were found not to be suitable candidates for this procedure (morphology of the left hepatic lobe). Forty-nine procedures were completed. One patient was re-explored on POD 2 for a tight hiatus post-Collis fundoplication. Post-operatively, all other patients did well without notable, unusual complaints. The average length of stay was 2.2 days. Although not statistically significant, 43 patients had no recurrence of symptoms with the longest follow-up at 10 years, two patients were lost to follow-up, one patient had a recurrence of the PEH and three patients stated they were experiencing some form of gastroesophageal reflux requiring medical management.

CONCLUSION

In selected patients, patients with an "at-risk" crural closure during a laparoscopic anti-reflux procedure or PEH can safely be managed via a laparoscopic anti-reflux procedure with the hepatic shoulder technique. This technique has shown good early post-operative results and could be used as an alternative to a laparoscopic mesh-reinforced fundoplication in difficult crural closures or in the management of large paraesophageal hernias.

Mesh reinforcement of paraesophageal hernia repair: Trends and outcomes from a national database

BACKGROUND

Placement of paraesophageal type of "mesh" in paraesophageal hernia repair is controversial. This study examines the trends and outcomes of mesh placement in paraesophageal hernia repair.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent paraesophageal hernia repair with or without mesh (2010-2017). Demographics, operative approach, and outcomes were compared over time.

RESULTS

Of 25,801, most paraesophageal hernia repair cases were elective (89.3%), without mesh (61.9%), and performed laparoscopically (91.3%).When compared with open paraesophageal hernia repair patients, the patients undergoing laparoscopic paraesophageal hernia repair had lesser rates of reoperation, readmission, mortality, overall complications and major complications (2.7% vs 4.8%, 6.2% vs 9.6%, 0.6% vs 2.9%, 7.1% vs 21.3%, 3.8% vs 11.1%, respectively; all P < .0001). Mesh placement was more common in laparoscopic paraesophageal hernia repair (38.9 vs 29.7, P < .0001) than opern paraesophageal hernia repair. During 2010-2017, mesh placement decreased from 46.2% to 35.2% of laparoscopic paraesophageal hernia repair (P < .0001). Operative times for laparoscopic paraesophageal hernia repair decreased over time, and laparoscpic paraesophageal hernia repair without mesh was consistently less (with mesh: 176.0 ± 71.0 to 149.9 ± 72.5 min, without mesh: 148.6 ± 71.4 to 134.6 ± 70.4). We observed no changes in comorbidities or adverse outcomes over time. Using multivariate analysis to control for potential confounding factors, chronic obstructive pulmonary disease was associated most strongly with adverse outcomes, including mortality (OR 2.53, CI 1.55-4.14), any complications (OR 1.80, CI 1.51-2.16), major complications (OR 1.80, CI 1.51-2.16), readmission (OR 1.63, CI 1.33-1.99) and reoperation (OR 1.49, CI 1.10-2.02). Mesh placement was not associated with adverse outcomes.

CONCLUSION

The placement of mesh during laparoscopic paraesophageal hernia repair is not associated with adverse outcomes. Use of mesh with laparoscopic paraesophageal hernia repair is decreasing with no apparent adverse impact on short-term patient outcomes. Further research is needed to investigate patient factors not captured by this national database, such as characteristics of the hernia, patient symptoms, and hernia recurrence.

Evidence-Based Practice Guideline for Surgical Treatment of Gastroesophageal Reflux Disease 2018

The prevalence of gastroesophageal reflux disease (GERD) is increasing in Korea, and physicians, including surgeons, have been focusing on its treatment. Indeed, in Korea, medical treatment using a proton pump inhibitor is the mainstream treatment for GERD, while awareness of surgical treatment is limited. Accordingly, to promote the understanding of surgical treatment for GERD, the Korean Anti-Reflux Surgery Study Group published the Evidence-Based Practice Guideline for the Surgical Treatment of GERD. The guideline consists of 2 sections: fundamental information such as the definition, symptoms, and diagnostic tools of GERD and a recommendation statement about its surgical treatment. The recommendations presented 5 debates regarding fundoplication: 1) comparison of the effectiveness of medical and surgical treatments, 2) effectiveness of surgical treatment in cases of refractory GERD, 3) effectiveness of surgical treatment of extraesophageal symptoms, 4) comparison of effectiveness between total and partial fundoplication, and 5) effectiveness of fundoplication in cases of hiatal hernia. The present guideline is the first to demonstrate the efficacy of the surgical treatment GERD in Korea.

Watchful waiting versus elective repair for asymptomatic and minimally symptomatic paraesophageal hernias: A cost-effectiveness analysis

OBJECTIVE

To evaluate the decision of watchful waiting (WW) versus elective laparoscopic hernia repair (ELHR) for minimally symptomatic paraesophageal hernias (PEH) with respect to cost-effectiveness.

BACKGROUND

The current recommendation for minimally symptomatic PEHs is watchful waiting. This standard is based on a decision analysis from 2002 that compared the two strategies on quality-adjusted life-years (QALYs). Since that time, the safety of ELHR has improved. A cost-effectiveness study for PEH repair has not been reported.

METHODS

A Markov decision model was developed to compare the strategies of WW and ELHR for minimally symptomatic PEH. Input variables were estimated from published studies. Cost data was obtained from Medicare. Outcomes for the two strategies were cost and QALY's.

RESULTS

ELHR was superior to the WW strategy in terms of quality of life, but it was more costly. The average cost for a patient in the ELHR arm was 11,771 dollars while for the WW arm it was 2207.

CONCLUSION

This study shows that WW and ELHR both have benefits in the management of minimally symptomatic paraesophageal hernias.

One More Time: Redo Paraesophageal Hernia Repair Results in Safe, Durable Outcomes Compared with Primary Repairs

The incidence and causes of failed paraesophageal hernia repairs (PEHR) remain poorly understood. Our study aimed to evaluate long-term clinical outcomes after reoperative fundoplication as compared with initial PEHR. A prospectively maintained institutional hernia-specific database was queried for PEHR between 2008 and 2017. Patients with prior history of PEHR were categorized as “redo” paraesophageal hernia (RPEH). Primary outcomes included postoperative morbidity, mortality, symptom resolution, and hernia recurrence. A total of 402 patients underwent minimally invasive PEHR (Initial PEH = 305, RPEH = 97). Redo PEHR had more prevalent preoperative nausea/vomiting (50.6% vs 34.1%, P < 0.007) and weight loss (24.1% vs 13.5%, P < 0.02). RPEH had had longer mean operative time (256.4 ± 91.2 vs 190.3 ± 59.9 minutes, P < 0.0001) and higher rate of conversion to open (10.3% vs 0.67%, P < 0.0001); however, no difference was noted in postoperative complications, hernia recurrence, or mortality between cohorts. Laparoscopic revision of prior PEHR in symptomatic patients can be safely performed with favorable outcomes compared with initial PEHR. Despite redo procedures seeming to be more technically demanding (as noted by longer operative time and higher conversion rates), outcomes are similar and overall resolution of symptoms is achieved in most patients.

Treatment of paraesophageal hiatal hernia in octogenarians: a systematic review and retrospective cohort study

Over the coming years octogenarians will make up an increasingly large proportion of the population. With the rise in octogenarians more paraesophageal hiatal hernias may be identified. In research for the optimal treatment for paraesophageal hiatal hernias, octogenarians are often omitted and the optimal surgical strategy for this patient group remains unclear. A systematic search in PubMed, Embase, and The Cochrane Library was conducted, including articles compromising 'surgery,' 'paraesophageal hiatal hernia,' and 'octogenarians.' Selection of articles was based on independent review by two authors. Alongside, a retrospective cohort study was conducted including all type II-IV hiatal hernia repairs performed in the VU Medical Center in Amsterdam, The Netherlands, from 2005 to 2015. A total of 486 papers were eligible for selection. After careful selection, a total of eight articles were included. All articles were retrospective cohort studies describing different proportions of octogenarians. The populations and surgical techniques were very heterogeneous. Elective paraesophageal hiatal hernia repair was performed safely in symptomatic octogenarians in all studies. Additional analysis of 84 patients, of which 9.5% octogenarians, was performed at our tertiary referral center. A larger hernia type, more acute interventions and a higher morbidity and mortality rate was observed in octogenarians compared to patients aged <80 years. In conclusion, elective paraesophageal hiatal hernia repair can be performed in octogenarians, especially in patients without comorbidity. Findings suggest improvement in symptoms in short-term follow up, with minimal morbidity and mortality. With regard to surgical techniques, laparoscopy and fundoplication were performed safely. Octogenarians need to be included in future clinical trials to further evaluate the optimal surgical intervention. Preoperative risk assessment by clinical prediction rules should guide operative intervention, in order to evaluate risks and benefits in this challenging population.

Anti-reflux procedures: complications, radiologic findings, and surgical and gastroenterologic perspectives

This article provides an overview of the current surgical anti-reflux procedures and their imaging findings, as well as the surgical complications. Accurate and timely clinical assessment requires an engaged radiologist fluoroscopist who understands the perspectives of their interdisciplinary colleagues, including the surgeon and gastroenterologist. The complex pathophysiology calls for an interdisciplinary approach, and the radiologist needs to tailor their evaluation to answer the specific questions posed by their clinical colleagues and by the presenting symptomatology.

The Use of Standardized Measures to Predict and Assess Quality of Life after Laparoscopic Hiatal Hernia Repair

The literature regarding laparoscopic hiatal hernia repair is difficult to interpret because of inconsistencies in describing hernia characteristics and outcome measures. This study was performed to evaluate risk factors for an unsatisfactory outcome after repair using objective definitions of hernia size and a clinically relevant outcome instrument. A retrospective review of a prospectively maintained database was conducted over a seven-year period. Data collected included patient demographics and hernia-related variables. Outcomes were defined using a validated quality of life (QOL) instrument. Postoperatively, the mean total QOL score decreased from 22.9 to 5.8 (P < 0.001). In all, 13.8 per cent of patients had unsatisfactory QOL scores postoperatively. Multivariate analysis showed that high gastroesophageal (GE) junction position (P = 0.03) and female gender (P = 0.02) were the only significant factors associated with an unsatisfactory postoperative QOL. Laparoscopic hiatal hernia repair significantly improves QOL. With respect to predicting clinically relevant outcomes, hernias are best characterized by the position of the GE junction. Females with high GE junction position are at the highest risk for an unsatisfactory outcome.

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.

Pre-Existing Mesh at the Hiatus in Revisional Surgery Does Not Result in Increased Morbidity: A Case-Control Evaluation

BACKGROUND

Mesh is sometimes used to reinforce the hiatus during primary and reoperative fundoplication. This is a controversial practice as it is not clear that this leads to a decreased rate of failure of the hiatal closure, and concerns about morbidity related to the presence of mesh in this location exist. One of these concerns is that if reoperation is ever required (fundoplication herniates through the hiatus, for example), revisional surgery would be significantly more difficult and associated with a higher rate of morbidity than if mesh had not been placed at the hiatus in a previous procedure.

METHODS

A retrospective review was conducted of prospectively collected data on 104 patients to undergo surgery for a failed fundoplication between 2011 and 2015. Fourteen patients (13.5%) had previous operations where mesh had been placed at the hiatus and underwent a subsequent revisional procedure. Procedures performed were reoperative fundoplication and Roux-en-Y gastric bypass as a salvage procedure for a failed fundoplication, especially in the setting of obesity. These 14 cases were matched 1:2 with randomly selected control patients from the database who underwent revisional surgery in whom mesh had not been placed at the original operation. Cases and controls were paired based on the number of previous revision attempts and operation type. Perioperative outcomes were compared.

RESULTS

There was no statistically significant difference in 30-day morbidity, readmission, operative time, or length of hospital stay.

CONCLUSIONS

In this retrospective case-control evaluation, mesh at the hiatus did have an impact on morbidity or operative time.

Prospective study of giant paraesophageal hernia repair with 1-year follow-up

OBJECTIVE

Evaluating giant paraesophageal hernia (GPEH) repair requires long-term follow-up. GPEH repair can have associated high recurrence rates, yet this incidence depends on how recurrence is defined. Our objective was to prospectively evaluate patients undergoing GPEH repair with 1-year follow-up.

METHODS

Patients undergoing elective GPEH repair between 2011 and 2014 were enrolled prospectively. Postoperatively, patients were evaluated at 1 month and 1 year. Radiographic recurrence was evaluated by barium swallow and defined as a gastroesophageal junction located above the hiatus. Quality of life was evaluated pre- and postoperatively with the use of a validated questionnaire.

RESULTS

One-hundred six patients were enrolled. The majority of GPEH repairs were performed laparoscopically (80.2%), and 7.5% were redo repairs. At 1-year follow-up, 63.4% of patients were symptom free, and radiographic recurrence was 32.7%. Recurrence rate was 18.8% with standard definition (>2 cm of stomach above the diaphragm). Quality of life scores at 1 year were significantly better after operative repair, even in patients with radiographic recurrence (7.0 vs 22.5 all patients, 13.0 vs 22.5 with recurrence; P < .001). Patients with small radiographic recurrences have similar satisfaction and symptom severity to patients with >2 cm recurrences.

CONCLUSIONS

GPEH repair can be performed with low operative mortality and morbidity. The rate of recurrence at 1 year depends on the definition used. Patient satisfaction and symptom severity are similar between patients with radiographic and greater than 2 cm hernia recurrences. Longer follow-up and critical assessment of our results are needed to understand the true impact of this procedure and better inform perioperative decision making.