Stapled-wedge Collis gastroplasty for the shortened esophagus

BRAZILIAN HERNIA AND ABDOMINAL WALL SOCIETY STATEMENT ON LARGE HIATAL HERNIAS MANAGEMENT

Large hiatal hernias, besides being more prevalent in the elderly, have a different clinical presentation: less reflux, more mechanical symptoms, and a greater possibility of acute, life-threatening complications such as gastric volvulus, ischemia, and visceral mediastinal perforation. Thus, surgical indications are distinct from gastroesophageal reflux disease-related sliding hiatal hernias. Heartburn tends to be less intense, while symptoms of chest pain, cough, discomfort, and tiredness are reported more frequently. Complaints of vomiting and dysphagia may suggest the presence of associated gastric volvulus. Signs of iron deficiency and anemia are found. Surgical indication is still controversial and was previously based on high mortality reported in emergency surgeries for gastric volvulus. Postoperative mortality is especially related to three factors: body mass index above 35, age over 70 years, and the presence of comorbidities. Minimally invasive elective surgery should be offered to symptomatic individuals with good or reasonable performance status, regardless of age group. In asymptomatic and oligosymptomatic patients, besides obviously identifying the patient's desire, a case-by-case analysis of surgical risk factors such as age, obesity, and comorbidities should be taken into consideration. Attention should also be paid to situations with greater technical difficulty and risks of acute migration due to increased abdominal pressure (abdominoplasty, manual labor, spastic diseases). Technical alternatives such as partial fundoplication and anterior gastropexy can be considered. We emphasize the importance of performing surgical procedures in cases of large hiatal hernias in high-volume centers, with experienced surgeons.

5-Year Collis-Nissen Gastroplasty Outcomes for Type III-IV Hiatal Hernia with Short Esophagus: A Prospective Observational Study

BACKGROUND

To assess the 5-year outcomes of patients undergoing Collis-Nissen gastroplasty for type III-IV hiatal hernia with short esophagus.

STUDY DESIGN

From a prospective observational cohort of patients who underwent antireflux surgery for type III-IV hiatal hernia between 2009 and 2020, those with short esophagus (abdominal length <2.5 cm) in whom a Collis-Nissen procedure was performed and reached at least 5 years of follow-up were identified. Hernia recurrence, patients' symptoms, and quality of life were assessed annually by barium meal x-ray, upper endoscopy, and validated symptoms and Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaires.

RESULTS

Of the 114 patients with Collis-Nissen gastroplasty, 80 patients who completed a 5-year follow-up were included (mean age 71 years). There were no postoperative leaks or deaths. Recurrent hiatal hernia (any size) was identified in 7 patients (8.8%). Heartburn, regurgitation, chest pain, and cough were significantly improved at each follow-up interval (p < 0.05). Preoperative dysphagia disappeared or improved in 26 of 30 patients, while new-onset dysphagia occurred in 6. Mean postoperative QOLRAD scores significantly improved at all dimensions (p < 0.05).

CONCLUSIONS

Collis gastroplasty combined with Nissen fundoplication provides low hernia recurrence, good control of symptoms, and improved quality of life in patients with large hiatal hernia and short esophagus.

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.

Quality of life and gastric acid-suppression medication post-laparoscopic fundoplication: a ten years retrospective study

Background: Although medical treatment is the best approach for treating gastroesophageal reflux disease (GERD), surgery has a significant role to play not only in cases of failure of medical treatment but also as in a long-term approach, specifically in young patient. On the other hand, alarming reports have been published concerning the outcomes and usefulness of antireflux surgery (ARS). The aim of this study was to evaluate medium and long-term functional outcomes following ARS performed in our institution over a 10 year period.Methods: This was a retrospective review of patients in our department who underwent primary or redo laparoscopic fundoplication between 2005 and 2015. Evaluation of the outcomes was made using a validated questionnaire specifically dedicated to GERD (the Gastroesophageal Reflux Disease - Health-Related Quality of Life (GERD-HRQL) questionnaire) and by investigation about the continued use of proton-pump inhibitors (PPIs). Exclusion criteria were patients treated for GERD with Roux-en-Y gastric bypass, emergency reduction of hiatal hernia, patients missing from follow-up and patients deceased from unrelated causes.Results: 296 patients out of 309 met the inclusion criteria. Primary procedures included 214 Nissen, 35 Toupet, and 23 Collis gastroplasty; there were additionally 62 redo operations. Neither postoperative mortality nor conversion was observed. The mean follow-up was 8 years post-surgery, and contact was made with 96% of the original group. 85% of the patients had stopped PPI use since their operation (86% after Nissen, 73% after Toupet, 94% after Collis and 82% after redos). 90% of the patients had good to excellent functional results as reported by their GERD-HRQL score, and independent of the type of previous procedure. 31 patients were dissatisfied due to dysphagia in 7 and GERD recurrence in 24. Again 75% were extremely satisfied and 15% satisfied. Our own incidence of redo procedures was 11% but the functional result and satisfaction index were comparable between redo and primary procedures. The addition of Collis gastroplasty in cases of real short oesophagus did not alter the final result.Conclusions: Laparoscopic ARS presents a superior alternative to lifetime medication use and can provide long-term control of GERD symptoms in the majority of patients if it is performed skillfully and in carefully evaluated patients. Based on the present study, we believed that significant improvement in GERD health-related quality of life can be attained following both primary and reoperative ARS.

IMPACT OF BODY MASS INDEX ON PERIOPERATIVE OUTCOMES FOR COMPLEX HIATUS HERNIA BY VIDEOLAPAROSCOPY

BACKGROUND:

The influence of body mass index on perioperative complications of hiatal hernia surgery is controversial in the surgical literature.

AIMS:

The aim of this study was to evaluate the influence of body mass index on perioperative complications and associated risk factors for its occurrence.

METHODS:

Two groups were compared on the basis of body mass index: group A with body mass index <32 kg/m² and group B with body mass index ³32 kg/m². A multivariate analysis was carried out to identify independent predictors for complications. Complications were classified based on the Clavien-Dindo score.

RESULTS:

A total of 49 patients were included in this study, with 30 in group A and 19 in group B. The groups were compared based on factors, such as age, Charlson Comorbidity Index, surgical techniques used, type and location of hiatal hernia, and length of stay. Findings showed that 70% of patients had complex hiatal hernia. In addition, 14 complications also occurred: 7 pleuropulmonary and 7 requiring reoperation. From the seven reoperated, there were three recurrences, two gastrointestinal fistulas, one diaphragmatic hernia, and one incisional hernia. Complications were similar in both the groups, with type IV hiatal hernia being the only independent predictor.

CONCLUSIONS:

Body mass index does not affect perioperative complications in anti-reflux surgery and type IV hiatal hernia is an independent predictor of its occurrence.

[Collis gastroplasty in surgical treatment of hiatal hernia]

OBJECTIVE

To analyze the early and long-term postoperative outcomes after Collis gastroplasty in the treatment of patients with hiatal hernia complicated by gastroesophageal reflux disease and shortening of the esophagus.

MATERIAL AND METHODS

Postoperative outcomes after Collis gastroplasty were analyzed in 22 patients with hiatal hernia and shortening of the esophagus. The control group consisted of 166 patients after simple repair of hiatal hernia without Collis procedure.

RESULTS

In case of Collis gastroplasty, surgery time was 185 (160-250) min. Intraoperative complications were observed in 3 (13.6%) patients, incidence of postoperative complications - 18.2%. There were no lethal outcomes in this group of patients. Mild functional dysphagia was observed in 2 (9.1%) patients. Length of hospital stay was 7.8±2.4 days. Mean follow-up was 34 (6-52) months. There were no anatomical recurrences. A relapse of gastroesophageal reflux was noted in 1 (4.6%) case. GERD-HRQL score was 4.8±2.2 points. Additional Collis gastroplasty did not affect the immediate and long-term results of surgical treatment in comparison with simple cruroraphy and fundoplication.

CONCLUSION

Unreduced shortening of the esophagus may be followed by high incidence of recurrent hiatal hernia and GERD in long-term period. In case of shortening of the esophagus, surgery should include Collis gastroplasty. This effective and safe procedure does not impair treatment outcomes. Indications and optimal technique of Collis gastroplasty require clarification and further research.

Comparative Analysis of Patients with Robotic Hiatal Hernia Repairs with and without Collis Gastroplasty

INTRODUCTION

After extensive mediastinal dissection fails to achieve adequate intra-abdominal esophageal length, a Collis gastroplasty(CG) is recommended to decrease axial tension and reduce hiatal hernia recurrence. However, concerns exist about staple line leak, and long-term symptoms of heartburn and dysphagia due to the acid-producing neoesophagus which lacks peristaltic activity. This study aimed to assess long-term satisfaction and GERD-related quality of life after robotic fundoplication with CG (wedge fundectomy technique) and to compare outcomes to patients who underwent fundoplication without CG. Outcomes studied included patient satisfaction, resumption of proton pump inhibitors (PPI), length of surgery (LOS), hospital stay, and reintervention.

METHODS

This was a single-center retrospective analysis of patients from January 2017 through December 2018 undergoing elective robotic hiatal hernia repair and fundoplication. 61 patients were contacted for follow-up, of which 20 responded. Of those 20 patients, 7 had a CG performed during surgery while 13 did not. There was no significant difference in size and type of hiatal hernias in the 2 groups. These patients agreed to give their feedback via a GERD health-related quality of life (GERD HRQL) questionnaire. Their medical records were reviewed for LOS, length of hospital stay (LOH), and reintervention needed. Statistical analysis was performed using SPSS v 25. Satisfaction and need for PPIs were compared between the treatment and control groups using the chi-square test of independence.

RESULTS

Statistical analysis showed that satisfaction with outcome and PPI resumption was not significantly different between both groups (P > .05). There was a significant difference in the average ranks between the 2 groups for the question on postoperative dysphagia on the follow-up GERD HRQL questionnaire, with the group with CG reporting no dysphagia. There were no significant differences in the average ranks between the 2 groups for the remaining 15 questions (P > .05). The median LOS was longer in patients who had a CG compared to patients who did not (250 vs. 148 min) (P = .01). The LOH stay was not significantly different (P > .05) with a median length of stay of 2 days observed in both groups. There were no leaks in the Collis group and no reoperations, conversions, or blood transfusions needed in either group.

CONCLUSION

Collis gastroplasty is a safe option to utilize for short esophagus noted despite extensive mediastinal mobilization and does not adversely affect the LOH stay, need for reoperation, or patient long-term satisfaction.

How high is too high? Extensive mediastinal dissection in patients with hiatal hernia repair

BACKGROUND

Approximately 10% of patients receiving anti-reflux procedures present with shortened esophagus. Collis gastroplasty (CG) is the current gold standard for esophageal lengthening, but mediastinal esophageal mobilization without gastroplasty may be an alternative approach. This study assesses preoperative and intraoperative hernia characteristics and mediastinal dissection impact in patients with large hiatal hernia repair (HHR).

METHODS

A single-institution, prospectively collected database was reviewed for adults who underwent laparoscopic HHR with mesh and anti-reflux surgery between 2005 and 2016, hernia ≥ 5 cm. Preoperative hernia and follow-up were assessed using upper endoscopy and barium swallow. Intraoperative hernia characteristics were collected from the operative note. Esophageal symptom scores were collected pre- and postoperatively. Analyses were conducted using SPSS v26.0.

RESULTS

Among 662 patients who had anti-reflux surgery in this period, a total of 205 patients who underwent HHR with mesh met the inclusion criteria and were included in study. Mean age was 61.7 ± 13.6 years, and majority of patients were female and Caucasian. Mean BMI was 29.9 ± 6.0 kg/m². Median hernia size was 6.5 cm [5.0-12.0 cm], and intra-thoracic stomach had a prevalence of 21.9%. Analysis of preoperative barium swallow revealed an average of elevated gastroesophageal junction above the diaphragm of 4.10 ± 1.67 cm. Radiographically, average hernia size was 6.34 ± 1.93 cm and 6.38 ± 1.92 cm in the anterior-posterior and obliquus view, respectively. Median follow-up time was 2.7 years [1-9 years]. Esophageal symptoms improved in all patients (p < 0.05). 45% of patients had radiographic recurrence, but only four presented symptomatic or were on PPI.

CONCLUSIONS

CG has been the standard for ensuring adequate esophageal length prior to anti-reflux surgery. Our results support that CG is unnecessary in the majority of cases, and extensive mediastinal dissection was successfully used instead of CG with durable, long-term outcomes. Extended mediastinal dissection may mitigate CG risks in patients requiring additional intra-abdominal esophagus.

Robotic approach for Collis gastroplasty

The true short esophagus is an entity of controversy among surgeons. Studies have been published about its diagnosis and laparoscopic treatment, without existing to date, publication of the treatment with robotic approach. We present, as a case report, our experience in robotic surgery for hiatal hernia with true short esophagus treated with Collis gastroplasty and Toupet fundoplication. Robotic surgery on the true short esophagus can facilitate mediastinal dissection and allow a more accurate suture technique. Studies are needed to compare the long-term results of this surgical technique between the conventional laparoscopic approach and the robotic approach.

The Collis Procedure and the Acquired Short Esophagus

One of the most intriguing problems in modern esophageal surgery is the acquired short esophagus. While some authors recognize this entity, others deny its existence. There is a consensus about types of the short esophagus, its etiology and pathophysiology. Definitive diagnosis can be established only intraoperatively. There are a few surgical procedures for this problem, and most frequently is used Collis gastroplasty with fundoplication. In this review we emphasize recent literature data and further perspectives of the Collis procedure.

Surgical Anatomy of Paraesophageal Hernias

Paraesophageal hernia represents a complex surgical problem involving significant distortion of the anatomy and function of the esophagus, stomach, gastroesophageal junction, mediastinum, lungs, and heart. Surgeons operating in the area must have deep understanding of the normal anatomy and pathologic derangements in patients with paraesophageal hernias. This article describes the normal anatomy and anatomic abnormalities in application to the various approaches used in the surgical repair of a paraesophageal hernia.

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.

Minimally invasive surgery for large hiatal hernia

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

Strategies for surgical remediation of the multi-fundoplication failure patient

BACKGROUND

Outcomes are not well studied in patients undergoing remediation for multi-fundoplication failure, that is, two or more prior failed fundoplications. Re-operation must balance reflux control and restoration of the ability to eat with the challenge of reconstructing a distorted hiatus and GE junction. The purpose of this study is to present our experience with surgical remediation for multi-fundoplication failure.

METHODS

Medical records were retrospectively reviewed of 91 patients who underwent third time or more esophagogastric operation for fundoplication failure at a single institution from 2007 to 2016. Dysphagia was present in 56% and heartburn in 51%. Median number of prior operations was 2 with range up to 6. Anatomic failure consisted of slipped wrap in 26 cases, wrap herniation in 23, hiatal stenosis in 24, hiatal mesh complication in 8, and wrap dehiscence in 10. Operative approaches generally followed an institutional algorithm and consisted of hiatal hernia repair with: re-do fundoplication in 55%, takedown of fundoplication alone in 24%, Roux-en-Y gastrojejunostomy in 14%, and GE junction resection in 7%. Laparoscopic approach was successful in 81%.

RESULTS

Mean duration of operations was 217 min and median length of stay was 3 days. The complication rate was 13%, with 7% undergoing unplanned early re-operation. Patients were followed for mean 11 months, and recurrent hiatal hernia was detected in 13%. Late re-operation was performed in 6% for recurrent hiatal hernia. Recurrent reflux symptomatology resolved in 93%. Dysphagia resolved in 84%. There were no significant differences in outcomes with regard to number of prior operations, operative approach, BMI, or age.

CONCLUSIONS

There is no single best approach to remediation in the multi-fundoplication failure patient. Re-do fundoplication is appropriate in over half of patients. Reoperation for multi-fundoplication failure can be performed via minimally invasive approach with excellent remediation of symptoms, low morbidity, and low recurrence rates.

A Hill Gastropexy Combined with Nissen Fundoplication Appears Equivalent to a Collis-Nissen in the Management of Short Esophagus

INTRODUCTION

A Collis gastroplasty combined with a Nissen fundoplication is commonly used when a shortened esophagus is encountered. An alternative combines intra-abdominal fixation of the gastroesophageal junction via a Hill gastropexy with a Nissen fundoplication to maintain length and avoid juxtaposing acid-secreting tissue against the diseased esophagus.

METHODS

A retrospective case-controlled analysis of 106 consecutive patients with short esophagus undergoing Hill-Nissen (HN) or Collis-Nissen (CN) was compared to a cohort of 105 matched patients without short esophagus undergoing primary Nissen fundoplication (NF).

RESULTS

At a median follow-up of 27 months, all groups (HN:CN:NF) improved significantly over preoperative baseline with no differences in overall complications (18 vs 16 vs 19%, p = 0.78), DeMeester score (11.1 vs 19.1 vs 14.2, p = 0.49), postoperative PPI use (16 vs 22 vs 15%, p = 0.24), anatomic recurrences (11.7 vs 5.5 vs 7%, p = 0.43), or quality of life (6.8 vs 6.7 vs 6.4, p = 0.3).

CONCLUSIONS

The management of shortened esophagus with Hill-Nissen is safe and as effective as Collis gastroplasty with Nissen fundoplication. Both options appear to produce similar outcomes to patients requiring only a Nissen fundoplication suggesting a shortened esophagus does not beget an inferior outcome.

Laparoscopic repair of giant paraesophageal hernia: are there factors associated with anatomic recurrence?

BACKGROUND

Repair of giant paraesophageal hernia (PEH) is associated with a favorably high rate of symptom improvement; however, rates of recurrence by objective measures remain high. Herein we analyze our experience with laparoscopic giant PEH repair to determine what factors if any can predict anatomic recurrence.

METHODS

We prospectively collected data on PEH characteristics, variations in operative techniques, and surgeon factors for 595 patients undergoing laparoscopic PEH repair from 2008 to 2015. Upper GI study was performed at 6 months postoperatively and selectively thereafter-any supra-diaphragmatic stomach was considered hiatal hernia recurrence. Exclusion criteria included revisional operation (22.4%), size <5 cm (17.6%), inadequate follow-up (17.8%), and confounding concurrent operations (6.9%). Inclusion criteria were met by 202 patients (31% male, median age 71 years, and median BMI 28.7).

RESULTS

At a median follow-up of 6 months (IQR 6-12), overall anatomic recurrence rate was 34.2%. Symptom recurrence rate was 9.9% and revisional operation was required in ten patients (4.9%). Neither patient demographics nor PEH characteristics (size, presence of Cameron erosions, esophagitis, or Barrett's) correlated with anatomic recurrence. Technical factors at operation (mobilized intra-abdominal length of esophagus, Collis gastroplasty, number of anterior/posterior stitches, use of crural buttress, use of pledgeted or mattress sutures, or gastrostomy) were also not correlated with recurrence. Regarding surgeon factors, annual volume of fewer than ten cases per year was associated with increased risk of anatomic failure (54 vs 33%, P = 0.02). Multivariate analysis identified surgeon experience (<10 cases per year) as an independent factor associated with early hiatal hernia recurrence (OR 3.7, 95% CI 1.34-10.9).

CONCLUSIONS

Laparoscopic repair of giant PEH is associated with high anatomic recurrence rate but excellent symptom control. PEH characteristics and technical operative variables do not appear to significantly affect rates of recurrence. In contrast, surgeon volume does appear to contribute significantly to durability of repair.

Paraesophageal Hernia Repair: Techniques for Success

With the introduction of laparoscopy, the outcomes of patients undergoing paraesophageal hernia repair have improved dramatically. When the fundamentals of a proper repair are followed, patients can expect to have improvement in gastroesophageal reflux symptoms, including heartburn, regurgitation, chest pain, dysphagia, and dyspnea. Adhering to these principles will alleviate patients' symptoms and avoid reoperation. This article describes the approach to paraesophageal hernia repair, including patient evaluation, operative technique, and postoperative management. Esophageal lengthening and crural reinforcement with mesh are addressed as well. Adhering to the basic techniques outlined in this article should lead to successful and durable patient outcomes following a paraesophageal hernia repair.

Collis-Nissen gastroplasty for short oesophagus

The Collis-Nissen procedure is performed for the surgical treatment of 'true short oesophagus'. When this condition is strongly suspected radiologically, the patient is placed in the 45° left lateral position on the operating table with the left chest and arm lifted to perform a thoracostomy in the V-VI space, posterior to the axillary line. The hiatus is opened and the distal oesophagus is widely mobilized. With intraoperative endoscopy, the position of the oesophago-gastric junction in relationship to the hiatus is determined and the measurement of the length of the intra-abdominal oesophagus is performed to decide either to carry out a standard anti-reflux procedure or to lengthen the oesophagus. If the oesophagus is irreversibly short ('true short oesophagus'), the short gastric vessels are divided and the gastric fundus is mobilized. An endostapler is introduced into the left chest. The left thoracoscopic approach is suitable to control effectively the otherwise blind passage of the endostapler into the mediastinum and upper abdomen (if a second optic is not used). The tip of the stapler is clearly visible while 'walking' on the left diaphragm. The Collis gastroplasty is performed over a 46 Maloney bougie. A floppy Nissen fundoplication and the hiatoplasty complete the procedure.

Results of left thoracoscopic Collis gastroplasty with laparoscopic Nissen fundoplication for the surgical treatment of true short oesophagus in gastro-oesophageal reflux disease and Type III-IV hiatal hernia

OBJECTIVES

Controversy exists regarding surgery for true short oesophagus (TSOE). We compared the results of thoracoscopic Collis gastroplasty-laparoscopic Nissen procedure for the treatment of TSOE with the results of standard laparoscopic Nissen fundoplication.

METHODS

Between 1995 and 2013, the Collis-Nissen procedure was performed in 65 patients who underwent minimally invasive surgery when the length of the abdominal oesophagus, measured intraoperatively after maximal oesophageal mediastinal mobilization, was ≤1.5 cm. The results of the Collis-Nissen procedure were frequency-matched according to age, sex and period of surgical treatment with those of 65 standard Nissen fundoplication procedures in patients with a length of the abdominal oesophagus >1.5 cm. Postoperative mortality and morbidity were evaluated according to the Accordion classification. The patients underwent a timed clinical-instrumental follow-up that included symptoms assessment, barium swallow and endoscopy. Symptoms, oesophagitis and global results were graded according to semi-quantitative scales. The results were considered to be excellent in the absence of symptoms and oesophagitis, good if symptoms occurred two to four times a month in the absence of oesophagitis, fair if symptoms occurred two to four times a week in the presence of hyperaemia, oedema and/or microscopic oesophagitis and poor if symptoms occurred on a daily basis in the presence of any grade of endoscopic oesophagitis, hiatal hernia of any size or type, or the need for antireflux medical therapy. The follow-up time was calculated from the time of surgery to the last complete follow-up.

RESULTS

The postoperative mortality rate was 1.5% for the Collis-Nissen and 0 for the Nissen procedure. The postoperative complication rate was 24% for the Collis-Nissen and 7% for Nissen (P = 0.001) procedure. The complication rate for the Collis-Nissen procedure was 43% in the first 32 cases and 6% in the last 33 cases (P < 0.0001). The median follow-up period was 96 months. The results were: excellent in 27% of Collis-Nissen and 29% of Nissen; good in 64% of Collis-Nissen and 55% of Nissen; fair in 3% of Collis-Nissen and 11% of Nissen and poor in 6% of Collis-Nissen and 5% of Nissen (P = 0.87).

CONCLUSIONS

In patients affected by a TSOE, the Collis-Nissen procedure may achieve equally satisfactory results as the standard Nissen procedure in uncomplicated patients.

CLINICAL REGISTRATION NUMBER

NCT02288988.

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.

Impact of crural relaxing incisions, Collis gastroplasty, and non-cross-linked human dermal mesh crural reinforcement on early hiatal hernia recurrence rates

BACKGROUND

Hernia recurrence is the leading form of failure after antireflux surgery and may be secondary to unrecognized tension on the crural repair or from a foreshortened esophagus. Mesh reinforcement has proven beneficial for repair of hernias at other sites, but the use of mesh at the hiatus remains controversial. The aim of this study was to evaluate the outcomes of hiatal hernia repair with human dermal mesh reinforcement of the crural closure in combination with tension reduction techniques when necessary.

STUDY DESIGN

We retrospectively reviewed the records of all patients who had hiatal hernia repair using AlloMax Surgical Graft (Davol), a human dermal biologic mesh. Objective follow-up was with videoesophagram and/or upper endoscopy at 3 months postoperatively and annually.

RESULTS

There were 82 patients with a median age of 63 years. The majority of operations (85%) were laparoscopic primary repairs of a paraesophageal hernia with a fundoplication. The crura were closed primarily in all patients and reinforced with an AlloMax Surgical Graft. A crural relaxing incision was used in 12% and a Collis gastroplasty in 28% of patients. There was no mesh-related morbidity and no mortality. Median objective follow-up was 5 months, but 15 patients had follow-up at 1 or more years. A recurrent hernia was found in 3 patients (4%).

CONCLUSIONS

Tension-reducing techniques in combination with human biologic mesh crural reinforcement provide excellent early results with no mesh-related complications. Long-term follow-up will define the role of these techniques and this biologic mesh for hiatal hernia repair.

Laparoscopic paraesophageal hernia repair: current controversies

The advent of laparoscopy has significantly improved postoperative outcomes in patients undergoing surgical repair of a paraesophageal hernia. Although this minimally invasive approach considerably reduces postoperative pain and recovery times, and may improve physiologic outcomes, laparoscopic paraesophageal hernia repair remains a complex operation requiring advanced laparoscopic skills and experience with the anatomy of the gastroesophageal junction and diaphragmatic hiatus. In this article, we describe our approach to patient selection, preoperative evaluation, operative technique, and postoperative management. Specific attention is paid to performing an adequate hiatal dissection and esophageal mobilization, the decision of whether to use a mesh to reinforce the crural repair, and construction of an adequate antireflux barrier (ie, fundoplication).

Laparoscopic paraesophageal hernia repair: critical steps and adjunct techniques to minimize recurrence

INTRODUCTION

Laparoscopic repair of paraesophageal hernias (PEH) is associated with a high objective hernia recurrence rate. Tension is a key factor in the repair of any hernia, and tension is a cause for hernia recurrence.

METHODS

This is a review of my current technique for PEH repair, and represents the culmination of years of experience and modifications in an effort to minimize objective hernia recurrence rates in my own practice.

RESULTS

There are 4 critical steps that must be part of every PEH repair in my opinion. These are excision of the hernia sac, mediastinal esophageal mobilization, crural repair, and fundoplication. Tension on the repair comes in the form of axial tension related to esophageal shortening and lateral tension related to widely splayed crura. Axial tension is addressed with a Collis gastroplasty, while lateral tension requires a right, left, or bilateral crural relaxing incision. The crura should not be bridged with mesh, rather a relaxing incision allows primary crural approximation even with very splayed crura. The primary crural closure is routinely reinforced with absorbable mesh. Follow-up with upper endoscopy or videoesophagram shows a low recurrence rate using these 4 steps and the adjunct techniques to reduce tension when necessary.

DISCUSSION

Efforts to reduce the objective recurrence rate after laparoscopic PEH repair should focus on minimizing tension with the use of a Collis gastroplasty and crural relaxing incisions when necessary. Similar to hernias at other sites, the use of mesh likely is another adjunct step that will improve outcomes with PEH repair, but to avoid erosion synthetic mesh should be avoided.

Laparoscopic paraesophageal hernia repair

The last 2 decades have witnessed a revolution in the treatment of patients with paraesophageal hernia (PEH). Nowadays, the laparoscopic repair with fundoplication is considered as the primary treatment modality in most academic centers for symptomatic patients. Three findings have clearly emerged: (1) this procedure is technically demanding; (2) it is associated with relief of symptoms in most patients; and (3) most recurrences are small and asymptomatic. This article describes our approach step-by-step to the repair of a paraesophageal hiatal hernia, focusing on several technical controversies.

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.

Twenty years of laparoscopic fundoplication for GERD

The first laparoscopic Nissen fundoplication was performed 20 years ago. Surgical management of gastroesophageal reflux disease (GERD) should be offered only to appropriately studied and selected patients, with the ultimate aim of improving the well-being of the individual, the "quality of life." The choice of fundoplication should be dictated by the surgeon's preference and experience.

Laparoscopic versus open repair of paraesophageal hernia: the second decade

BACKGROUND

A decade ago we reported that laparoscopic repair of paraesophageal hernia (PEH) had an objective recurrence rate of 42% compared with 15% after open repair. Since that report we have modified our laparoscopic technique. The aim of this study was to determine if these modifications have reduced the rate of objective hernia recurrence.

STUDY DESIGN

We retrospectively identified all patients that had primary repair of a PEH with ≥ 50% of the stomach in the chest from May 1998 to January 2010 with objective follow-up by videoesophagram. The finding of any size of hernia was considered to be recurrence.

RESULTS

There were 73 laparoscopic and 73 open PEH repairs that met the study criteria. There were no significant differences in gender, body mass index, or prevalence of a comorbid condition between groups. The median follow-up was similar (12 months laparoscopic versus 16 months open; p = 0.11). In the laparoscopic group, 84% of patients had absorbable mesh reinforcement of the crural closure and 40% had a Collis gastroplasty, compared with 32% and 26%, respectively, in the open group. A recurrent hernia was identified in 27 patients (18%), 9 after laparoscopic repair and 18 after open repair (p = 0.09). The median size of a recurrent hernia was 3 cm, and the incidence of recurrence increased yearly in those with serial follow-up with no early peak or late plateau.

CONCLUSIONS

In our first decade of laparoscopic PEH repair, no mesh crural reinforcement was used, and no patient had a Collis gastroplasty. Evolution in the technique of laparoscopic PEH repair during the subsequent decade has reduced the hernia recurrence rate to that seen with an open approach. Reduced morbidity and shorter hospital stay make laparoscopy the preferred approach, but continued efforts to reduce hernia recurrence are warranted.

Laparoscopic Collis-Nissen for recurrent severe reflux in pediatric patients with esophageal atresia and recurrent hiatal hernia

PURPOSE

Patients following esophageal atresia repair may often have a congenitally short esophagus, leading to severe reflux and failed fundoplications. This report evaluates the efficacy of a laparoscopic Collis-Nissen fundoplication in this group of patients who have failed a previous fundoplication.

METHODS

From January 2005 to February 2010, 6 patients born with esophageal atresia presented with recurrent gastroesophageal reflux disease (GERD) and hiatal hernia (H/H). Patient's ages ranged from 5 to 12 years and weights from 17 to 32 kg. All patients had undergone at least three previous fundoplications and hiatal hernia repair. Four of 5 patients had at least one open laparotomy for their previous repair. Patient 6 had had a previous open Collis gastroplasty. The procedure was performed through five ports and consisted of a takedown of the previous fundoplication, elongation of the esophagus using an endoscopic stapler, closure of the hiatus using Teflon pledgets to buttress the repair, and formation of the fundoplication.

RESULTS

All procedures were completed successfully laparoscopically. Procedure times ranged from 180 to 300 minutes. A nasogastric (NG) tube was left for an average of 3 days in 5 patients. Patient 6 had a delayed perforation on day 3 and required reexploration and an NG tube that was left for 10 days. Five of 6 patients were started on feeds on day 4 and were discharged on day 5. Patient 6 with the perforation was discharged on day 14. At an average follow-up of 42 months, all patients have intact wraps and no recurrence of their hiatal hernia.

CONCLUSIONS

A laparoscopic Collis-Nissen in a child with previous failed fundoplication is a complex, but efficacious, procedure. Elongating the esophagus in patients with esophageal atresia may decrease the high recurrence rate of hiatal hernia in these patients and should be considered if the patient fails their primary repair.

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

INTRODUCTION

Laparoscopic surgery is a viable treatment option for intrathoracic stomach (ITS); however, doubts have been raised regarding its efficacy. Routine use of mesh has been advocated. The aim of this study is to look at long-term objective and symptomatic outcomes after repair of ITS with selective use of mesh and fundoplication.

MATERIALS AND METHODS

A retrospective review of prospectively collected data was performed for patients who underwent surgical treatment of ITS from January 2004 to April 2009. ITS was defined as herniation of greater than 75% of the stomach into the chest on barium swallow. A standardized foregut symptom questionnaire was administered along with contrast study at 1, 3, and 5 years post surgery.

RESULTS

Seventy-three patients with intrathoracic stomach were included in the study. Mean age was 70.6±10.4 (44-88) years, and two-thirds were females. There were 7 transthoracic and 66 transabdominal repairs (64 laparoscopic, 1 open, and 1 laparoscopic to open conversion). There was one intraoperative death, due to bleeding. Antireflux surgery was performed in 43 patients (20 Nissen, 18 Toupet, 1 Dor, and 4 Roux-en-Y gastric bypass (RNYGB)). Ten patients had Collis gastroplasty for short esophagus. Mesh was used in ten (13.7%) patients for crus reinforcement. Objective follow-up was available for 88%, 78%, and 92% patients at 1, 3, and 5 years, respectively. There were 5% (3/61), 11% (4/36), and 17% (2/12) radiological failures at these intervals. There was no significant difference in mean symptom and satisfaction scores or use of proton pump inhibitor (PPI) between patients with and without antireflux surgery. Mean satisfaction scores were 9.1, 9.0, and 9.0 at 1, 3, and 5 years, respectively.

CONCLUSION

Laparoscopic repair of ITS with selective use of mesh and fundoplication is feasible, safe, and durable, resulting in a high degree of patient satisfaction.

Laparoscopic paraesophageal hernia repair. How I do it

INTRODUCTION

The approach to paraesophageal hernias has changed radically over the last 15 years, both in terms of indications for the repair and of surgical technique.

DISCUSSION

Today we operate mostly on patients who are symptomatic and the laparoscopic repair has replaced in most cases the open approach through either a laparotomy or a thoracotomy. The following describes a step by step approach to the laparoscopic repair of paraesophageal hernia.

When did the esophagus start shrinking? The history of the short esophagus

Even though the history of this condition extends for almost 100 years, the short esophagus (SE) is still one of the most controversial topics in esophageal surgery with its existence still denied by some distinguished surgeons. We reviewed the evolution behind the diagnosis and treatment of the SE and the persons who wrote its history, from the first descriptions by radiologists, endoscopists, and surgeons to modern treatment.

Long-term symptomatic outcomes after Collis gastroplasty with fundoplication

Collis gastroplasty with fundoplication is an accepted treatment for gastroesophageal reflux disease (GERD) complicated by short esophagus. The procedure can be done either via left thoracotomy or using minimally invasive laparoscopic techniques. Few centers have reported long-term follow-up for patients undergoing a Collis gastroplasty using both the open and minimal access techniques. Retrospective review of prospectively collected data at Creighton University was done to identify patients who underwent Collis gastroplasty with fundoplication for GERD. After approval from the institutional review board, the patients were contacted and administered a questionnaire regarding symptoms and satisfaction. Data were entered in a dataset and analyzed from the patient's perspective. Eighty-five patients underwent a Collis gastroplasty procedure over a period of 13 years. Forty-eight percent (41 cases) were performed laparoscopically, and a transthoracic open repair was performed in the rest. Long-term data (more than 9 months) was available on 52 patients. Surgery resulted in complete resolution of heartburn, chest pain, regurgitation, and dysphagia in 52, 22, 54, and 29% of patients, respectively. More than 75% of the patients were satisfied with the outcome of surgery, and more than 85% would recommend the procedure to another patient. Collis gastroplasty with fundoplication results in good long-term patient satisfaction and symptom control.

Transthoracic Collis-Nissen repair for massive type IV paraesophageal hernia

An 80-year-old woman presented with type IV massive hiatal hernia with intrathoracic upside-down stomach and transverse colon. She was dyspneic and vomited upon consuming food or water. Consequently, she developed aspiration pneumonia. Both esophagoscopy and upper gastrointestinal series demonstrated significant cephalad displacement of the gastroesophageal junction. A Collis-Nissen hernial repair by muscle-sparing mini-thoracotomy was performed successfully. To date, 3 years after surgery, the patient is enjoying normal oral intake, has an excellent activities of daily living level, and there is no hernia recurrence. Cases of massive paraesophageal hernia are frequently associated with esophageal shortening that causes tension on the repairs and late failure. Advantages of the transthoracic approach in such cases include feasibility of direct esophageal mobilization, accurate assessment of esophageal tension, and facilitation of Collis gastroplasty. The true indication for transthoracic Collis-Nissen repair among cases of paraesophageal hiatal hernia with a short esophagus should be acknowledged more in the era of laparoscopy.

Vagotomy during hiatal hernia repair: a benign esophageal lengthening procedure

INTRODUCTION

This study describes the use of vagotomy in patients during complex laparoscopic esophageal surgery (e.g., reoperative antireflux surgery (rLARS) or paraesophageal hernia (PEH) repair) when, after extensive esophageal mobilization, the gastroesophageal junction cannot be made to reach the abdomen without tension. In doing so, we hope to understand the risk incurred by vagus nerve division in this setting in order to evaluate its role in managing the short esophagus.

METHODS

One hundred and sixty-six patients underwent rLARS or PEH repair between 1/1998 and 6/2003 at our institution. Clinical data was obtained from a prospectively maintained database and systematic patient questionnaires administered for this study. Follow-up was available for 102 (61%) of these patients, at a median of 19 months (range 6-69 months).

RESULTS

Fifty-two patients underwent rLARS while 50 patients underwent PEH repair. Thirty patients had a vagotomy during the course of their operation (Vag Group; 20 anterior, six posterior, four bilateral), 13 in the rLARS group (25%), and 17 in the PEH group (34%). The primary presenting symptoms for rLARS and PEH repair patients were improved in 89% in the Vag Group and 91% in the No Vag Group. Similarly, there was no difference in the severity of abdominal pain, bloating, diarrhea, or early satiety between the Vag and No Vag groups at follow-up. No patient required a subsequent operation for gastric outlet obstruction.

CONCLUSIONS

Vagotomy during rLARS and PEH repair does not lead to a higher rate delayed gastric emptying, dumping syndrome, or other side effects. Thus, we propose vagotomy to be a legitimate alternative to Collis gastroplasty when extensive mobilization of the esophagus fails to provide adequate esophageal length.

Combined transabdominal gastroplasty and fundoplication for shortened esophagus: impact on reflux-related and overall quality of life

BACKGROUND

Transabdominal gastroplasty for shortened esophagus at the time of fundoplication results in a segment of aperistaltic, acid-secreting neoesophagus above the fundoplication. We hypothesized that transabdominal gastroplasty impairs quality of life (QOL).

METHODS

This was a matched paired analysis with retrospective chart review and follow-up questionnaire of 116 patients undergoing transabdominal fundoplication with gastroplasty with 116 matched controls undergoing transabdominal fundoplication alone from January 1997 to June 2005. Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36) and Quality Of Life in Reflux And Dyspepsia (QOLRAD) instruments were used to measure overall and reflux-related QOL. Overall response rate was 75%; including 65 matched pairs used for long-term follow-up and QOL analysis.

RESULTS

Groups were similar in age, sex, duration of hospitalization, and complications (p > 0.05). Gastroplasty patients had larger hiatal hernias and were more likely to have undergone a previous fundoplication (p < 0.01). No perioperative deaths or major morbidity occurred in 18% of both groups. Survey respondents were older than nonrespondents (p < 0.01). Complications did not impact response rates (p = 0.11). Median follow-up was 14 months in the gastroplasty group and 17 months in controls (p = 0.02). The groups had similar scores on the SF-36 and QOLRAD (p > 0.05) and similar overall frequency of patient satisfaction, perceived health status, and self-reported symptoms of reflux, dysphagia, bloating, diarrhea, and excessive flatus (p > 0.05). Control patients were more likely to require rehospitalization or reinterventions (p = 0.04).

CONCLUSIONS

Transabdominal gastroplasty and fundoplication for shortened esophagus is safe and results in similar overall and reflux-related QOL compared with fundoplication alone.

Technical considerations in laparoscopic fundoplication. How I do it

Gastroesophageal reflux disease (GERD) is a common disease and can be successfully treated by laparoscopic fundoplication. This article describes the technique of laparoscopic surgery for GERD with a focus on operative pitfalls.

The influence of transabdominal gastroplasty: early outcomes of hiatal hernia repair

OBJECTIVE

The aim of our study was to review our experience with transabdominal gastroplasty to determine the safety and short-term efficacy of the procedure.

METHODS

Retrospective review of all patients that underwent transabdominal hiatal hernia repair with concurrent gastroplasty for shortened esophagus between October 1999 and May 2004.

RESULTS

There were 63 patients, 27 men and 36 women. Median age was 68 years. The hiatal hernia was classified as type-I in 6 patients, type-II in 10, type-III in 43, and type-IV in 4. The operative approach was laparoscopic in 44 patients and laparotomy in 19. A Nissen fundoplication was performed in 62 patients and a Toupet fundoplication in 1. Wedge gastroplasty was performed in 47 patients and modified Collis gastroplasty in 16. Median hospitalization was 3 days (range, 2-10). Intraoperative complications occurred in 11 patients (17%). One laparoscopic approach (2%) was converted to laparotomy. Postoperative complications occurred in 12 patients (19%), there were no operative deaths. Median follow-up was 12 months (range, 0 to 64). One patient (2%) was found to have a recurrent hiatal hernia diagnosed 14 months, postoperatively. Functional results were excellent in 41 (68%), good in 6 (10%), fair in 12 (20%), and poor in 1 (2%).

CONCLUSION

Transabdominal gastroplasty can be performed safely, with good functional results and a low incidence of recurrent herniation during the short-term follow-up period.

Laparoscopic Collis Gastroplasty and Nissen Fundoplication for Reflux Esophagitis With Shortened Esophagus in Japanese Patients

BACKGROUND

There is an extremely small number of surgical cases of laparoscopic Collis gastroplasty and Nissen fundoplication (LCN procedure) in Japan, and it is a fact that the surgical results are not thoroughly examined.

PURPOSE

To investigate the results of LCN procedure for shortened esophagus.

PATIENTS AND METHODS

The subjects consisted of 11 patients who underwent LCN procedure for shortened esophagus and followed for at least 2 years after surgery. The group of subjects consisted of 3 men and 8 women with an average age of 65.0+/-11.6 years, and an average follow-up period of 40.7+/-14.4 months. Esophagography, pH monitoring, and endoscopy were performed to assess preoperative conditions. Symptoms were clarified into 5 grades between 0 and 4 points, whereas patient satisfaction was assessed in 4 grades. The use of postoperative acid-reducing medication and the recurrence of esophagitis were also investigated.

RESULTS

None of the patients experienced intraoperative complications, received transfusions, required conversion to open surgery, or died postoperatively. The average preoperative heartburn, regurgitation, and dysphagia scores were 2.36+/-1.29, 2.27+/-1.19, and 1.82+/-1.78 points, respectively. These scores improved after surgery to 0.55+/-1.21 (P=0.0063), 0.55+/-1.21 (P=0.0094), and 1.0+/-1.18 (P=0.1236) points, respectively. All patients had esophagitis preoperatively, which recurred in 3 patients (27%). In these 3 patients, acid-secreting mucosa was confirmed on the oral side of the wrap, by positive Congo-red staining. Hiatal hernia recurred in one patient, who also experienced recurrent esophagitis. Five patients received acid-reducing medication postoperatively. The degree of satisfaction was excellent in 2, good in 6 patients, fair in 2, and poor in 1 patient(s).

CONCLUSIONS

Although the LCN procedure can be performed safely, the outcome was not necessarily satisfactory. The LCN procedure requires avoidance of residual acid-secreting mucosa on the oral side of the wrapped neoesophagus. If acid-secreting mucosa remains, continuous acid suppression therapy should be employed postoperatively.

Wedge gastroplasty and reinforced crural repair: Important components of laparoscopic giant or recurrent hiatal hernia repair

OBJECTIVE

Laparoscopic repair of a giant hiatal hernia (>50% of the stomach above the diaphragm) is associated with short-term recurrence rates of 12% to 42%. Recurrent hiatal hernias often have significantly altered anatomy, making laparoscopic repair challenging. We hypothesized that increasing intra-abdominal esophageal length by means of Collis wedge gastroplasty, complete fat-pad dissection, hernia-sac excision, and primary reinforced crural repair would minimize short-term recurrence and provide adequate symptomatic relief.

METHODS

From January 1, 2001, though May 1, 2005, 61 patients underwent laparoscopic repair of a giant or recurrent hiatal hernia with a Collis wedge gastroplasty and Nissen fundoplication. Symptomatic outcomes were assessed with a validated questionnaire (Gastroesophageal Reflux Disease Health-Related Quality of Life). We obtained postoperative radiographic imaging to objectively assess anatomic results at a median of 1.13 years.

RESULTS

Of the 61 patients, 12 (20%) were referred to our institution after previous repairs. Operating time averaged 308 +/- 103 minutes. The median hospital stay was 4 days. Postoperative complications occurred in 5 (8.2%) patients. One (1.6%) patient died of cardiac complications. Postoperatively, 52 (85%) patients completed the questionnaire with mean a Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaire score of 1.15 +/- 2.78 (scale, 0-45; 0 = asymptomatic). Overall, 51 (98%) of the 52 respondents were satisfied with their surgical outcome. Postoperative radiographic data were available for 54 (89%) patients. We identified no recurrences at 1-month follow-up, and only 4.7% (2/42) had evidence of radiographic recurrence at 1 year or more.

CONCLUSIONS

Consistent use of a Collis wedge gastroplasty with reinforced crural repair minimizes short-term recurrence after minimally invasive giant hiatal hernia repair. Symptomatic results are excellent in most patients.