Laparoscopic Hiatal Hernia Repair in 221 Patients: Outcomes and Experience

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 hernia reporting: time to remove subjectivity?

INTRODUCTION

The size of a hiatal hernia (HH) is a key determinant of the approach for surgical repair. However, endoscopists will often utilize subjective terms, such as "small," "medium," and "large," without any standardized objective correlations. The aim of this study was to identify HHs described using objective axial length measurements versus subjective size allocations and compare them to their corresponding manometry and barium swallow studies.

METHODS AND PROCEDURES

Retrospective chart reviews were conducted on 93 patients diagnosed endoscopically with HHs between 2017 and 2021 at Newton-Wellesley Hospital. Information was collected regarding their HH subjective size assessment, axial length measurement (cm), manometry results, and barium swallow readings. Linear regression models were used to analyze the correlation between the objective endoscopic axial length measurements and manometry measurements. Ordered logistic regression models were used to correlate the ordinal endoscopic and barium swallow subjective size allocations with the continuous axial length measurements and manometry measurements.

RESULTS

Of the 93 endoscopy reports, 42 included a subjective size estimate, 38 had axial length measurement, and 12 gave both. Of the 34 barium swallow reads, only one gave an objective HH size measurement. Axial length measurements were significantly correlated with the manometry measurements (R2 = 0.0957, p = 0.049). The endoscopic subjective size estimates were also closely related to the manometry measurements (R2 = 0.0543, p = 0.0164). Conversely, the subjective size estimates from barium swallow reads were not significantly correlated with the endoscopic axial length measurements (R2 = 0.0143, p = 0.366), endoscopic subjective size estimates (R2 = 0.0481, p = 0.0986), or the manometry measurements (R2 = 0.0418, p = 0.0738). Mesh placement was significantly correlated to pre-operative endoscopic axial length measurement (p = 0.0001), endoscopic subjective size estimate (p = 0.0301), and barium swallow read (p = 0.0211). However, mesh placement was not significantly correlated with pre-operative manometry measurements (0.2227).

CONCLUSIONS

Endoscopic subjective size allocations and objective axial length measurements are associated with pre-operative objective measurements and intra-operative decisions, suggesting both can be used to guide clinical decision making. However, including axial length measurements in endoscopy reports can improve outcomes reporting.

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.

Trends in outcomes of 862 giant hiatus hernia repairs over 30 years

PURPOSE

Laparoscopic giant hiatus hernia repair is technically difficult with ongoing debate regarding the most effective surgical technique. Repair of small hernia has been well described but data for giant hernia is variable. This study evaluated trends in outcomes of laparoscopic non-mesh repair of giant paraesophageal hernia (PEH) over 30 years.

METHODS

Retrospective analysis of a single-surgeon prospective database. Laparoscopic non-mesh repairs for giant PEH between 1991 and 2021 included. Three-hundred-sixty-degree fundoplication was performed routinely, evolving into "composite repair" (esophagopexy and cardiopexy to the right crus). Cases were chronologically divided into tertiles based on operation date (Group 1, 1991-2002; Group 2, 2003-2012; Group 3, 2012-2021) with trends in casemix, operative factors and outcomes evaluated. Hernia recurrence was plotted using weighted moving average and cumulative sum (CUSUM) analysis.

RESULTS

862 giant PEH repairs met selection criteria. There was an increasing proportion of "composite repair" after the first decade (Group 1, 2.7%; Group 2, 81.9%; Group 3, 100%; p < 0.001). There were less anatomical hernia recurrence (Group 1, 36.6%; Group 2, 22.9%; Group 3, 22.7%; p < 0.001) and symptomatic recurrence (Group 1, 34.2%; Group 2, 21.9%; Group 3, 7%; p < 0.001) over time. The incidence of anatomical recurrence declined over time, decreasing from 30.8% and plateauing below 17.6% near the study's end. Median followup (months) in the first decade was higher but followup between the latter two decades comparable (Group 1, 49 [IQR 20, 81]; Group 2, 30 [IQR 15, 65]; Group 3, 24 [14, 56]; p < 0.001). There were 10 (1.2%) Clavien-Dindo grade ≥ III complications including two perioperative deaths (0.2%).

CONCLUSION

Hernia recurrence rates decreased with increasing case volume. This coincided with the increasing adoption of "composite repair", supporting the possible improvement in recurrence rates with this approach.

A Rare Case of Paraesophageal Hernia Repair Complicated by Pancreatic Injury

Esophageal hernias are anatomical defect that affects up to 50% of the population. While they may be asymptomatic, hernias may also result in reflux and dysphagia, among other symptoms. In such cases, hernia repair is warranted. The most common type of repair is laparoscopic Nissen fundoplication, which is usually well-tolerated. Herein, we present a rare case of paraesophageal hernia repair complicated by pancreatic injury and pancreatic leak.

A Narrative Review on Treatment of Giant Hiatal Hernia

Background: The current gold standard of treatment for giant hiatal hernias (GHHs) is laparoscopic surgery. Laparoscopic surgery was performed as a less invasive procedure for paraesophageal hernias more than 25 years ago. Its viability and safety have almost all been shown. Materials and Methods: A review of recent and current studies' literature was done. Prospective randomized trials, systematic reviews, clinical reviews, and original articles were all investigated. The data were gathered in the form of a narrative evaluation. We examine the state of laparoscopic GHH repair today and outline the GHH management strategy. Results: In this review, we clear up misunderstandings of GHH and address bad habits that may have contributed to poor results, and we have consequently performed a methodical evaluation of GHH. First, we address subcategorizing GHH and provide criteria to define them. The preoperative workup strategies are then discussed, with a focus on any pertinent and frequent atypical symptoms, indications for surgery, timing of surgery, and the importance of surgery. The approach to the techniques and the logic behind surgery are then presented along with some important dissection techniques. Finally, we debate the role of mesh reinforcement and evaluate the data in terms of recurrence, reoperation rate, complications, and delayed stomach emptying. Finally, we suggest a justification for common postoperative investigations. Conclusions: Surgery is the only effective treatment for GHH at the moment. If the right operational therapy principles are applied, this is generally successful. There is a growing interest in laparoscopic paraesophageal hiatal hernia repair as a result of the introduction of laparoscopic antireflux surgery. Today's less invasive procedures provide a better therapeutic choice with a lower risk.

Hiatal hernia repair with transoral incisionless fundoplication versus Nissen fundoplication for gastroesophageal reflux disease: A retrospective study

Background and study aims  Concomitant hiatal hernia (HH) repair with transoral incisionless fundoplication (TIF) is a therapeutic option for patients with HH > 2 cm and gastroesophageal reflux disease (GERD). Data comparing this approach with laparoscopic Nissen fundoplication (LNF) are lacking. We performed an exploratory analysis to compare these two approaches' adverse events (AEs) and clinical outcomes. Patients and methods  This was a multicenter retrospective cohort study of HH repair followed by LNF versus HH repair followed by TIF in patients with GERD and moderate HH (2-5 cm). AEs were assessed using the Clavien-Dindo classification. Symptoms (heartburn/regurgitation, bloating, and dysphagia) were compared at 6 and 12 months. Results  A total of 125 patients with HH repair with TIF and 70 with HH repair with LNF were compared. There was no difference in rates of discontinuing or decreasing proton pump inhibitor use, dysphagia, esophagitis, disrupted wrap, and HH recurrence between the two groups ( P  > 0.05). The length of hospital stay (1 day vs. 2 days), 30-day readmission rate (0 vs. 4.3 %), early AE rate (0 vs. 18.6 %), and early serious AE rate (0 vs. 4.3 %) favored TIF (all P  < 0.05). The rate of new or worse than baseline bloating was lower in the TIF group at 6 months (13.8 % vs. 30.0 %, P  = 0.009). Conclusions  Concomitant HH repair with TIF is feasible and associated with lower early and serious AEs compared to LNF. Further comparative efficacy studies are warranted.

Tension-free hiatal hernia repair with biological mesh: A real-world experience

Laparoscopic Nissen fundoplication and esophagoplasty are the standards for gastroesophageal reflux disease (GERD) and hiatal hernia (HH) repair. Biologically derived mesh is also associated with reduced recurrence. This study attempted to evaluate the effectiveness of a biological mesh in the 4K laparoscopic repair of HH. This retrospective study reviewed patients with a severe GERD complicated with HH from August 2019 to August 2020. All patients underwent the HH repair using a biological mesh under a 4K laparoscope accompanying Nissen fundoplication. Up to 16 months postoperatively, GERD-health-related quality-of-life (GERD-HRQL) scale, radiologic studies on HH recurrence, and symptoms were recorded. The mean surgical time and postoperative hospital stay were 70.9 ± 8.72 min, 4.8 ± 0.76 days, respectively. The postoperative symptom relief rate was 96.5%, and no recurrence exhibited during follow-up. Dysphagia occurred in 10 (9.43%) patients. There were no intraoperative vagus nerve injury or postoperative complications, mesh infection, and reoperation for mesh. The tension-free repair of HH with the biological mesh is an option for clinical use, with effectiveness and few short-term complications being reported.

Routine Intraoperative Use of Esophageal Bougie in Minimally Invasive Hiatal Hernia Repair is Not Necessary

Background

Laparoscopic hiatal hernia repair can be performed with an antireflux procedure. Routine use of an esophageal bougie has been advocated to avoid an excessively tight fundoplication. The use of an esophageal bougie carries a risk of iatrogenic complications, such as perforation or laceration of the viscera. However, there is equivocal evidence for the routine use in the surgical literature.

Methods

We present a retrospective analysis of patients with Types 3 and 4 paraesophageal hiatal hernias who underwent laparoscopic hiatal hernia repair with fundoplication without the use of an esophageal bougie, between December 1, 2010 and February 28, 2020, by a single surgeon at a community-based, academic hospital. Patients with a diagnosis of achalasia and gastroesophageal dysmotility were excluded. Perioperative outcome measures included: recurrence; prolonged postoperative proton pump inhibitor use; dysphagia; re-operation, and mortality.

Results

A total of 174 patients (34 males, 140 females) underwent laparoscopic hiatal hernia repair with fundoplication. The average age was 63-years old. Four patients (2.3%) developed dysphagia with narrowing of the gastroesophageal junction, with one patient (0.6%) requiring postoperative esophageal dilation with bougie and eventual re-operation. Postoperative proton pump inhibitor use was 31.0% after 1 month. Overall hernia recurrence rate was 14.9% and the rate of re-operation was 6.3%. Overall mortality was 0.6%.

Conclusion

We conclude that laparoscopic hiatal hernia repair with fundoplication without an esophageal bougie is safe, effective, and efficient. Furthermore, bougie related risks are obviated with a comparable reported incidence of postoperative dysphagia and hiatal hernia recurrence.

Laparoscopic repair of giant hiatal hernia for elderly patients

Background

Giant hiatal hernias are more common in older patients and can significantly reduce their quality of life. However, open surgery for patients of advanced age is thought to be associated with high morbidity and mortality. The aim of this retrospective study was to evaluate the safety of laparoscopic giant hiatal hernia repair for elderly patients as compared to younger patients.

Methods

From January 2015 to January 2020, 152 consecutive patients underwent laparoscopic mesh repair of giant hiatal hernia. Two cases of missing follow up were excluded. Patients were divided into an elderly group (N=62, age ≥75) and a younger group (N=88, age <75). Interrupted non-absorbable suture was applied for crus closure and as an additional reinforcement, the mesh was fixed with absorbable tacks or medical glue. Procedure-related complications, score-based variation tendency of symptoms, gastrointestinal quality of life index (GIQLI), mortality, recurrence rate, hemoglobin, and the use of PPI were investigated.

Results

All patients underwent the procedure uneventfully. Dor fundoplication was used in 39 patients (62.9%) in the elderly group and 44 (50.0%) in the younger group and no case was converted to open. While the elderly group had a significantly higher percentage of ASA Class level 3 and cardiovascular and cerebrovascular diseases as compared to the younger group, the two groups had similar operative times, intraoperative blood loss, and percentage of intrathoracic stomach. Elderly group patients tended to have higher perioperative complications including pneumonia (3.2%) and atelectasis (3.2%) without statistical significance, as well as transfer to the intensive care unit compared, to younger patients (9.7% vs. 3.2%; P=0.144). The mean post-operative hospital stay was also significantly shorter in the younger group (2.8 days) compared with the elderly group (3.5 days; P=0.001). There was no mortality, recurrence, mesh-related complications such as visceral erosion, adhesion, or severe dysphagia during follow up in the two groups, and both groups demonstrated significant improvement in GIQLI scores and hemoglobin. The percentage of patients who needed PPI was also reduced in both groups.

Conclusions

Laparoscopic mesh repair of giant hiatal hernia for elderly patients is safe and effective when performed at experienced centers.

Clinical efficacy and safety of magnetic sphincter augmentation (MSA) and transoral incisionless fundoplication (TIF2) in refractory gastroesophageal reflux disease (GERD): a systematic review and meta-analysis

Background and study aims Proton pump inhibitors (PPI) are effective medical therapy options for gastro-esophageal reflux disease (GERD). However, 20 % to 40 % of patients report symptoms despite taking daily PPI. Transoral incisionless fundoplication (TIF2) and magnetic sphincter augmentation (MSA) are less invasive options for the treatment of refractory GERD and are increasingly gaining popularity.

Methods We conducted a comprehensive search of several databases to identify relevant studies. Our primary aim was to compare the efficacy of both interventions reported as improvement in Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) score, overall patient satisfaction, improvement in post-procedure regurgitation, and fraction of patients completely off PPI therapy at follow up.

Results Twenty-four studies with 1942 patients were included in the final analysis. Both MSA and TIF2 had comparable technical success and clinical success based on improvement in GERD-HRQL scores i. e. 98.8 % (CI 95.6,99.7) vs 98.5 % (CI 95.7,99.5) and 80.4 % (CI 66,89.6) vs 77.7 % (CI 64.1,87.2), respectively. A significantly greater proportion of patients reported improvement in regurgitation, i. e. 91.1 % (CI 83.8,95.3) vs 73.1 % (CI 62.5,81.7) and were able to completely discontinue PPI therapy with MSA compared to TIF2 i. e. 91.3 % (CI 81.5,96.2) vs 63.8 % (CI 51.6,74.4). Patients’ BMI and presence of a hiatal hernia did not have any effect on procedural outcomes.

Conclusion Both procedures performed at par when comparing clinical success in terms of improvement in GERD-HRQL scores. In terms of overall patient satisfaction, post procedure regurgitation and cumulative number of patients off PPI therapy, MSA outperforms TIF2.

Laparoscopic fixation of biological mesh at hiatus with glue and suture during hiatal hernia repair

BACKGROUND

Laparoscopic paraesophageal hernia repair is associated with higher recurrence rate. Mesh is used to reduce the recurrence rate. This retrospective study is to review our experience of biological mesh fixed with suture and medical glue in hiatal hernias repairs.

METHODS

A retrospective chart review was conducted for a consecutive series of patients undergoing laparoscopic hiatal herniorrhaphy between January 2018 and January 2019. After hiatus closure, a piece of biological prosthesis was fixed with medical glue and suture for reinforcement of the crural closure. Clinical outcomes were reviewed, and data were collected regarding operative details, complications, symptoms, and follow-up imaging. Radiological evidence of any size of hiatal hernia was considered to indicate a recurrence.

RESULTS

Thirty-six patients underwent surgery uneventfully without any serious complication. There was no mortality. The follow-up was, on average, 18.4 months, and there was no symptomatic recurrence. There was one anatomical recurrence without any related presentation. The method of mesh fixation with medical glue and suture took 12 min on average, and the handling was fairly easy.

CONCLUSIONS

Biological mesh fixed with suture and medical glue was safe and effective for repairing large hiatal hernias. Of course, a longer follow-up is still needed for determining long-term outcomes.

Small hiatal hernia and postprandial reflux after vertical sleeve gastrectomy: A multiethnic Asian cohort

Background

Laparoscopic vertical sleeve gastrectomy (LSG) is a popular bariatric procedure performed in Asia, as obesity continues to be on the rise in our population. A major problem faced is the development of de novo gastroesophageal reflux disease (GERD) after LSG, which can be chronic and debilitating. In this study, we aim to assess the relationship between the presence of small hiatal hernia (HH) and the development of postoperative GERD, as well as to explore the correlation between GERD symptoms after LSG and timing of meals. In doing so, we hope to gain a better understanding about the type of reflux that occurs after LSG and take a step closer towards effectively managing this difficult to treat condition.

Methods

We retrospectively reviewed data collected from patients who underwent LSG in our hospital from Dec 2008 to Dec 2016. All patients underwent preoperative upper GI endoscopy, during which the identification of hiatal hernia takes place. Patients' information and reflux symptoms are recorded using standardized questionnaires, which are administered preoperatively, and again during postoperative follow up visits.

Results

Of the 255 patients, 125 patients (74%) developed de novo GERD within 6 months post-sleeve gastrectomy. The rate of de novo GERD was 57.1% in the group with HH, and 76.4% in the group without HH. Adjusted analysis showed no significant association between HH and GERD (RR = 0.682; 95% CI 0.419 to 1.111; P = 0.125). 88% of the patients who developed postoperative GERD reported postprandial symptoms occurring only after meals, and the remaining 12% of patients reported no correlation between the timing of GERD symptoms and meals.

Conclusion

There is no direct correlation between the presence of small hiatal hernia and GERD symptoms after LSG. Hence, the presence of a small sliding hiatal hernia should not be exclusion for sleeve gastrectomy. Electing not to perform concomitant hiatal hernia repair also does not appear to result in higher rates of postoperative or de novo GERD.

Herniorrafia hiatal y fundoplicatura laparoscópica de Toupet en un paciente con esófago corto

El esófago corto es una complicación infrecuente del reflujo gastroesofágico, polémico para algunos autores. Su diagnóstico se hace de manera intraoperatoria, ante la imposibilidad de conservar un esofago intrabdominal mayor a tres centímetros desde el hiato diafragmático. Algunos expertos niegan la existencia de esta entidad, argumentando que se debe a una mala disección del esófago. En este artículo, se presenta el caso de un paciente sometido a herniorrafia hiatal con colocación de malla, con gran dificultad para conservar una adecuada longitud del esófago abdominal, y que no requirió gastroplastia.

Retrospective Review and Prospective Follow-up of 85 Consecutive Patients Treated With a Novel Hepatic-derived Surgical Mesh for Hiatal Hernia Repair: Outcomes, Surgical Complications, and Revisions

This study examined outcomes, surgical complications, and revisions in patients treated with laparoscopic Nissen fundoplication for hiatal hernia and substantial gastroesophageal reflux disease. In total, 85 consecutive patients who underwent hernia repair with MIROMESH Biologic Matrix, a novel hepatic-derived surgical mesh served as subjects. Subjects were contacted by phone, consented, and participated in an Institutional Review Board-approved structured phone interview. Responses were acquired from 73 of the 85 patients. The gastroesophageal reflux disease health-related quality of life showed significant improvement postoperatively. Subjects reported high satisfaction with the procedure. The use of proton pump inhibitors was significantly reduced. Three minor complications were reported; these were quickly resolved without further sequelae. There were no mesh-related complications. No subjects reported further surgery. Placement of the surgical mesh, during surgery, to reinforce the hiatal repair was easy and safe. Excellent outcomes and no revisions a mean of 1.3 years after surgery suggest that a durable repair had been achieved.

Laparoscopic Approach to Paraesophageal Hernia Repair

The introduction of minimally invasive techniques to the field of foregut surgery has revolutionized the surgical approach to giant paraesophageal hernia repair. Laparoscopy has become the standard approach in patients with giant paraesophageal hernia because it has been shown to be safe and is associated with lower morbidity and mortality when compared with various open approaches. Specifically, it has been associated with decreased intraoperative blood loss, decreased complications, and reduced hospital length of stay. This is despite a rise in comorbid conditions associated with this patient population. This article describes our operative approach to laparoscopic giant paraesophageal hernia repair.

Biological Mesh Repair of Paraesophageal Hernia: An Analysis of Our Outcomes

Introduction: Symptomatic paraesophageal hernia (PEH) is an indication for surgical repair. Laparoscopic suture repair has high recurrence rates. Many surgeons prefer mesh repair to reduce PEH recurrence. Several types of mesh, synthetic and biological, are in use. Synthetic mesh has a risk of erosion and stricture, hence we preferred biological mesh repair. Our aim in this study is to assess medium-term outcomes of PEH repair with the use of biological mesh reinforcement over the cruroplasty. We also aimed to correlate clinical recurrences with radiological recurrences. Materials and Methods: This is a retrospective study of 154 consecutive patients from a single centre who underwent a standardized laparoscopic suture repair of the hiatus reinforced with an on-lay patch of Surgisis (porcine small intestine submucosa) and fundoplication. The mean age of the patients was 65 years. All patients were called for regular clinical follow-up and a barium study. Modified GERD-HRQL symptom severity instrument was used to assess postoperative symptoms and satisfaction. Results: The mean follow-up for barium swallow and clinical assessment were 28.42 ± 21.2 and 33.69 ± 23.46 months. The mean patient satisfaction score after surgery was 4.43 ± 1.09 (0-5). Follow-up barium swallow was performed in 122 (79.22%), 87 (56.49%) patients completed clinical follow-up questionnaire, and 77 (50%) had both. Symptomatic recurrence was noted in 25 (28.73%), recurrence on barium swallow 25(20.4%), and 10 (12.98%) had both. The reoperation rate was 3.25%. Mann-Whitney U test showed no statistical significance in reflux-related score between radiological recurrence group compared with no radiological recurrence (P = .06). Conclusions: Biological mesh repair of PEH is safe and well accepted by patients. There is significantly high PEH recurrence rate in long-term follow-up, even with mesh repair. Majority of these recurrences are small, asymptomatic, and the reoperation rate is very low.

Endoscopic GERD therapy: a primer for the transoral incisionless fundoplication procedure

Patients with medically refractory GERD have the option of surgery but may opt for effective minimally invasive interventions, when available. However, the primary GERD pharmacologic therapy, proton pump inhibitors, does not satisfactorily address the pathophysiology of the disease. Moreover, a therapeutic gap exists in those severely symptomatic patients who fail medical management and who are poor candidates for surgical fundoplication. Recently, a revival of minimally invasive endoscopic interventions aiming to correct the antireflux barrier has followed existing device modifications, enhancing their safety and efficacy profile. Of these technologies, the trans-oral incisionless fundoplication (TIF) technique, in its current 2.0 iteration, has been studied in several randomized controlled trials with favorable outcomes and a low rate of adverse events. In this review, we discuss the landscape of endoscopic GERD therapy, focusing on recent updates in the TIF 2.0 procedure with the EsophyX-Z device (EndoGastricSolutions, Redmond, Wash, USA). We discuss the evolution, differences, and improvements in this technique across different generations of the EsophyX device. We also present a framework for candidate selection, based on medical and anatomic considerations. When streamlined within a milieu of comprehensive multidisciplinary programs, these improved endoscopic interventions can provide viable avenues for a carefully selected patients population, bridging therapy gaps, and selectively targeting the primary pathophysiology of the disease.

Predictors of Hiatal Hernia Recurrence After Laparoscopic Anti-reflux Surgery with Hiatal Hernia Repair: a Prospective Database Analysis

BACKGROUND

The aim of this study is to identify factors that can predict hiatal hernia recurrence (HHR) in patients after anti-reflux surgery with hiatal hernia (HH) repair.

METHODS

A single-institution, prospectively collected database was reviewed (January 2002-October 2015) with inclusion criteria of GERD and laparoscopic anti-reflux (AR) surgery with HH repair. Demographics, esophageal symptom scores, and pre- and post-upper gastrointestinal imaging (UGI) were collected. Mesh usage, HH type (sliding, paraesophageal (HH) or type IV), and size were evaluated, and patients who had HHR versus those who did not (NHHR) were compared. Statistical analysis was performed using IBM SPSS v.23.0.0, with α = 0.05.

RESULTS

Three hundred twenty-two patients met inclusion criteria. Mean age was 56.9 ± 14.8 years (60.9% female), and mean follow-up was 19.9 ± 23.8 months. 88.2% underwent total fundoplication and 11.8% underwent partial fundoplication. HHR rate was 15.5%. HHR patients had larger HH than the NHHR group. There was no significant difference between groups for age, gender, BMI, race, and mesh usage. Only 3 patients (10.3%) with HHR reported mild-to-moderate heartburn, regurgitation, and solid or liquid dysphagia at 12-month follow-up. Overall reoperation rate was 1% in this population.

CONCLUSIONS

HHR is correlated with large hernia size. Mesh use and patient BMI were not predictors, and no correlation was identified between HHR and presence of GERD symptoms. Recurrence after repair is not uncommon, but is asymptomatic in most cases. Reoperation is rare and mesh is not routinely needed. Large asymptomatic HHs in the elderly often do not require intervention.

Evaluating the feasibility of phrenoesophagopexy during hiatal hernia repair in sleeve gastrectomy patients

BACKGROUND

Both hiatal hernias (HH) and morbid obesity significantly contribute to gastroesophageal reflux disease, which increases the risk for esophagitis and esophageal cancer. Therefore, concomitant HH repair is recommended during bariatric surgery procedures. Unfortunately, recurrence of HH after repair is not uncommon and the optimal surgical technique has yet to be established.

OBJECTIVE

To evaluate the feasibility of recreating the phrenoesophageal ligaments by adding phrenoesophagopexy to HH repair during sleeve gastrectomy.

SETTING

Independent, university-affiliated teaching hospital.

METHODS

Retrospective chart review of all patients with a body mass index ≥35 kg/m² who underwent a combined sleeve gastrectomy and HH repair between January 2010 and December 2014 by a single surgeon at a single institution. Demographic data and 30-day postoperative complications rates were obtained.

RESULTS

There were 106 patients evaluated. Mean age was 50.8 ± 12.5 years, mean body mass index was 45.8 ± 7.1 kg/m², and 87% were female. Mean operative time was 112 ± 24.5 minutes, and mean length of stay was 1.9 ± .7 days. The 30-day complication rate was .94% (1 gastric sleeve leak) and there were no deaths. Six patients (5.7%) required emergency department evaluation, and 5 (4.7%) required readmission for abdominal pain (2), dysphagia/dehydration (1), esophagitis (1), or gastric sleeve leak (1), which required reoperation.

CONCLUSION

The addition of an interrupted phrenoesophagopexy for HH repair during sleeve gastrectomy appears to be a feasible technique with low 30-day morbidity and mortality rates. Long-term follow-up is needed to evaluate the efficacy in reducing HH recurrence rates.

Routine use of mesh during hiatal closure is safe with no increase in adverse sequelae

BACKGROUND

Primary laparoscopic hiatal repair with fundoplication is associated with a high recurrence rate. We wanted to evaluate the potential risks posed by routine use of onlay-mesh during hiatal closure, when compared to primary repair.

METHODS

Utilizing single-institutional database, we identified patients who underwent primary laparoscopic hiatal repair from January 2005 through December 2014. Retrospective chart review was performed to determine perioperative morbidity and mortality. Long-term results were assessed by sending out a questionnaire. Results were tabulated and patients were divided into 2 groups: fundoplication with hiatal closure + absorbable or non-absorbable mesh and fundoplication with hiatal closure alone.

RESULTS

A total of 505 patients underwent primary laparoscopic fundoplication. Mesh reinforcement was used in 270 patients (53.5%). There was no significant difference in the 30-day perioperative outcomes between the 2 groups. No clinically apparent erosions were noted and no mesh required removal. Standard questionnaire was sent to 475 patients; 174 (36.6%) patients responded with a median follow-up of 4.29 years. Once again, no difference was noted between the 2 groups in terms of dysphagia, heartburn, long-term antacid use, or patient satisfaction. Of these, 15 patients (16.9%, 15/89) in the 'Mesh' cohort had symptomatic recurrence as compared to 19 patients (22.4%, 19/85) in the 'No Mesh' cohort (p = 0.362). A reoperation was necessary in 6 patients (6.7%) in the 'Mesh' cohort as compared to 3 patients (3.5%) in the 'No Mesh' cohort (p = 0.543).

CONCLUSIONS

Onlay-mesh use in laparoscopic hiatal repair with fundoplication is safe and has similar short and long-term results as primary repair.