Esophageal Lengthening Procedures Research Articles

210. BIORESORBABLE SYNTHETIC MESHES IN LARGE PARAESOPHAGEAL HERNIAS. TECHNIQUE OF APLICATION AND EARLY RESULTS

Abstract Background Large paraesophageal hernias (LPEH) are still a challenge faced by foregut surgeons. Surgical options are highly debated among specialists; esophageal lengthening procedures, diaphragmatic relaxing incisions, gastropexy and—mesh reinforcement. Severe complications related to synthetic meshes has led many surgeons to avoid this type of reinforcement. However, newly developed synthetic bioresorbable meshes have been used as an alternative for hiatal reinforcement, lowering the rates of recurrence without the drawbacks of synthetic materials. Methods From April 2018 to February 2023, 65 patients underwent LPEH repair with hiatal augmentation with an inverted C-shape bioresorbable mesh. All surgeries were performed by two surgeons (AB and NCA). The meshes (Bio-A®—Gore® and Phasix ST®—BARD) were applied over crurorrhaphy, covering the anterior and posterior aspects of the hiatus and secured in place with sutures and cyanoacrylate. The choice of mesh was determined by the surgeon’s preference. Follow up visits were at 1, 6 and 12 months and yearly after that. Results There were 34 patients where Bio-A was used and 31 with Phasix. Median age (55,5 vs 54,8 years) didn’t differ between groups. LPEH were primary (PS) in 39 patients and recurrence from prior interventions (RS) in 26. Median age was higher in PS (58,6 vs 49,6 years). There were no intraoperative complications related to the use of mesh. The patients were discharged after 24–48 hours. The average follow-up period was similar between PS and RS (10,1 vs 9,6 months). There were three recurrences (2 Bio-A, 1 Phasix) in PS (7,6%) and seven (26,9%) in RS (2 Bio-A, 5 Phasix). There weren’t complaints of prolonged dysphagia or need for dilatation. Nine out of 10 recurrences are small. One large recurrence, required reintervention for acute volvulus after 1 year (RS group with Phasix). Conclusion bioresorbable meshes are safe to use as a reinforcement of hiatoplasty in LPEH. They can reduce recurrence and reoperation rates in PS at a short term follow-up. Large recurrent hiatal hernias still present as a major challenge and adjuvant techniques should be employed to further reduce recurrences.

How I Do It: Collis Gastroplasty

A key principle of hiatal hernia repair is mitigation of tension. While considerable emphasis is placed on the radial tension of the crural closure itself, of equal importance is assuring that axial tension on the esophagus is appropriately addressed. Because of this, esophageal lengthening procedures such as the transabdominal laparoscopic wedge Collis gastroplasty described here have been proposed. Such esophageal lengthening procedures allow for the creation of additional length of tubularized stomach to create a neo-esophagus that will allow for a tension free and appropriately sized fundoplication to be performed.

Esophageal Interventions in Infants Born with Esophageal Atresia: A Comprehensive Analysis of a National Database.

Esophageal atresia (EA) is a rare malformation that often requires a series of procedures, including surgical primary anastomosis, staged repair, and endoscopic procedures. Actual numbers and trends in interventions and variety in treatment strategies remain unclear. Data from the German federal bureau of statistics containing all EA-related inpatient procedures encoded from 2005 until 2018 were analyzed for children during the first year of life. The sum of esophageal anastomoses and replacements was used to calculate an estimate of incidence of EA. Over 14 years, 12,627,888 inpatient cases were recorded in infants in Germany. The mean incidence of EA was 1 per 4,217 live births. On average, 163.3 (95% confidence interval [CI]: 150.8-176.1) esophageal anastomoses, 11.2 (95% CI: 8.7-13.7) esophageal lengthening procedures, and 6.7 (95% CI: 5.42-8.00) esophageal replacements were recorded annually. Overall, 187.8 (95% CI: 147.1-200.4) endoluminal treatments (ballon dilatation, bougienage, stent placement, or injection) were performed per 100 anastomoses. Over the years, bougienage was increasingly replaced by ballon dilatation as primary treatment. Boys had a significantly higher number of esophageal procedures than girls, but the incidence of endoscopic treatments in relation to anastomoses was the same for both genders. The low incidence of EA in relation to a relatively large number of units treating those patients in Germany may pose challenges for maintaining competency and training of all specialists involved. The number of esophagoscopic treatments for esophageal stricture per anastomosis is lower than previously estimated.

Large hiatal hernia: minimizing early and long-term complications after minimally invasive repair

Paraesophageal Hernia (PEH) is the protrusion of the stomach and/or other abdominal viscera into the mediastinum due to an enlargement of the diaphragmatic hiatus. The treatment of PEH is challenging: On the one hand, watchful waiting carries the risk of developing acute life-threatening complications requiring an emergency operation. On the other hand, elective repair of PEH has non-negligible morbidity and mortality rates, also due to the characteristics of PEH affected patients, who are generally elder and frail. A review of the literature is presented to highlight strategies that can be adopted to minimize early and long-term complications after PEH surgical repair. The laparoscopic approach has been shown to provide reduced hospital stay, postoperative morbidity and mortality, and overall costs compared to traditional open surgery, and it is currently considered the standard approach both to elective and emergency operations. The evidence suggests that strict adherence to surgical principles, such as hernia sac excision, extended mediastinal dissection of the esophagus, and tension-free crural repair with or without mesh are mandatory to achieve optimal surgical outcomes and reduce PEH recurrence rate. Different shapes, materials, and techniques of prosthetic repair and the use of relaxing incisions have been proposed, but long-term data are lacking, and no conclusions can be drawn regarding the ideal method of crural closure. When a short esophagus is recognized despite extensive mediastinal dissection, esophageal lengthening procedures are indicated. Systematic addition of a fundoplication is strongly encouraged, for either treating gastroesophageal reflux or reducing recurrence rate.

Favorable peri-operative outcomes observed in paraesophageal hernia repair with robotic approach.

The robotic surgical approach offers enhanced visualization, dexterity and reach, which may facilitate the more technically demanding portions of paraesophageal hernia (PEH) repair such as hiatal reconstruction and mediastinal dissection. We sought to compare the peri-operative clinical outcomes of the laparoscopic vs. robotic approach to PEH repair. A prospective, IRB-approved database was maintained for all robotic PEH repairs performed by a single surgeon at a tertiary academic hospital from 2009 to 2019. A retrospective review of laparoscopic PEH over this same time period was used as a comparison group. Outcome measures included: operative time, conversion to open, need for an esophageal lengthening procedure, operative equipment costs and length of stay (LOS). 1854 patients underwent PEH repair during this time period (830 robotic; 1024 laparoscopic). Demographics of both groups were similar, including BMI and PEH type, although a higher proportion of robotic cases were re-operative PEH repairs (32.5% vs 24.0%; p < 0.001). Patients who underwent a robotic PEH had a significant reduction in esophageal lengthening procedures performed (0.1% vs. 11.0%; p < 0.001), conversion to open (0% vs. 7.0%; p < 0.001), and LOS (1.8days vs. 3.1days; p < 0.001). Intra-operative equipment costs were similar. In one of the largest robotic PEH case series reported to date, there were significant improvements in peri-operative outcomes in patients undergoing a robotic-assisted approach. Although a greater number of patients in the robotic group were redo PEH repairs, when compared to the laparoscopic group, there were no conversions to open and significantly fewer esophageal lengthening procedures, both of which carry significant morbidity. The similar intra-operative costs were likely balanced by the higher costs associated with stapling equipment and conversions in the laparoscopic group. Our findings show that the robotic PEH repair is safe and can result in improved peri-operative outcomes.

Evolution of Gastro-esophageal Fundoplication

Fundoplication has evolved from 360° total wraps to now 120° partial wraps. These are the second commonest laparoscopic procedures at present. Esophageal lengthening procedures have re-entered the debate since the days of open surgery. This is a review article.

Development of a novel approach to safely couple the intestine to a distraction-induced device for intestinal growth: use of reconstructive tissue matrix.

Distraction-induced intestinal growth may be a novel treatment for short bowel syndrome. Longitudinal, distractive tension created by the application of force creates a significant challenge: to produce adequate force, yet not cause perforation at the fixation points. This paper describes our development of a coupling strategy to allow for successful bowel lengthening. A curvilinear hydraulic device was implanted in an isolated Roux limb of small bowel in young Yorkshire pigs. Bowel was lengthened over a 2-week period. Study groups included: Group 1: Twelve silk transmural anchoring sutures into an engineered-coupling ring at the ends of each device. Group 2: Addition of felt pledgets to the coupling rings on the serosal surface of the small bowel. Group 3: Extraluminal use of either thin AlloDerm(®), thick AlloDerm(®), or Strattice™ mesh to anchor the device. Group 1 (suture-only) resulted in a gradual pulling through the suture with increasing tension and no lengthening. Felt pledgets eroded in a similar fashion, causing abdominal sepsis. Thin AlloDerm(®) failed to prevent erosion; however, it protected against gross contamination. Animals in which either thick AlloDerm(®) or Strattice™ mesh was used survived complication free to the study endpoint. Both thick AlloDerm(®) and Strattice™ prevented erosion and perforation allowing for an average of 10.85cm expansion. This study demonstrates the use of either thick AlloDerm(®) or Strattice™ reconstructive tissue matrix which allows for safe and effective coupling. Further, we suggest this approach could be an adjunct to esophageal lengthening procedures.

Evolution and Development of Surgery for Large Paraesophageal Hiatus Hernia

Laparoscopic repair is the standard surgical approach to the problem of large paraesophageal hiatus hernia. It is associated with low risks of morbidity and mortality, although there is a small risk (less than 5%) of a clinically significant recurrent hernia. Various techniques have been proposed to minimise this risk, including esophageal lengthening procedures and mesh reinforcement of the hiatus. Both remain controversial. Radiological outcomes from randomised trials suggest that a reduction in hernia recurrence rates can be achieved with the use of mesh repair, although these trials have not demonstrated any clinically significant benefits for mesh repair. The risk of complications following mesh placement at the esophageal hiatus or an esophageal lengthening procedure needs to be balanced against potential benefits. More work is required to define the optimal approach to repair of large paraesophageal hiatus hernias.

Disparity between symptomatic and physiologic outcomes following esophageal lengthening procedures for antireflux surgery.

Although esophageal lengthening procedures (Collis gastroplasty) have been recommended as an adjunct to antireflux surgery in patients with shortened esophagus, there are few data on physiologic outcomes in these patients. This study details the long-term outcomes in patients who underwent antireflux surgery with Collis gastroplasty. All patients undergoing esophagogastric fundoplication (EGF) with a Collis gastroplasty for the management of gastroesophageal reflux disease or paraesophageal hernia were identified from a prospectively maintained database. Symptom questionnaires were used during follow-up to assess symptomatic outcomes. Barium esophogram, upper endoscopy with biopsy, and catheterless esophageal acid monitoring (BRAVO system) were recommended for all patients. Patients with abnormal results of physiologic studies underwent further treatment based on a standardized algorithm. Between 1996 and 2002, a total of 68 patients underwent EGF with Collis gastroplasty. Twenty-seven (40%) had a large paraesophageal hernia, and 20 (30%) had undergone a prior EGF. Fifty-six (82%) of the procedures were performed laparoscopically. Mean follow-up time was 30 months, with 10 (15%) patients lost to latest follow-up. Symptomatic outcome data were available for 85% of patients, with significant improvements reported for heartburn (86%), chest pain (90%), dysphagia (89%), and regurgitation (91%). Most patients (84%) were off medications. Physiologic data were completed in 37% of the patients. Of those undergoing physiologic follow-up studies, 17% had recurrent hiatal hernia, and 80% had endoscopically identified esophagitis and pathologic esophageal acid exposure on pH testing. Despite this, 65% of the patients with objectively identified abnormalities reported significant symptomatic improvement compared to their preoperative symptoms. Two patients developed changes associated with Barrett's esophagus that were not present preoperatively. Distal esophageal injury can persist after EGF with Collis gastroplasty, despite significant symptomatic improvements. Appropriate follow-up in these patients requires objective surveillance, which should eventuate in further treatment if esophageal acid is not completely controlled. Although the Collis gastroplasty is conceptually appealing, these results call into question the liberal application of this technique during EGF.

Disparity between symptomatic and physiologic outcomes following esophageal lengthening procedures for antireflux surgery

Although esophageal lengthening procedures (Collis gastroplasty) have been recommended as an adjunct to antireflux surgery in patients with shortened esophagus, there are few data on physiologic outcomes in these patients. This study details the long-term outcomes in patients who underwent antireflux surgery with Collis gastroplasty. All patients undergoing esophagogastric fundoplication (EGF) with a Collis gastroplasty for the management of gastroesophageal reflux disease or paraesophageal hernia were identified from a prospectively maintained database. Symptom questionnaires were used during followup to assess symptomatic outcomes. Barium esophogram, upper endoscopy with biopsy, and catheterless esophageal acid monitoring (BRAVO system) were recommended for all patients. Patients with abnormal results of physiologic studies underwent further treatment based on a standardized algorithm. Between 1996 and 2002, a total of 68 patients underwent EGF with Collis gastroplasty. Twenty-seven (40%) had a large paraesophageal hernia, and 20 (30%) had undergone a prior EGF. Fifty-six (82%) of the procedures were performed laparoscopically. Mean follow-up time was 30 months, with 10 (15%) patients lost to latest follow-up. Symptomatic outcome data were available for 85% of patients, with significant improvements reported for heartburn (86%), chest pain (90%), dysphagia (89%), and regurgitation (91%). Most patients (84%) were off medications. Physiologic data were completed in 37% of the patients. Of those undergoing physiologic follow-up studies, 17% had recurrent hiatal hernia, and 80% had endoscopically identified esophagitis and pathologic esophageal acid exposure on pH testing. Despite this, 65% of the patients with objectively identified abnormalities reported significant symptomatic improvement compared to their preoperative symptoms. Two patients developed changes associated with Barrett’s esophagus that were not present preoperatively. Distal esophageal injury can persist after EGF with Collis gastroplasty, despite significant symptomatic improvements. Appropriate follow-up in these patients requires objective surveillance, which should eventuate in further treatment if esophageal acid is not completely controlled. Although the Collis gastroplasty is conceptually appealing, these results call into question the liberal application of this technique during EGF.

Laparoscopic Management of Giant Type III Hiatal Hernia and Short Esophagus: Objective Follow-Up at Three Years

We wished to evaluate the long-term effectiveness of the laparoscopic Hill repair in the treatment of type III hiatal hernia. Fifty-two patients underwent laparoscopic repair of a type III hiatal hernia. No esophageal lengthening procedures were performed. Short esophagus was determined from the operative record. Late symptomatic follow-up and a satisfaction questionnaire were completed in 71% (37/52) of patients at a mean of 39 months (range 6 to 84 months). Esophagrams were completed in 65% (34/52) of patients at a mean of 37 months (range to 84 months) after repair. Eighty-one percent were without any adverse symptoms, and 86% rated outcome as excellent or good at 39 months. Symptoms requiring treatment were present in 19% (7/37). Esophagrams revealed a recurrent hernia in 32% (11/34) of patients of whom 36% (4/11) were asymptomatic. Six patients with short esophagus underwent esophagram with one recurrence identified (17%). This was compared with 28 patients without short esophagus, of whom 10 had a recurrence (35%) ( P = 0.70). The laparoscopic Hill repair provides long-term satisfaction and relief of symptoms. The incidence of anatomic recurrence on video esophagram is high and does not always correlate with symptoms. The presence of short esophagus does not play a role in recurrence when the Hill repair is used. ( J Gastrointest Surg 2002;6:181–188.)

Laparoscopic management of giant type III hiatal hernia and short esophagus: Objective follow-up at three years

We wished to evaluate the long-term effectiveness of the laparoscopic Hill repair in the treatment of type III hiatal hernia. Fifty-two patients underwent laparoscopic repair of a type III hiatal hernia. No esophageal lengthening procedures were performed. Short esophagus was determined from the operative record. Late symptomatic follow-up and a satisfaction questionnaire were completed in 71% (37/52) of patients at a mean of 39 months (range 6 to 84 months). Esophagrams were completed in 65% (34/52) of patients at a mean of 3 7 months (range to 84 months) after repair. Eighty-one percent were without any adverse symptoms, and 86% rated outcome as excellent or good at 39 months. Symptoms requiring treatment were present in 19% (7/37). Esophagrams revealed a recurrent hernia in 32% (11/34) of patients of whom 36% (4/11) were asymptomatic. Six patients with short esophagus underwent esophagram with one recurrence identified (17%). This was compared with 28 patients without short esophagus, of whom 10 had a recurrence (35%) (P = 0.70). The laparoscopic Hill repair provides long-term satisfaction and relief of symptoms. The incidence of anatomic recurrence on video esophagram is high and does not always correlate with symptoms. The presence of short esophagus does not play a role in recurrence when the Hill repair is used.