Giant Paraesophageal Hernia Research Articles

BN SO53 - Thoracotomy for the Repair of Giant Paraesophageal and Hiatal Hernias: A Systematic Review

Abstract Background The utilisation of transthoracic approaches for the repair of large hiatus hernias remains a topic of clinical debate. This study aims to evaluate and compare the efficacy, safety, and recovery metrics for transthoracic hiatal hernia repair and comparisons to the laparoscopic approach. Method A literature search was conducted using the key terms "hiatus hernia," "thoracotomy," "thoracic approach," and "Belsey Mark IV." The databases searched included MEDLINE, EMBASE, and Web of Science, covering the period from 2000 to June 2024. Extracted data included patient demographics, study design characteristics, length of stay, complication rate and mortality rate. Results A total of 5 citations were selected comprising a total of 560 patients of which 164 were male (29.3%) with an overall mean age was 64.9 (pooled SD = 1.93) and weighted mean follow-up length was 56.4 months (pooled SD = 39.1 months). The weighted overall mean length of stay was 14.5 days (Pooled SD = 7.42). The overall rate of minor complications was 19% (95% CI [6%, 31%]). The overall rate of major complications was 13% (95% CI [6%, 21%]). There were 4 reported mortalities in total and an overall leak rate of 1% (95% CI [0%, 2%]). Conclusion Both thoracotomy and laparoscopy have unique benefits and risks in the context of hiatal hernia surgery. Access via thoracotomy is associated with a higher incidence of complications. However, for large or emergent paraesophageal hernias, the transthoracic approach may represent a viable option in select patients.

Outcomes after revisional surgery for paraesophageal hernias at a high-volume tertiary care center.

Although recurrences after repair of giant paraesophageal hernias (PEH) are common, revisional procedures are challenging and associated with higher complication rates than primary repair. Therefore, repair of recurrent PEH is often avoided except in symptomatic patients. Data describing operative outcomes in these infrequent cases is lacking. Therefore, this study aimed to report and compare peri-operative outcomes of revisional PEH repair to similar patients undergoing primary surgery. A single-institution, retrospective cohort study was conducted on all adult patients undergoing primary repair of Type II-IV PEH and any revisional surgery for recurrent hiatal hernia after previous primary PEH repair (2012-2019). Patient and operative characteristics and post-operative outcomes were extracted from medical records. Patients were grouped into revisional (rPEH) and primary repair (pPEH). Coarsened exact matching was performed to create balanced cohorts. A total of 347 cases were identified. The matched cohort included 234 patients (rPEH: 46, pPEH: 188). Patient sex and comorbidities were well balanced, while those who underwent revisions were younger (64 ± 13 vs. 69 ± 11years; p = 0.01). Median time between primary and rPEH was 40[17-121] months. Incidence of emergency repair were similar among groups (rPEH: 9(15%), pPEH: 14(8%); p = 0.10). All revisional cases commenced laparoscopically with 7(15%) requiring conversion to open. The conversion rate was higher for rPEH than primary surgery (7(15%) vs. 3(2%); p < 0.01), with the most common reasons being adhesions and gastric fundus injury. Intra-operative complications occurred in 12(26%) revisional cases, of which 58% were gastric fundus injuries. Median length of stay was longer for rPEH than pPEH (2[1-5] vs. 1[1-2] day; p = 0.02). Incidence of severe complications (rPEH: 5(11%), pPEH: 11(6%); p = 0.23) and reoperations (rPEH: 2(4%), pPEH: 7(4%); p = 0.84) were similar between groups. There were no peri-operative deaths. In a high-volume tertiary care center, repair of recurrent giant paraesophageal hernias can be performed successfully laparoscopically in the majority of cases with acceptable morbidity and peri-operative outcomes in comparison to primary surgery.

ThP3.6 - Long Term Surgical Outcome of Complete Intrathoracic Stomach (CIS)

Abstract Background &amp; Aims Surgery is required for medically fit symptomatic CIS patients to avoid complications (volvulus, obstruction &amp; strangulation) that have high morbidity &amp; mortality. To assess the long term outcome including QOL (quality of life) for patients who underwent laparoscopic biological hiatal mesh reconstruction for CIS (100%). Methods Retrospective analysis of a prospectively collected of 34 CIS of 154 consecutive GPEH(Giant Para-Esophageal Hernia) patients intervened between March 2008- December 2023 in a large DGH. Data collected included demographics, BMI, ASA, Preoperative investigations (OGD &amp; Computerised Tomography), operative details including complications, &amp; standardised GERD-Health Related Quality of Life Questionnaire(GERD-QOL) scores of 0-5, 6-10, 11-15 &amp; more than 15 as excellent, good, fair &amp; poor respectively (pre-operatively, 6-month post-operative &amp; long-term), postoperative diet, SOB (shortness of breath) &amp; patient satisfaction. Results 34 included M:F 11: 23, age 72*(45-83) years, BMI 29 *(20-43), ASA III *(II-III). 20(59%), 20(59%), 18(53%), 14(41%), 14(41%) &amp; 12(35%) had heartburn, dysphagia, retrosternal discomfort, vomiting, weight loss and SOB respectively. 6 (18%) emergencies, 22 (65%) incomplete OGDs, operative time 210* (150-510) mins, 1(3%) conversion, 3*(9%) surgical mortality &amp; PO stay 3*(2-27) days. Pre and 6-month post surgery GERD-QOL poor (≥15) &amp; excellent (&amp;lt;5) in 21(62%) &amp; 32(94%) respectively with 32(94%) excellent satisfaction. Follow up at 102*(16-190) months had 2 more unrelated deaths, 21(72%) contacted with GERD-QOL excellent (&amp;lt;5) in 14(67%), poor 1(5%), 19(90%) solid diet, 2(10%) SOB with 19(90%) excellent satisfaction. Conclusion Favourable long term outcome achieved here supports complex surgery for this debilitating condition in the medically fit symptomatic elderly patients. * Median

Assessing the effect of body mass index on perioperative outcomes and short-term recurrence after paraesophageal hernia repair.

Previous assessments suggest that surgical results of paraesophageal hernia (PEH) repair were negatively impacted by increasing levels of obesity. A better understanding of the association of obesity on outcomes of PEH repair will support surgeons making evidence-based decisions on the surgical candidacy of individual patients. This single institution retrospective cohort study included 884 consecutive patients with giant PEH undergoing surgical repair between 1 January 2000 and 30 June 2020. Preoperative body mass index (BMI) was documented at the time of surgery. Main outcomes included perioperative blood loss, length of hospital stay, major complications, early hernia recurrence, and mortality. The mean (standard deviation [SD]) age at surgery was 68.4 (11.1), and 645 (73.0%) were women. Among the 884 patients, 875 had a documented immediate preoperative BMI and were included in the analysis. Mean (SD) BMI was 29.24 (4.91) kg/m2. Increasing BMI was not associated with increased perioperative blood loss (coefficient, 0.01; 95% confidence interval [CI], -0.01 to 0.02), prolonged length of stay (coefficient, -0.01; 95% CI, -0.02 to 0.01), increased incidence of recurrent hernia (odds ratio [OR], 1.03; 95% CI, 0.95-1.10), or increased major complications (OR, 0.93; 95% CI, 0.82-1.05). The 90-day mortality rate was 0.3%. Furthermore, when compared with the normal weight group, overweight and all levels of obesity were not related to unfavorable outcomes. No association was found between BMI and perioperative outcomes or short-term recurrence in patients undergoing PEH repair. Although preoperative weight loss is advisable, a higher BMI should not preclude or delay surgical management of giant PEH.

801. ROBOTIC ASSISTED LAPAROSCOPIC GIANT PARA-OESOPHAGEAL HERNIA REPAIR: 5-YEAR EXPERIENCE

Abstract Background Prior to laparoscopic era, giant paraesophageal hernia repair (GPEHR) was considered a relatively morbid operation requiring thoracotomy or laparotomy or both. GPEHR has been shown to be amenable to laparoscopic approach with low morbidity and mortality. We presented the outcome of over 200 cases of laparoscopic GPEHR (LGPEHR) with long-term follow- up over 20 years at DDW 2022. We have been performing robotic-assisted laparoscopic giant paraesophageal hernia repair (RAL-GPEHR) since 2018 and present our results. Methods We did a retrospective analysis of prospectively collected data of RAL- GPEHR using the DaVinci Xi between December 2018 and March 2024. All operating data are electronically recorded automatically by DaVinci Xi system for each surgeon/console user. Demographic data, clinical presentation, pre-operative assessment, and testing including haemoglobin (Hb), respiratory function {Forced Vital Capacity (FVC), Forced Expiratory Volume in 1 Second (FEV1)} as well as quality-of-life (QoL) with SF-36 questioners (including general health, physical, emotional, and social components), length of hospital stay (LOS), morbidity, mortality and follow up outcomes (Clinical, Hb, radiological, respiratory and QoL) were recorded. Results Twenty patients underwent RAL-GPEHR with 15(75%) having crural repair plus gastropexy and 5(25%) patients having additional Toupet fundoplication. Fourteen (70%) were females. Data is presented in Table 1. Presenting symptoms were dyspnoea, reflux, post-prandial pain, and dysphagia with 7(35%) anaemic. Eight (40%) were ASA III and 12(60%) ASA II. Thirteen (65%) were Type III-GPEH, 4(20%)-Type IV, one-Type II (5%) and 2(10%) recurrent GPEH. Blood loss was minimal with no intra-operative complications or conversions to open. One (5%) had post-operative chest infection. Symptoms improved in all post-operatively with improvement of Hb, FVC, FEV1 and QoL. Radiological recurrence occurred in one (5%) but remains asymptomatic. Conclusions This report represents our initial experience of a small number of patients undergoing RAL-GPEHR which has proved to be feasible and safe. A long-term follow- up with a large series of patients is required to compare long-term outcomes especially symptomatic recurrences and QoL.

Should We Operate Nonagenarians with Symptomatic Giant Paraesophageal Hernias?

Introduction: Hiatal hernia (HH) is a common disorder of the upper gastrointestinal (UGI) tract that general surgeons encounter. Giant paraesophageal is a subtype of HH in which more than 30% of the stomach is located in the chest. It can cause symptoms such as dysphagia, UGI bleeding, gastroesophageal reflux disease, and vomiting. As the life expectancy of the general population increases, the incidence of giant HH increases and can cause morbidity, including recurrent admissions and prolonged length of hospitalization. In this article, we describe a cohort of nonagenarian patients with HH who were admitted to our institution and were treated either surgically or medically. Methods: We retrospectively reviewed our prospectively maintained database of all nonagenarians who were admitted to our center between 2018 and 2022 with the diagnosis of HH. We compared the demographic data, clinical data, and outcomes between patients undergoing operative and nonoperative management. Results: Twenty patients of age over 90 years were hospitalized with HH-related symptoms. Six underwent surgery, whereas 14 received medical management. Surgical patients had fewer overall hospitalization days, shorter length of stay, and less blood product requirements. Notably two cases of in-hospital mortality occurred in the nonoperative group, whereas none occurred in the operative group. All surgical procedures were performed laparoscopically, with two minor perioperative complications. Conclusion: In selected nonagenarian patients, laparoscopic HH repair is safe and should be considered favorably. It can reduce hospitalization time and can mitigate morbidity.

Laparoscopic surgery of a rare giant paraesophageal hernia: a case report

Introduction and Importance: In the case of a hiatal hernia, the weakening of the esophageal hiatus allowed part of the stomach to slide to the mediastinum. Although the identification of hernias in esophageal hiatus is prone to subjectivity because of anatomical diversity, it is thought to occur often in radiological or endoscopic tests, with a range of 10–20% in the western population. Although asymptomatic, a rare form of hiatal hernia called a paraesophageal hernia (PEH) can be linked to serious, perhaps fatal consequences such as stomach volvulus. Only symptomatic patients should receive surgical treatment. In this case study, the authors present and discuss a giant PEH patient treated with laparoscopic hernial repair and fundoplication. A laparoscopic approach to PEH is important because of the shorter length of stay and fewer complications. Case Presentation: A 46-year-old Asian entered the hospital with symptoms of frequent dyspepsia syndrome, and from a computed tomography (CT) scan, she was diagnosed with a giant paraesophageal hernia. Hernia repair and fundoplication were performed laparoscopically. She was discharged three days after the surgery without significant complications. Clinical Discussion: This report represents a rare case of giant PEH. Although there are some limitations to laparoscopic surgery, it might be associated to fewer complication rate, a shorter stay in the hospital, and a faster recovery. Conclusion: Laparoscopic hernia repair and fundoplication is a safe and applicable surgery for people with symptomatic PEH.

Tackling complex thoracic surgical operations with robotic solutions: a narrative review.

The adoption of robotic surgery for general thoracic surgery has rapidly progressed over the last two decades from its application in basic operations to complex pathologies. As such, the purpose of this narrative review is to highlight the collective experience of tackling complex thoracic surgical operations with minimally invasive robotic solutions. Electronic searches of PubMed were conducted for each subtopic, using specific keywords and inclusion criteria. Once identified, the articles were screened through the abstract, introduction, results and conclusion for relevancy, and included based on a standard narrative review inclusion criteria. The role of the robotic approach has increased in thoracic outlet syndrome, chest wall resection, tracheobronchomalacia, airway and sleeve lung surgery, lobectomy after neoadjuvant therapy, complex segmentectomy, giant paraesophageal hernia repair, esophagectomy and esophageal enucleation, mediastinal masses and thymectomy and lung transplantation. Robotic surgery has several advantages when compared to video-assisted and open thoracoscopic surgery. These include better pain control and aesthetic outcome, improved handling of complex anatomy, enhanced access to lymph nodes, and faster recovery rates. Although it is associated with longer operative time, robotic surgery has comparable morbidity rates. The robotic approach to complex thoracic problems is safe, effective, and associated with improved patient outcomes. To encourage wider adoption of robotic technology, increased training and expanded research efforts are essential, alongside improved worldwide access to this technology.

OGBN P31 Laparoscopic versus open repair of giant paraoesophageal herniae: a 4-year retrospective study

Abstract Background Although laparoscopic repair of giant paraoesophageal hernia (PEH) has known advantages over open repair including a reduced post-operative length of stay (LOS) and reduced post-operative pain, there has been concern amongst surgeons regarding the recurrence rate. We sought to further analyse differences in outcomes in a retrospective series of patients with giant hiatus hernia in a single tertiary centre. Methods All giant PEH receiving operative repair at a tertiary referral centre (UCLH) were reviewed retrospectively over a one-year period from July 2019-July 2022. Diagnosis was made on gastroscopy and computer tomography (CT). A giant PEH was defined as one in which the hernia contained at least 50% of the stomach. If the patient was symptomatic post-operatively they were investigated for recurrence with gastroscopy and CT. Results The laparoscopic cohort (n=14, median age of 72 years, ASA 2) had similar demographics to those receiving open repair (n=21, median age of 68 years, ASA 2.5). Median length of stay was shorter in the laparoscopic cohort compared to the open cohort (3.5 days (1-7) versus 7 days (5-9)). The laparoscopic and open cohorts had similar rates of minor complications (42.8% (6=2, Clavien Dindo 2) versus 47.6% (n=10, Clavien Dindo 2))respectively. Recurrence of reflux or dysphagia symptoms was higher in those who had a laparoscopic repair (28.6% versus 14.3%). One radiologically confirmed recurrence occurred in the open group (4.7%). Conclusions Although the benefits of a faster post-operative recovery with a shorter LOS were clear in the cohort following laparoscopic repair, a higher rate of recurrence of symptoms was evident within those receiving a laparoscopic repair. Large, controlled, prospective studies with long-term follow-up are required in order to further establish differences in outcomes between laparoscopic and open repair of giant PEH.

OGBN O07 Factors in recurrence following 862 giant paraesophageal hernia repairs

Abstract Background Repair of giant paraesophageal hernia (PEH) is associated with a considerable hernia recurrence rate by objective measures. This study evaluated trends in outcomes of laparoscopic non-mesh repair of giant PEH over 30 years, and factors associated with anatomical recurrence. Methods Data was extracted from a single-surgeon prospective database of laparoscopic repair of giant PEH from 1991-2021. Upper endoscopy was performed within 12 months postoperatively and selectively thereafter. Any supra-diaphragmatic stomach was defined as anatomical recurrence. Cases were chronologically divided into tertiles with trends in casemix, operative factors and outcomes evaluated. Patient and hernia characteristics, and technical operative factors, including “composite repair” (360-degree fundoplication with esophagopexy and cardiopexy to right crus), were evaluated with univariate and multivariate analysis. Results 862 repairs met selection criteria. Mean age 69.3years, majority(65.8%) female and hernia type III(87.4%) with median hernia size 66%. There was an increasing proportion of “composite repair” after the first decade(Group1, 2.7%;Group2, 81.9%;Group3, 100%;p&amp;lt;0.001).There were less anatomical hernia recurrence(Group1, 36.6%;Group2, 22.9%;Group3, 22.7%;p&amp;lt;0.001) over time. The overall anatomical recurrence rate was 27.3% with median followup 33months(IQR 16, 68). There were 10(1.2%) Clavien-Dindo grade ≥III complications including two perioperative deaths(0.2%). Multivariate analysis identified age&amp;lt;70years, presence of Barrett’s, absence of “composite repair”, and hiatus closure under tension as independent factors associated with recurrence(HR1.27,95%CI0.88-1.82,p=0.01;HR1.58,95%CI1.12-2.23,p=0.009;HR1.72,95%CI1.2-2.44,p=0.002;HR2.05,95%CI1.33-3.17,p=0.001,respectively). Conclusions Hernia recurrence rates decreased with increasing case volume. This coincided with the increasing adoption of “composite repair”, supporting the possible improvement in recurrence rates with this approach. Repair was associated with substantial anatomical recurrence associated with patient and technique factors. Patient factors included age &amp;lt;70 years, Barrett’s esophagus, and hiatus tension. “Composite repair” was associated with lower recurrence rate.

Recurrence in Paraesophageal Hernia: Patient Factors and Composite Surgical Repair in 862 Cases

BackgroundRepair of giant paraesophageal hernia (PEH) is associated with a considerable hernia recurrence rate by objective measures. This study analyzed a large series of laparoscopic giant PEH repair to determine factors associated with anatomical recurrence. MethodData was extracted from a single-surgeon prospective database of laparoscopic repair of giant PEH from 1991 to 2021. Upper endoscopy was performed within 12 months postoperatively and selectively thereafter. Any supra-diaphragmatic stomach was defined as anatomical recurrence. Patient and hernia characteristics and technical operative factors, including “composite repair” (360° fundoplication with esophagopexy and cardiopexy to right crus), were evaluated with univariate and multivariate analysis. ResultsLaparoscopic primary repair was performed in 862 patients. The anatomical recurrence rate was 27.3% with median follow-up of 33 months (IQR 16, 68). Recurrence was symptomatic in 45% of cases and 29% of these underwent a revision operation. Hernia recurrence was associated with younger age, adversely affected quality of life, and were associated with non-composite repair. Multivariate analysis identified age < 70 years, presence of Barrett’s esophagus, absence of “composite repair”, and hiatus closure under tension as independent factors associated with recurrence (HR 1.27, 95%CI 0.88–1.82, p = 0.01; HR 1.58, 95%CI 1.12–2.23, p = 0.009; HR 1.72, 95%CI 1.2–2.44, p = 0.002; HR 2.05, 95%CI 1.33–3.17, p = 0.001, respectively). ConclusionRepair of giant PEH is associated with substantial anatomical recurrence associated with patient and technique factors. Patient factors included age < 70 years, Barrett’s esophagus, and hiatus tension. “Composite repair” was associated with lower recurrence rate.

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

PurposeLaparoscopic giant hiatus hernia repair is technically difficult with ongoing debate regarding the most effective surgical technique. Repair of small hernia has been well described but data for giant hernia is variable. This study evaluated trends in outcomes of laparoscopic non-mesh repair of giant paraesophageal hernia (PEH) over 30 years.MethodsRetrospective analysis of a single-surgeon prospective database. Laparoscopic non-mesh repairs for giant PEH between 1991 and 2021 included. Three-hundred-sixty-degree fundoplication was performed routinely, evolving into “composite repair” (esophagopexy and cardiopexy to the right crus). Cases were chronologically divided into tertiles based on operation date (Group 1, 1991–2002; Group 2, 2003–2012; Group 3, 2012–2021) with trends in casemix, operative factors and outcomes evaluated. Hernia recurrence was plotted using weighted moving average and cumulative sum (CUSUM) analysis.Results862 giant PEH repairs met selection criteria. There was an increasing proportion of “composite repair” after the first decade (Group 1, 2.7%; Group 2, 81.9%; Group 3, 100%; p < 0.001). There were less anatomical hernia recurrence (Group 1, 36.6%; Group 2, 22.9%; Group 3, 22.7%; p < 0.001) and symptomatic recurrence (Group 1, 34.2%; Group 2, 21.9%; Group 3, 7%; p < 0.001) over time. The incidence of anatomical recurrence declined over time, decreasing from 30.8% and plateauing below 17.6% near the study’s end. Median followup (months) in the first decade was higher but followup between the latter two decades comparable (Group 1, 49 [IQR 20, 81]; Group 2, 30 [IQR 15, 65]; Group 3, 24 [14, 56]; p < 0.001). There were 10 (1.2%) Clavien–Dindo grade ≥ III complications including two perioperative deaths (0.2%).ConclusionHernia recurrence rates decreased with increasing case volume. This coincided with the increasing adoption of “composite repair”, supporting the possible improvement in recurrence rates with this approach.

181 Lessons Learned from Complex Abdominal Wall Reconstruction for the Management of Giant Paraoesophageal Hernia - a Case Analysis

Abstract Aim In this case report, we present a new method in the management of a giant hiatus hernia: the use of crural relaxing incisions. This new method in combination with previously known strategies including botox and preoperative optimisation for surgery with weight loss and prehabiliation can result in a more effective surgical hiatus hernia repair and subsequently lead to a reduced risk of hiatus hernia recurrence. Case Presentation 71yo man admitted to hospital with a one-week history of generalised abdominal pain, nausea, vomiting and chest pain. He had a background of a known large hiatus hernia for the last 10 years. An abdominal CT showed a large type IV hiatus hernia containing the stomach, transverse colon, pancreatic body, and pancreatic neck. CT guided botulinum toxin A injections were given by interventional radiology during which the muscle bellies of the transversus abdominus, internal and external obliques were targeted. The patient was placed on a meal replacement (Optifast) diet. A laparoscopic thoraco-abdominal hiatus repair was performed finding a giant hiatus hernia containing the entire stomach, first part of the duodenum, left lobe of liver, transverse colon, small bowel and distal pancreas. Due to the size of the hiatus hernia and the potential tension likely to result from a repair, both right and left crural relaxing incisions were made to facilitate closure. Crural closure was reinforced with a Bio A mesh secured in a C configuration covering the right crural relaxing incision. The patient recovered well postoperatively. Follow up imaging did now show recurrence.

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

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

The impact of frailty on outcomes following laparoscopic repair of 'giant' paraesophageal hernias.

Frailty is a measure of physiologic reserve and correlates with surgical outcomes in the elderly. Patients who present with giant paraesophageal hernias (PEH) are typically older than 65. We defined 'giant' as a PEH with 50% or more of the stomach in the chest. We hypothesized that frailty correlates with 30-day complications, length of stay, and discharge destination following laparoscopic giant PEH repair. Patients older than 65 to undergo primary laparoscopic repair of a giant PEH at a single academic medical center between 2015 and 2022 were included. Hernia size was determined by preoperative imaging. Frailty was assessed clinically prior to surgery using the modified Frailty Index (mFI), an 11-item instrument that counts clinical deficits associated with frailty. A score ≥ 3 was considered frail. A major complication was a Clavien grade IIIB or higher. Of the 162 patients included in the study, mean age was 74.4 ± 7.2, and 66% of patients were female (n = 128). The mFI was ≥ 3 in 37 patients (22.8%). Frail patients were older (78 ± 7.9 vs. 73 ± 6.6years, p = 0.02). There was no difference in overall complication rate (40.5% vs. 29.6%, p = 0.22) or major complication rate (8.1% vs. 4.8%, p = 0.20) between frail and non-frail patients. Functionally impaired patients (METS < 4) were more likely to develop a major complication (17.9% vs. 3.0%, p < 0.01). Average length of stay was 2.4days, and frail patients experienced a longer mean hospital stay (2.5 ± 0.2 vs. 2.3 ± 1.8, p = 0.03). Frail patients were more likely to be discharged to a destination other than home. Increased frailty as assessed by the mFI is correlated with length of stay and discharge destination following laparoscopic repair of giant PEH in patients > 65. Complication rates were comparable for both frail and non-frail cohorts.

Robot-assisted giant paraesophageal hernias repair in a fourth level hospital in Bogotá, Colombia, Shaio Clinic: Case series and literature review

Robot-assisted giant paraesophageal hernias repair in a fourth level hospital in Bogotá, Colombia, Shaio Clinic: Case series and literature review

Laparoscopic Management of Giant Paraesophageal Hernia: Case Report and Review

There are 4 types of hiatal hernia, being type IV the rarest of all. The management today remains controversial about the ideal approach (abdominal, thoracic, mixed approach, laparoscopic or open surgery), the use or not of mesh, what type of fundoplication (anterior, posterior, total or parcial). We will present a giant paraesophageal hernia with gastric herniation and transverse colon resolved by laparoscopy, in an emergency surgery.

Minimally invasive esophagectomy for cancer in a patient with giant paraesophageal hernia

Minimally invasive esophagectomy in prone position is a procedure during which the patient is placed in a prone position during the thoracoscopic approach. A 67-year-old male patient consulted whit giant paraesophageal hernia and esophageal cancer. The treatment should be focused on the oncological resection of the esophagus despite the technical difficulties caused by the presence of a large hernia. A minimally invasive approach in the prone position and laparoscopic hernia repair can be considered an appropriate option for the resolution of both diseases with satisfactory results.

Dyspnoea improves following composite repair of giant paraoesophageal hernia.

Paraoesophageal hernias (PEH) are often symptomatic and can lead to life-threatening complications such as volvulus and ischaemia. Dyspnoea is one of the most prevalent symptoms of giant hiatus herniae. The primary outcome of this study is resolution of dyspnoea following composite repair of giant paraoesophageal hernia. Secondary outcomes include complications of surgery, hernia recurrence rates and effect of recurrence on dyspnoea. Data were extracted from a prospectively maintained single-surgeon database containing records of all patients undergoing composite repair of paraoesophageal hernia. Patients presenting with dyspnoea who underwent composite laparoscopic repair of giant (>30% of stomach above diaphragm) paraoesophageal hernia between March 2009 and December 2015 were included. Inclusion criteria were met by 154 patients. The mean age at time of surgery was 71.2 years (range 49-93, SD 9.66) with an average BMI of 28 (range 19-38kg/m2, SD 4.1). On average hernia contained 64% of stomach (range 30-100%, SD 20.2). One procedure was converted to laparotomy. Surgery resulted in near complete resolution of dyspnoea (2.6% postoperatively, p<0.001). Recurrence rate was 24% and was not associated with persistent dyspnoea. There was one death and two significant complications. Dyspnoea resolves following laparoscopic repair of giant paraoesophageal hernia. The presence of dyspnoea in patients with known large paraoesophageal hernia should be regarded as an indication for referral to a surgical service with expertise in hiatal hernia management.

631. OPERATIVE OUTCOMES OF ROBOTIC GASTROPEXY IN THE TREATMENT OF GIANT PARAESOPHAGEAL HERNIA IN PATIENTS WITH PREDOMINANTLY OBSTRUCTIVE SYMPTOMS

Abstract Our approach to the repair of giant paraesophageal hernia (GPEH) has undergone a paradigm shift. In cases with predominantly obstructive symptoms, following hernia repair, we have transitioned from a mandatory antireflux procedure to a comprehensive extended gastropexy. Further, we have successfully adopted the robotic platform, faithfully replicating the tenets of the operation that we previously refined using the laparoscopic approach. The objective of this study was to describe operative outcomes with this approach. With IRB approval, we retrospectively analyzed prospectively collected data. Operative technique included complete mediastinal dissection of the hernia sac, reduction of contents, tension free return of the stomach to its normal intraabdominal position, preservation of the crural lining, and repair of the crura with nonabsorbable suture. For patients with predominantly obstructive symptoms and minimal reflux, in lieu of an antireflux procedure, we performed an extended gastropexy involving accentuation of the angle of His and placement of a series of horizontal mattress sutures between the greater curvature of the stomach along the line of the short gastric vessels and the diaphragm. Between 2014 and 2021, 113 patients underwent robotic GPEH repair with gastropexy (median age 74.3 ± 9.05 years, 79.6% female, elective 78.7% vs. 21.2% urgent). Majority were Type III GPEH (75.2% vs 24.7% Type IV) and 22.3% had an organ-axial volvulus. Most common presenting symptoms were dysphagia (35.4%), vomiting (23.8%) and chest pain (17.7%). All operations were completed robotically. Cardinal tenets of GPEH repair were achieved in all cases. Average length of stay was 5.85 ± 5.18 days. Two patients (1.7%) died within 30 days, and 24.7% developed a postoperative complication, 13 (11.5%) were readmitted and 4 (3.5%) required reoperation. In patients with a GPEH who have predominantly obstructive symptoms, a robotic approach that adheres to the principal tenets of GPEH repair with an extended gastropexy in lieu of an antireflux procedure appears to be feasible and safe. Further studies that evaluate functional outcome and long-term follow-up to assess durability appear to be warranted.