Quality of life after collis gastroplasty for short esophagus in patients with paraesophageal hernia

Antireflux surgeries and hiatal repair: keys to success

INTRODUCTION

Gastroesophageal reflux is common, and when medical therapy is ineffective, alternative treatments should be considered. Nissen fundoplication controls reflux but can be followed by side effects such as dysphagia and flatulence. To improve outcomes, modifications have been advocated.

AREAS COVERED

Modifications to Nissen fundoplication and newer procedures for gastroesophageal reflux aim to improve overall outcome. Randomized controlled trials (RCTs) and long-term outcomes from large cohorts are prioritized to consider the optimal procedure for reflux and hiatus hernia.

EXPERT OPINION

Fundoplication is an effective treatment for gastroesophageal reflux, with success rates of >80% reported at 18-20-year follow-up. RCTs confirm that Nissen fundoplication delivers better reflux control than medication. However, some patients are troubled by side effects. Anterior and posterior partial fundoplication variants have been proposed as procedures that offer equally good reflux control, but fewer side effects, and RCTs have confirmed this with follow-up to 20 years. Which partial fundoplication is better is debated. Alternative laparoscopic or endoscopic approaches require expensive implants or equipment and deliver less reliable reflux control than partial fundoplication. Currently, level I evidence confirms that laparoscopic partial fundoplication delivers the optimal outcome in fit patients with reflux that is not well controlled by medication.

Management of Paraesophageal Hernias

Paraesophageal hernias are classified according to the altered anatomic relationships between the gastroesophageal junction or stomach and the diaphragmatic hiatus. Herniation of these structures into the mediastinum may produce common complaints such as reflux, chest pain, and dysphagia. The elective repair of these hernias is well tolerated and significantly improves quality of life among patients with symptomatic disease. The hallmarks of a quality repair include the circumferential mobilization of the esophagus to generate 3 cm of tension-free intra-abdominal length and the performance of a fundoplication.

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.

Impact of laparoscopic repair on type III/IV giant paraesophageal hernias: a single-center experience

PURPOSE

Giant paraesophageal hernia (GPEH) is a challenging problem for surgeons because of its high recurrence rate. This study was conducted to compare the outcomes in type IV vs. type III GPEHs after laparoscopic repair. Other outcomes included peri-operative morbidity and long-term quality of life.

METHODS

A retrospective analysis of 130 GPEH patients in a period between 2010 and 2019 underwent a tailored laparoscopic repair in our tertiary center with a minimum follow-up of 48 months. Operative steps included hernial sac excision, crural repair, relaxing incisions, and mesh cruroplasty with special indications.

RESULTS

The study enrolled 90 patients with type III and 40 patients with type IV GPEH. Type IV GPEH patients were older, more fragile, and scored worse on ASA classification, aside from having a more challenging surgical technique (wider crura, weaker muscles, increased need for release incisions, and mesh cruroplasty).Type IV GPEHs had a prolonged operative durations, and a higher conversion rate. Additionally, the same group showed increased morbidity, mortality, and re-operation rates. With a mean follow-up of 65 months (range 48-150 months), the incidence of recurrence was 20.7%, with an increased incidence in type IV GPEH (37.5% vs. 13.33% in type III GPEH). Type IV GPEH, low pre-operative albumin, larger crural defect, and low surgeon experience were significant risk factors for recurrence after laparoscopic repair of GPEH.

CONCLUSION

Type IV GPEH has a higher peri-operative morbidity and recurrence rate; so, a more tailored laparoscopic repair with a high surgeon experience is needed.

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

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

[Surgical treatment of hiatal hernia complicated by short esophagus: a prospective study]

OBJECTIVE

To analyze immediate and long-term postoperative results in patients with hiatal hernia complicated by short esophagus.

MATERIAL AND METHODS

We prospectively analyzed postoperative outcomes in 113 patients with hiatal hernia who underwent surgery between 2013 and 2021. The main group consisted of 54 patients with length of intra-abdominal segment of esophagus <4 cm who underwent Collis procedure or esophagus >4 cm and indications for Nissen fundoplication cuff. The control group consisted of 59 patients and indications for esophageal lengthening procedure only if length of intra-abdominal segment of esophagus was less than 2 cm. This surgery was started with anterolateral vagotomy, and Collis procedure was performed in case of ineffective vagotomy. Nissen fundoplication was performed for abdominal segment of esophagus >2 cm.

RESULTS

In the main group, 17 (31.5%) patients with intra-abdominal segment of esophagus <4 cm required Collis procedure. In the control group, length of intra-abdominal segment of esophagus <2 cm was observed in 6 (10.2%) patients. In all cases, anterolateral vagotomy was performed. Surgery time was 189 (80-290) and 136 (90-320) min, respectively (p=0.001). Postoperative complications in the main group occurred in 8 (14.8%) patients, in the control group - 4 (6.8%) patients (p=0.281). One (1.7%) patient died in the control group. The follow-up period was 38 (12-66) months. In long-term period, recurrence developed in 2 (3.7%) and 11 (20%) patients, respectively (p=0.026). High satisfaction with postoperative outcomes was observed in 51 (94.4%) and 46 (79.3%) patients, respectively (p=0.038).

CONCLUSION

Uncorrected shortening of the esophagus can be one of the main risk factors of recurrence in long-term period. Expanding the indications for Collis gastroplasty can reduce the incidence of poor outcomes without affecting the incidence of postoperative complications.

Prosthetic Reinforcement in Hiatal Hernia Repair, Does Mesh Material Matter? A Systematic Review and Network Meta-Analysis

Background: Hiatal hernia repair (HHR) is a complex surgical procedure and its management is not standardized. Several meta-analyses have compared cruroplasty with hiatus reinforcement with mesh, and crura augmentation appears to have better outcomes. However, heterogeneity in type of mesh and placement techniques has differed significantly. Materials and Methods: A systematic review and network meta-analysis were carried out. An electronic systematic research was carried out throughout Pubmed, CENTRAL, and Web of Science, of articles analyzing HHR with cruroplasty, nonabsorbable mesh (NAM), and absorbable mesh (AM) reinforcement. Results: Seventeen articles based on 1857 patients were enrolled in this article. The point estimation showed that when compared against the control group (NAM), the HH recurrence risk in AM and cruroplasty group was higher (relative ratio [RR] 2.3; CrI 0.8-6.3, RR 3.6; CrI 2.0-8.3, respectively). Postoperative complication rates were alike in all groups. The prevalence of mesh erosion after HHR is low. Conclusions: This network meta-analysis showed that prosthetic reinforcement significantly reduced HH recurrence when compared with cruroplasty alone. However, there is not enough evidence to compare different mesh compositions.

Quality of life after giant hiatus hernia repair: A systematic review

BACKGROUND

Elective surgery is the treatment of choice for symptomatic giant hiatus hernia (GHH), and quality of life (QoL) has become an important outcome measure following surgery. The aim of this study is to review the literature assessing QoL following repair of GHH.

METHODOLOGY

A systematic literature search was performed by two reviewers independently to identify original studies evaluating QoL outcomes after GHH surgery. MeSH terms such as paraoesophageal; hiatus hernia; giant hiatus hernia and quality of life were used in the initial search. Original studies in English language using validated questionnaires on humans were included. Review articles, conference abstracts and case reports and studies with duplicate data were excluded.

RESULTS

Two hundred and eight articles were identified on initial search, of which 38 studies (4404 patients) were included. Studies showed a significant heterogeneity in QoL assessment tools, surgical techniques and follow-up methods. All studies assessing both pre-operative and post-operative QoL (n = 31) reported improved QoL on follow-up after surgical repair of GHH. Improvement in QoL following GHH repair was not affected by patient age, surgical technique or the use of mesh. Recurrence of GHH after surgery may, however, adversely impact QoL.

CONCLUSION

Surgical repair of GHH improved QoL scores in all the 38 studies. The impact of recurrence on QoL needs further assessment. The authors also recommend uniform reporting of surgical outcomes in future studies.

[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.

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.

Health-related quality of life after laparoscopic repair of giant paraesophageal hernia: how does recurrence in CT scan compare to clinical success?

Background

Computed tomography (CT) is widely used in the diagnosis of giant paraesophageal hernias (GPEH) but has not been utilised systematically for follow-up. We performed a cross-sectional observational study to assess mid-term outcomes of elective laparoscopic GPEH repair. The primary objective of the study was to evaluate the radiological hernia recurrence rate by CT and to determine its association with current symptoms and quality of life.

Methods

All non-emergent laparoscopic GPEH repairs between 2010 to 2015 were identified from hospital medical records. Each patient was offered non-contrast CT and sent questionnaires for disease-specific symptoms and health-related quality of life.

Results

The inclusion criteria were met by 165 patients (74% female, mean age 67 years). Total recurrence rate was 29.3%. Major recurrent hernia (> 5 cm) was revealed by CT in 4 patients (4.3%). Radiological findings did not correlate with symptom-related quality of life. Perioperative mortality occurred in 1 patient (0.6%). Complications were reported in 27 patients (16.4%).

Conclusions

Successful laparoscopic repair of GPEH requires both expertise and experience. It appears to lead to effective symptom relief with high patient satisfaction. However, small radiological recurrences are common but do not affect postoperative symptom-related patient wellbeing.

Laparoscopic Surgery for Recurrent Hiatal Hernia

Surgical treatment of hiatal hernia (HH) is well standardized. However, recurrence is observed in 15%-60% of cases, and is challenging to manage. The aim of this study was to analyze the causes of surgical failure and provide some guidelines for treatment. The symptoms of recurrent HH vary widely, and include persistent reflux, dysphagia, and permanent discomfort, leading to a marked change in the quality of life. Morphological and functional pretherapeutic evaluation is necessary to determine whether the symptoms are due to recurrent HH, and to understand the cause of failure. Redo surgery is technically difficult and challenging, and should only be used in symptomatic patients whose symptoms are definitively those of recurrent HH.

Critical appraisal of the impact of surgical repair of type II-IV paraoesophageal hernia (POH) on pulmonary improvement: A systematic review and meta-analysis

BACKGROUND

Paraoesophageal hernia (POH) comprising type II-IV hiatal hernia often presents with pulmonary symptoms such as shortness of breath. However, impact of surgical repair on improvement in pulmonary symptoms is unclear.

OBJECTIVE

This systematic review and meta-analysis aimed at characterising impact of POH repair on patient reported improvement in pulmonary symptoms.

METHODS

This systematic review identified studies reported pulmonary symptoms in patients with undergoing surgical repair for Type II-IV POH from 1st January 2001 to 1st December 2018. Primary outcome was improvement in pulmonary symptoms. Secondary outcomes were improvement in other patient-reported outcomes such as heartburn, regurgitation, chest pain, and dysphagia and intraoperative and postoperative outcomes.

RESULTS

This systematic review identified 27 studies (n = 4428 patients) reporting assessment of pulmonary symptoms. However, only 21 studies (n = 2902 patients) reported preoperative and postoperative pulmonary symptoms and hence these were included in the final meta-analysis. There was significant improvement in pulmonary symptoms following POH repair (OR: 8.40, CI_95%: 4.91-14.35, p < 0.001), with improvement in all types of POH. Rates of overall and major complications were 16% and 5%, respectively. Rates of conversion, 30-day mortality, reoperation and recurrence were 2%, 1% 4% and 12% respectively.

CONCLUSION

This review demonstrates that POH repair is associated with improvement in pulmonary symptoms with acceptable low laparoscopic conversion rates, morbidity, mortality and recurrence rates.

Update on the Durability and Performance of Collis Gastroplasty For Chronic GERD and Hiatal Hernia Repair At 4-Year Post-Intervention

BACKGROUND

Collis gastroplasty (CG) remains an important procedure to lengthen the esophagus when indicated in patients undergoing fundoplication for longstanding refractory gastroesophageal reflux disease (GERD) or large hiatal hernias. Concerns over potential sequelae of CG such as dysphagia and worsening heartburn as well as questions regarding the durability of the procedure remain a subject of debate. In this study, 3 and 4-year postoperative data is presented assessing patient quality of life (QOL) measures for those undergoing laparoscopic antireflux surgery (LARS) with and without CG.

METHODS

Comparative review of a prospectively maintained GERD patient database was conducted between patients undergoing LARS with CG versus non-CG (NC) at two institutions between October 2004 and February 2019. Patient demographic, perioperative, and QOL data was analyzed at 3 and 4 years postoperatively using four validated instruments: the Reflux Symptom Index (RSI), Laryngopharyngeal Reflux QOL (LPR-QOL), Swallowing QOL (SWAL), and Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQOL) surveys.

RESULTS

A total of 214 CG and 798 NC patients were included in this study. The CG group was older (66.1 ± 12.9 vs. 59.0 ± 14.1, p < 0.001), had a higher frequency of ASA class 3 patients (39.7% vs. 29.7%), and had greater proportion of comorbid disease compared to NG. The groups were parallel in BMI (Collis 28.4 ± 5.2 kg/m² vs. non-Collis 28.6 ± 5.3 kg/m², p = 0.673). Subset analysis revealed persistent benefits through 4 years reflected by survey results in both groups. There were no statistically significant differences in QOL outcomes between CG and NC. A majority of patients in both groups reported discontinuation of antireflux medications and satisfaction with surgical outcomes and symptom control.

CONCLUSION

Long-term QOL outcomes after laparoscopic CG are comparable to patients treated with fundoplication alone in cases of long-standing GERD and hiatal hernias. Furthermore, CG patients enjoyed equivalent durability of the procedure without risk of subsequent dysphagia. Collis gastroplasty remains an important tool in the armamentarium of foregut surgeons.

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.

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.

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.

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.

Mesh cruroplasty in laparoscopic repair of paraesophageal hernias is not associated with better long-term outcomes compared to primary repair

BACKGROUND

Equipoise still exists regarding routine mesh cruroplasty during laparoscopic paraesophageal hernia (PEH). We aimed to determine whether selective mesh cruroplasty is associated with differences in recurrence and patient-reported outcomes.

METHODS

We compared symptom outcomes (n = 688) and radiographic recurrences (n = 101; at least 10% [or 2 cm] of stomach above hiatus) for 795 non-emergent PEH repair with fundoplication (n = 106 with mesh).

RESULTS

Heartburn, regurgitation, epigastric pain, and anti-reflux medication use decreased significantly in both groups while postoperative dysphagia (mesh; p = 0.14), and bloating (non-mesh; p = 0.32), were unchanged. Radiographic recurrence rates were similar (15 mesh [22%] versus 86 non-mesh [17%]; p = 0.32; median 27 [IQR 14, 53] months), but was associated with surgical dissatisfaction (13% vs 4%; p = 0.007).

CONCLUSIONS

Selective mesh cruroplasty was not associated with differences in symptom outcomes or radiographic recurrence rates during laparoscopic PEH repair. Radiographic recurrence was associated with dissatisfaction, emphasizing the need for continued focus on reducing recurrences.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Optimal Approach to Symptomatic Paraesophageal Hernia Repair: Important Technical Considerations

While the asymptomatic paraesophageal hernia (PEH) can be observed safely, surgery is indicated for symptomatic hernias. Laparoscopic repair is associated with decreased morbidity and mortality; however, it is associated with a higher rate of radiologic recurrence when compared with the open approach. Though a majority of patients experience good symptomatic relief from laparoscopic repair, strict adherence to good technique is critical to minimize recurrence. The fundamental steps of laparoscopic PEH repair include adequate mediastinal mobilization of the esophagus, tension-free approximation of the diaphragmatic crura, and gastric fundoplication. Collis gastroplasty, mesh reinforcement, use of relaxing incisions, and anterior gastropexy are just a few adjuncts to basic principles that can be utilized and have been widely studied in recent years. In this article, we present a comprehensive review of literature addressing key aspects and controversies regarding the optimal approach to repairing paraesophageal hernias laparoscopically.

Non-Elective Paraesophageal Hernia Repair Portends Worse Outcomes in Comparable Patients: a Propensity-Adjusted Analysis

INTRODUCTION

Patients undergoing non-elective paraesophageal hernia repair (PEHR) have worse perioperative outcomes. Because they are usually older and sicker, however, these patients may be more prone to adverse events, independent of surgical urgency. Our study aimed to determine whether non-elective PEHR is associated with differential postoperative outcome compared to elective repair, using propensity-score weighting.

METHODS

We abstracted data for patients undergoing PEHR (n = 924; non-elective n = 171 (19 %); 1997-2010). Using boosted regression, we generated a propensity-weighted dataset. Odds of 30-day/in-hospital mortality and major complications after non-elective surgery were determined.

RESULTS

Patients undergoing non-elective repair were significantly older, had more adverse prognostic factors, and significantly more major complications (38 versus 18 %; p < 0.001) and death (8 versus 1 %; p < 0.001). After propensity weighting, median absolute percentage bias across 28 propensity-score variables improved from 19 % (significant imbalance) to 5.6 % (well-balanced). After adjusting propensity-weighted data for age and comorbidity score, odds of major complications were still nearly two times greater (OR 1.67, CI 1.07-2.61) and mortality nearly three times greater (OR 2.74, CI 0.93-8.1) than for elective repair.

CONCLUSIONS

Even after balancing significant differences in baseline characteristics, non-elective PEHR was associated with worse outcomes than elective repair. Symptomatic patients should be referred for elective repair by experienced surgeons.

Complications Following Surgery for Gastroesophageal Reflux Disease and Achalasia

Surgical procedures to treat reflux disease are common, but good outcomes rely on both a thorough preoperative workup and careful surgical techniques. Although complications are uncommon, surgeons should recognize these and possess the skills to overcome them in clinical practice.

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.

Durability of giant hiatus hernia repair in 455 patients over 20 years

INTRODUCTION

The surgical management of symptomatic giant hiatus hernia (GHH) aims to improve quality of life (QoL) and reduce the risk of life threatening complications. Previous reports are predominantly those with small sample sizes and short follow-up periods. The present study sought to assess a large cohort of patients for recurrence and QoL over a longer time period.

METHODS

This was a follow-up study of a prospectively collected database of 455 consecutive patients. Primary repair of GHH was evaluated by endoscopy/barium meal for recurrence and a standardised symptom questionnaire for QoL. Recurrence was assessed for size, elapsed time, oesophagitis and symptoms.

RESULTS

Objective and subjective review was achieved in 91.9% and 68.6% of patients. The median age was 69 years (range: 15-93 years) and 64% were female. Laparoscopic repair was completed in 95% (mesh in 6% and Collis gastroplasty in 7%). The 30-day mortality rate was 0.9%. The proportion of patients alive at five and ten years were 90% and 75% respectively. Postoperative QoL scores improved from a mean of 95 to 111 (p<0.01) and were stable over time (112 at 10 years). The overall recurrence rate was 35.6% (149/418) at 42 months; this was 11.5% (48/418) for hernias >2cm and 24.2% (101/418) for <2cm. The rate of new recurrence at 0-1 years was 13.7% (>2cm = 3.4%, <2cm = 10.3%), at 1-5 years it was 30.8% (>2cm = 9.5%, <2cm = 21.3%), at 5-10 years it was 40.1% (>2cm = 13.8%, <2cm = 26.3%) and at over 10 years it was 50.0% (>2cm = 25.0%, <2cm = 25.0%). Recurrence was associated with oesophagitis but not decreased QoL. Revision surgery was required in 4.8% of cases (14.8% with recurrence). There were no interval major GHH complications.

CONCLUSIONS

Surgery has provided sustained QoL improvements irrespective of recurrence. Recurrence occurred progressively over ten years and may predispose to oesophagitis.

Symptom Relief After Laparoscopic Paraesophageal Hernia Repair Without Mesh

BACKGROUND

Laparoscopic repair of paraesophageal hernia (LPEHR) is considered today the standard of care for this condition. While attention has been mostly focused on the incidence of postoperative radiologic recurrence of a hiatal hernia, few data are available about the effect of the operation on symptoms.

AIMS

In this study, we aim to determine the effect of primary LPEHR on postoperative symptoms.

PATIENTS AND METHODS

One hundred and sixty-two patients underwent LPEH repair in two academic tertiary care centers. Preoperative evaluation included barium swallow (100 %), endoscopy (80 %), manometry (81 %), and pH monitoring (25 %). Type III PEH was the most common (94 %), and it was associated with a gastric volvulus in 27 % of patients.

RESULTS

A fundoplication was performed in all patients: Nissen in 57 %, Dor in 36 %, and Toupet in 6 %. A Collis gastroplasty was added in 6 % of patients. There were no perioperative deaths. The intraoperative complication rate was 7 %. The operation was completed laparoscopically in 98 % of patients. Postoperative complications occurred in four patients, and three needed a second operation. Average follow-up was 24 months. Heartburn, regurgitation, chest pain, dysphagia, respiratory symptoms, and hoarseness improved as a result of the operation. Anemia fully resolved in all patients.

CONCLUSIONS

LPEH repair is safe and effective, and the need for reoperation is rare. Few patients experience postoperative symptoms, and these are easily controlled with acid-reducing medications.

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.

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

OBJECTIVES

Type III-IV hiatal hernia (HH) is associated with a true short oesophagus in more than 50% of cases; dedicated treatment of this condition might be appropriate to reduce the recurrence rate after surgery. A case series of patients receiving surgery for Type III-IV hernia was examined for short oesophagus, and the results were analysed.

METHODS

From 1980 to 1994, 60 patients underwent an open surgical approach, and the position of the oesophago-gastric junction was visually localized; from 1995 to 2013, 48 patients underwent a minimally invasive approach, and the oesophago-gastric junction was objectively localized using a laparoscopic-endoscopic method. The patients underwent a timed clinical-instrumental follow-up that included symptoms assessment, barium swallow and endoscopy. 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, HH 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

Among the open surgery patients, 78% underwent abdominal fundoplication, 10% the Belsey Mark IV procedure, 8% laparotomic Collis-Nissen fundoplication and 3% the Pearson operation. Among the minimally invasive surgery patients, 44% underwent a laparoscopic floppy Nissen procedure and 56% a left thoracoscopic Collis-laparoscopic Nissen procedure. The postoperative mortality and complication rates were 1.6% (1/60) and 15% for open surgery and 4.1% (2/48) and 12.5% for minimally invasive surgery. A total of 105 patients were followed up for a median period of 96 months. Five relapses occurred after open surgery (5/59, 8%) and two after minimally invasive surgery (2/46, 4%). Among the 105 patients, excellent, good, fair and poor outcomes were observed in 38%, 44%, 9% and 9%, respectively.

CONCLUSIONS

These data suggested that the selective treatment of short oesophagus in association with a Type III-IV hernia reduced the anatomical recurrence rate and achieved satisfactory outcomes.

CLINICALTRIALSGOV ID

NCT01606449.

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.

Novel combined VATS/laparoscopic approach for giant and complicated paraesophageal hernia repair: description of technique and early results

BACKGROUND

The laparoscopic approach for repair of giant and/or recurrent paraesophageal hernias (PEH) is challenging, due to limited access to the dissection of the hernia sac into the proximal mediastinum and esophageal mobilization through the diaphragmatic hiatus. An esophageal lengthening procedure is often necessary, due to the difficulty in obtaining adequate intra-abdominal esophageal length. We, therefore, developed a VATS and laparoscopic technique, which allows for safe and extensive thoracic dissection and intra-abdominal gastric fixation and cruroplasty, yet preserving the benefits of minimally invasive surgery.

METHODS

We use a standard VATS approach. The hernia sac, optimally visualized, is dissected posteriorly from the thoracic aorta, inferiorly from its diaphragmatic attachments, anteriorly from the pericardium, and laterally from the mediastinal pleura. The esophagus is completely mobilized up to the aortic arch, and the anterior vagus nerve is released from its bronchial branches. The hernia sac is then opened, dissected, and completely removed. The hernia content is then reduced into the abdomen laparoscopically, the short gastric vessels are divided and the gastric fundus is completely mobilized. The hiatus is closed with interrupted sutures, and the cruroplasty is buttressed with a biological mesh. A floppy Nissen or a partial fundoplication and a gastropexy are done for reflux control and gastric fixation.

RESULTS

From January 2012 to January 2014, we treated 18 patients (7 with type III PEH and 11 with type IV) with the above-described procedure. Six patients had previous history of antireflux surgery. We performed a planned laparotomy instead of laparoscopy in two patients, who needed concurrent repair of complex incisional hernias. We did not need esophageal lengthening procedures, nor experienced damages to thoracic structures in any patient.

CONCLUSIONS

Our newly developed surgical approach has proven to be safe and feasible. This technique represents a good option for treatment of giant and complicated PEH.

A clinical prediction rule for perioperative mortality and major morbidity after laparoscopic giant paraesophageal hernia repair

OBJECTIVE

In the current era, giant paraesophageal hernia repair by experienced minimally invasive surgeons has excellent perioperative outcomes when performed electively. However, nonelective repair is associated with significantly greater morbidity and mortality, even when performed laparoscopically. We hypothesized that clinical prediction tools using pretreatment variables could be developed that would predict patient-specific risk of postoperative morbidity and mortality.

METHODS

We assessed 980 patients who underwent giant paraesophageal hernia repair (1997-2010; 80% elective and 97% laparoscopic). We assessed the association between clinical predictor covariates, including demographics, comorbidity, and urgency of operation, and risk for in-hospital or 30-day mortality and major morbidity. By using forward stepwise logistic regression, clinical prediction models for mortality and major morbidity were developed.

RESULTS

Urgency of operation was a significant predictor of mortality (elective 1.1% [9/778] vs nonelective 8% [16/199]; P < .001) and major morbidity (elective 18% [143/781] vs nonelective 41% [81/199]; P < .001). The most common adverse outcomes were pulmonary complications (n = 199; 20%). A 4-covariate prediction model consisting of age 80 years or more, urgency of operation, and 2 Charlson comorbidity index variables (congestive heart failure and pulmonary disease) provided discriminatory accuracy for postoperative mortality of 88%. A 5-covariate model (sex, age by decade, urgency of operation, congestive heart failure, and pulmonary disease) for major postoperative morbidity was 68% predictive.

CONCLUSIONS

Predictive models using pretreatment patient characteristics can accurately predict mortality and major morbidity after giant paraesophageal hernia repair. After prospective validation, these models could provide patient-specific risk prediction, tailored for individual patient characteristics, and contribute to decision-making regarding surgical intervention.

Transthoracic repair of slipped Nissen fundoplications: technique and results

BACKGROUND

Laparoscopic Nissen fundoplication is a common operation performed for reflux disease, generally with good results. A small percentage of patients experience transthoracic migration of the wrap, causing recurrent symptoms and eventually requiring transthoracic repair.

METHODS

A retrospective chart review was performed for all patients who underwent a transthoracic repair of a slipped Nissen fundoplication at our institution from 2006 to 2010. Data included demographics, previous antireflux operations, symptoms at presentation, findings at operation, and overall outcome.

RESULTS

Sixteen patients with a mean age of 61 years (range, 51-76 years) were identified who fit inclusion criteria. The most common presenting symptom was pain. Intraoperative findings included hiatal breakdown in all patients, shortened esophagus in 10 (62%) patients, and foreign body/mesh in 4 (25%) patients. Nine (56%) patients underwent a Collis gastroplasty along with a Nissen fundoplication. Nissen fundoplication alone was performed in 6 (38%) patients and a Belsey fundoplication with a Collis gastroplasty was performed in 1 (6%) patient. Minor complications occurred in 4 (25%) patients and major complications were seen in 2 (13%) patients. The median length of stay was 9 days (range, 6-30 days). There were no postoperative deaths. Overall, 12 (75%) of the patients were judged to have a good outcome, 3 (19%) a fair outcome, and 1 (6%) a poor outcome over a median 9-month follow-up.

CONCLUSIONS

Transthoracic repair in patients who have had transthoracic migration of a previous Nissen fundoplication has acceptable surgical outcome and affords symptomatic relief to the majority of patients.