Preoperative predictability of the short esophagus: endoscopic criteria

Manometric Esophageal Length to Height (MELH) Ratio Predicts Hiatal Hernia Recurrence

INTRODUCTION

The shortened esophagus is poorly defined and is determined intraoperatively, as there exists no objective test to identify a shortened esophagus before surgical hiatal hernia repair. We devised a unique manometric esophageal length to height (MELH) ratio to define the presence of a shortened esophagus and examined the role of esophageal length in hiatal hernia recurrence.

PATIENTS AND METHODS

A retrospective review identified 254 patients with hiatal hernia who underwent preoperative esophageal manometry and either an open hernia repair with Collis gastroplasty and fundoplication (with Collis) or laparoscopic repair and fundoplication without Collis gastroplasty (without Collis) from 2005-2016. The MELH ratio was calculated by measuring the upper to lower esophageal sphincter distance divided by the patient's height.

RESULTS

Of 245 patients, 157 underwent repair with Collis, while 97 underwent repair without Collis. The Collis group had a shorter manometric esophageal length (20.2 vs. 22.4 cm, P<0.001) and lower MELH (0.12 vs. 0.13, P<0.001). The Collis group had fewer hernia recurrences (18% vs. 55%, log-rank P<0.001) and fewer reoperations for recurrence (0% vs. 10%, log-rank P<0.001) at 5 years. A 33% decrease in risk of hernia recurrence was seen for every 0.01 U increment in MELH ratio (hazard ratio: 0.67; 95% confidence interval: 0.55-0.83, P<0.001) while repair without Collis (hazard ratio: 6.1; 95% confidence interval: 3.2-11.7, P<0.001) was associated with increased risk of hernia recurrence.

CONCLUSION

MELH ratio is an objective predictor of a shortened esophagus preoperatively. Lower MELH is associated with increased risk of recurrence and the risk associated with shortened esophagus can be mitigated with an esophageal lengthening procedure such as Collis gastroplasty.

Esophageal Mobilization in the Treatment of Short Esophagus

Short esophagus is well known complication of a long term gastroesophageal disease. There are several ways to solve this problem intraoperatively. One of the first steps is extensive esophageal mobilisation. In this review we emphasize different approaches and types of this procedure, with their advantages and disadvantages.

[Report of 12 years experience in the surgical treatment of 286 paraesophageal hernias]

BACKGROUND

In contrast to axial hiatus hernias, paraesophageal hernias are rare but can lead to chronic iron deficiency anemia and severe acute complications. Treatment is manifold and consistent standards are lacking.

OBJECTIVES

The aim of this study was to describe our experiences of 286 patients with paraesophageal hernias, who underwent surgery from 2003 to 2014 at a tertiary referral center. The study was particularly concerned with morbidity, mortality, quality of life and recurrence rates.

MATERIAL AND METHODS

In 12 years a total of 286 paraesophageal hernias were surgically treated, 255 with a minimally invasive procedure and 31 with an open approach. In 138 patients (48 %) the suture-based hiatoplasty was reinforced by means of a lightweight mesh, which was fixed with fibrin glue in 90 cases. Abdominal fixation of the stomach consisted of a gastropexy and anterior (n = 244) or posterior (n = 42) fundoplication.

RESULTS

Complications arose in 8.4 % of the patients. The mean hospital stay was 5.3 (± 2.8) days for elective surgery and 24.7 (± 17.8) days for emergency operations. The gastrointestinal quality of life index according to Eypasch significantly increased from mean preoperative values of 92.8 (± 22.5) to 109.6 (± 20.2) in the postoperative course (p < 0.001). Of the patients 20 (7 %) suffered a recurrence requiring surgery, including 7 early and 13 late recurrences. During the immediate postoperative period radiographically detected recurrences were promptly revised. The strategy of late recurrences in the long-term course was based on patient symptoms and asymptomatic hernias were treated conservatively while symptomatic hernias were surgically treated. Symptomatic late recurrences developed in 4.6 % of the patients, including 7.4 % (11 out of 148) without and 1.4 % (2 out of 138) with primary mesh repair.

CONCLUSION

The repair of paraesophageal hernias in 286 patients provided excellent patient satisfaction and symptom improvement with low perioperative morbidity and mortality. Mesh reinforcement reduced the recurrence rate. The quality of life index is a suitable clinical course parameter for evaluation of paraesophageal hernias.

Hiatal hernia repair with or without esophageal lengthening: is there a difference?

OBJECTIVE

The need for esophageal lengthening (EL) as part of hiatal hernia (HH) repair is perceived to elevate perioperative risk and provide functionally inferior outcomes. Our objectives were to determine the risk factors of undergoing EL and to compare outcomes between operations with and without EL. We hypothesized that operative and functional outcomes for HH repair were similar in patients whether they required EL or not.

METHODS

We reviewed institutional experience with EL as part of HH repair. The patients underwent symptom evaluation before and after surgery using a validated tool.

RESULTS

Between 1999 and 2009, a total of 375 patients underwent HH repair. The operative approach was thoracotomy, 153 (41%); laparotomy, 18 (5%); laparoscopy, 167 (44%); or combined, 37 (10%). Of these, 168 (45%) required EL. There was a higher need for thoracotomy in the patients undergoing EL (79/168 vs 74/207, χ = 4.88, P = 0.034). The incidence of perioperative complications (leak, pneumonia, ileus, respiratory failure, and bleeding) was similar between the groups. Sixty-five selected patients undergoing EL were compared with 63 patients with comparable demographics not requiring EL. In a well-validated questionnaire that assessed symptoms before and after surgery, the patients undergoing EL showed significant improvement in their heartburn (76.8%), dysphagia (67.6%), regurgitation (71.7%), chest pain (91.9%), and nausea (86.5%) (P < 0.05). The patients not undergoing EL also showed significant improvement in their heartburn (81.1%), dysphagia (71.1%), regurgitation (64.4%), chest pain (64.1%), and nausea (61.0%) (P < 0.05). Improvement in symptoms, the continued use of antacid medications, and overall surgery satisfaction score were statistically similar between the two groups.

CONCLUSIONS

Operative and functional outcomes for HH repair with or without EL are acceptable and comparable. Thoracic surgeons should use EL without reservations for appropriate indications.

A novel laparoscopic approach for severe esophageal stenosis due to reflux esophagitis: how to do it

We herein report our technique for laparoscopic esophageal myotomy combined with Collis gastroplasty and Nissen fundoplication for severe esophageal stenosis. Our patient had experienced vomiting since childhood, and his dysphagia had gradually worsened. He was referred to our department for surgery because of resistance to pneumatic dilation. He was diagnosed with a short esophagus based on the findings of a preoperative upper gastrointestinal series and GI endoscopy. After exposing the abdominal esophagus, esophageal myotomy around the esophago-gastric junction (EGJ) was undertaken to introduce an esophageal bougie into the stomach. Then, stapled wedge gastroplasty was performed, and a short and loose Nissen fundoplication was performed. In addition, the bulging mucosa after myotomy was patched using the Dor method. The patient's postoperative course was uneventful. Most patients with esophageal stricture require subtotal esophagectomy. Laparoscopic surgery for patients with benign esophageal stricture refractory to repeated pneumatic dilation is challenging. However, our current procedure might abrogate the need for invasive esophagectomy for the surgical management of severe esophageal stenosis.