Surgery for Type III-IV hiatal hernia: anatomical recurrence and global results after elective treatment of short oesophagus with open and minimally invasive surgery

Recurrence in Paraesophageal Hernia: Patient Factors and Composite Surgical Repair in 862 Cases

BACKGROUND

Repair of giant paraesophageal hernia (PEH) is associated with a considerable hernia recurrence rate by objective measures. This study analyzed a large series of laparoscopic giant PEH repair to determine factors associated with anatomical recurrence.

METHOD

Data was extracted from a single-surgeon prospective database of laparoscopic repair of giant PEH from 1991 to 2021. Upper endoscopy was performed within 12 months postoperatively and selectively thereafter. Any supra-diaphragmatic stomach was defined as anatomical recurrence. Patient and hernia characteristics and technical operative factors, including "composite repair" (360° fundoplication with esophagopexy and cardiopexy to right crus), were evaluated with univariate and multivariate analysis.

RESULTS

Laparoscopic primary repair was performed in 862 patients. The anatomical recurrence rate was 27.3% with median follow-up of 33 months (IQR 16, 68). Recurrence was symptomatic in 45% of cases and 29% of these underwent a revision operation. Hernia recurrence was associated with younger age, adversely affected quality of life, and were associated with non-composite repair. Multivariate analysis identified age < 70 years, presence of Barrett's esophagus, absence of "composite repair", and hiatus closure under tension as independent factors associated with recurrence (HR 1.27, 95%CI 0.88-1.82, p = 0.01; HR 1.58, 95%CI 1.12-2.23, p = 0.009; HR 1.72, 95%CI 1.2-2.44, p = 0.002; HR 2.05, 95%CI 1.33-3.17, p = 0.001, respectively).

CONCLUSION

Repair of giant PEH is associated with substantial anatomical recurrence associated with patient and technique factors. Patient factors included age < 70 years, Barrett's esophagus, and hiatus tension. "Composite repair" was associated with lower recurrence rate.

True Short Esophagus in Gastroesophageal Reflux Disease: Old Controversies With New Perspectives

OBJECTIVE

To explore the true short esophagus (TSE) frequency and long-term results of patients undergoing gastroesophageal reflux disease (GERD) or hiatus hernia (HH) surgery.

BACKGROUND

The existence and treatment of TSE during GERD/HH surgery is controversial. Satisfactory long-term results have been achieved with and without surgical techniques dedicated to TSE.

METHODS

In 311 consecutive patients undergoing minimally invasive surgery for GERD/HH, the distance between the endoscopically-localized gastroesophageal junction (GEJ) and the apex of the diaphragmatic hiatus after maximal thoracic esophagus mobilization was measured. A standard Nissen fundoplication (SN) was performed in cases with an abdominal length >1.5 cm; in cases of TSE (abdominal length <1.5 cm), a Collis-Nissen (CN) or stomach around the stomach fundoplication (SASF) in elderly patients was performed. The fundoplication superior margin was fixed below the hiatus, but over the GEJ. The patients' symptoms, and radiological and endoscopic data were pre/postoperatively recorded.

RESULTS

After intrathoracic esophageal mobilization (median 9 cm), TSE was diagnosed in 31.8% of 311 cases. With a median follow-up of 96 months (309 patients), HH relapse was radiologically diagnosed in 3.2% of patients, with excellent, good, fair, and poor outcomes in 45.6%, 44.3%, 6.2%, and 3.9% of cases, respectively, and no significant differences among SN (68.5%), CN (26.4%), and SASF (5.2%).

CONCLUSIONS

TSE was present in 31.8% of patients routinely submitted to GERD/HH surgery. In the presence of TSE, CN and SASF performed according to determined surgical principles may achieve similar satisfactory results. This finding warrants confirmation with a prospective multicenter study.