Hiatal Hernia Patients Research Articles

The association between helicobacter pylori infection and erosive gastroesophageal reflux disease; a cross-sectional study

BackgroundThe association between H. pylori (Helicobacter pylori) infection and gastroesophageal reflux disease (GERD) is a complex and confusing subject. The aim of this study was to evaluate the association between helicobacter pylori infection and erosive gastroesophageal reflux disease.MethodIn a cross-sectional study, all patients referred for endoscopy due to dyspepsia were enrolled. The diagnosis of erosive GERD was made by endoscopy. Patients with normal esophagus were selected as comparison group. Random gastric biopsies were taken from all participants to diagnose H. pylori infection.ResultIn total, 1916 patients were included in this study, of whom 45.6% had GERD. The mean age (SD) was 42.95 (16.32). Overall, 1442 (75.3%) patients were positive for H. pylori infection. The frequency of H. pylori infection in mild GERD patients was higher than the severe GERD, but this difference was not significant (P = 0.214). Except for sociodemographic status (P < 0.001), other variables including gender, age, ethnicity, body mass index (BMI), smoking, and presence of hiatus hernia in patients had no significant association with the frequency of H. pylori infection. According to Robust Poisson regression models analysis, the association of H. pylori (PR 1.026; 95% CI 0.990–1.064; P = 0.158) and sociodemographic status were not significantly different between the two groups. But smoking, increased BMI, older age, presence of hiatus hernia, and peptic ulcer diseases were significantly associated with GERD compared with the non-GERD group.ConclusionIn our results, there was no association between H. pylori infection and erosive GERD. Further studies are recommended.

High prevalence of esophagitis in patients with severe ineffective esophageal motility: need for a new diagnostic cutoff.

BackgroundA new classification criterion for diagnosing ineffective esophageal motility (IEM) was proposed at the 2018 Stanford symposium, but limited data exists about the utility of this criterion.MethodsWe conducted a cross-sectional study among 3826 patients treated at the Institute of Gastroenterology and Hepatology, Hanoi, Vietnam, between March 2018 and May 2020. Patients were classified as having normal motility, mild IEM, severe IEM, or absent contractility based on the Chicago classification version 3.0 and the new IEM criterion (severe IEM was defined as having >70% ineffective swallows). We examined the association between these 4 motility subgroups and the presence of erosive esophagitis and Barrett’s esophagus, using multivariate logistic regression analysis.ResultsThe mean age of the study sample was 44.7 years and 66.3% were women. The prevalence of symptoms, hiatal hernia, and Helicobacter pylori-positive patients was similar in the 4 study groups. The 4-second integrated relaxation pressures and lower esophageal sphincter resting pressures were lower in patients with severe IEM and absent contractility. Severe IEM and absent contractility, but not mild IEM, were significantly associated with Los Angeles (LA) grade B-D esophagitis (relative risk ratio [RRR] for severe IEM 1.81, 95% confidence interval [CI] 1.17-2.80; and RRR for absent contractility 2.37, 95%CI 1.12-5.04). None of the hypomotility subgroups were associated with LA grade A esophagitis and Barrett’s esophagus.ConclusionsPatients with severe IEM have a high prevalence of severe erosive esophagitis. These findings suggest the need for a more meaningful classification criterion for IEM.

Preoperative hiatal hernia in oesophageal adenocarcinoma: An impact on patient outcomes?

Abstract Objective Uncontrolled gastroesophageal reflux and the often-associated hiatal hernia (HH) are frequently encountered in oesophageal adenocarcinoma patients. Previous data suggest unfavourable long-term oncologic outcomes in the presence of a HH, but the evidence remains scarce. The aim of this study was to assess the potential impact of preoperative HH on histologic response after neoadjuvant treatment (NAT), as well as on overall and disease-free survival. Methods All patients operated for an adenocarcinoma of the oesophagus or gastro-oesophageal junction (GOJ) between 2012-2018 were assessed. Baseline endoscopy and CT-scan images were retrospectively reviewed to identify the presence of a clinically significant HH (≥3cm). Response to neoadjuvant treatment (Mandard TRG grade), postoperative outcomes and survival were compared between HH and non-HH patients. Categorical variables were compared with the x2 or Fisher’s test, whereas continuous ones with the Mann-Whitney-U test. Survival analyses were performed with the Kaplan-Meier method and log-rank test. Results Overall, 101 patients were included (84.1% male, median age 63 years); among them, 33 (32.7%) had a HH ≥ 3cm at diagnosis of oesophageal cancer. There were no significant baseline differences in demographics and tumour stages between the two groups. NAT was used in 80.9% of non-HH versus 81.8% HH patients (P = 0.910), most often chemoradiation (57.3% in non-HH versus 63.6% in HH patients, P = 0.423). Surgical approach and postoperative complication rates were similar in all patients. Good response to NAT (TRG 1-2) was observed in 32.3% of non-HH, versus 33.3% of HH patients (P = 0.297), whereas R0 resection was achieved in 94.1% vs 90.9% of patients respectively (P = 0.551). Overall survival was comparable between HH (median 28 mo, 95%CI 22-NA) and non-HH patients (median 41mo, 95% CI 29-NA) (P = 0.605). Disease-free survival was also similar (median 18 mo, 95%CI 12-NA for HH, vs 34mo, 95%CI 14-NA for non-HH patients, P = 0.283), although HH patients experienced higher rates of distant (51.6% vs 29.2% for non-HH, P = 0.033), but not locoregional recurrence. Conclusion A clinically significant HH is encountered in almost a third of patients with oesophageal adenocarcinoma. However, in our study, it was not associated with a worse response to NAT, nor did it lead to a worse overall and disease-free survival.

Sliding Hiatus Hernia: A Two-Step Pressure Pump of Gastroesophageal Reflux

It is the general consensus that a sliding hiatus hernia (HH) is important in the pathogenesis of gastroesophageal reflux (GER) disease. However, the mechanism by which HH contributes to the pathogenesis of GER disease has been debated for many decades. 1 Tack J. et al. Gastroenterology. 2018; 154: 277-288 Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar GER implies the flow of stomach contents into the esophagus; it should follow the physical principles of pressure gradient and sphincter that facilitate and restrict flow, respectively. High-resolution manometry (HRM) impedance recordings allow the accurate measurement of the intraluminal pressure and flow at closely spaced intervals. We studied whether respiration-induced pressure changes in the esophagus, lower esophageal sphincter (LES), HH, crural diaphragm (CD), and stomach are conducive to GER in HH patients.

Study on incidence of hiatus hernia in patients undergoing upper gastrointestinal endoscopy for upper gastrointestinal symptoms in a secondary care hospital

Background: Hiatus hernia refers to condition in which elements of the abdominal cavity, most commonly the stomach, herniate through the oesophageal hiatus into the mediastinum.Hiatal hernia is a frequent finding during upper gastrointestinal endoscopy. Type I hiatal hernia is the sliding hiatal hernia, which accounts for more than 95% of all hiatal hernias with the remaining 5% being paraesophageal hiatal hernias taken together. Surgical therapy is recommended for patients with severe and refractory GERD symptoms such as poor compliance to long-term medical therapy and young patients wishing to avoid lifetime medical treatment. The objective of this study was to identify the associated symptoms and to determine diagnostic accuracy of endoscopic evaluation in patients with hiatus hernia.Methods: Current retrospective study comprised of 250 patients who presented with complaints of upper gastrointestinal symptoms and underwent upper gastrointestinal endoscopy in JSS hospital, Chamarajnagar during the period of October 2018 to May 2020.Results: Out of 250 patients, 162 males (64.8%) and 88 females (35.2%) were part of the study, who presented with upper GI symptoms, 12 (4.8%) patients were diagnosed with hiatus hernia. Out of these 12 cases, 9 patients (75%) were found to be having sliding type of hiatus hernia and 3 patients (25%) having rolling type.Conclusions: Early diagnosis and timely management or surgical intervention reduces morbidity associated with hiatus hernia and acid reflux. Hence, all patients presenting with persistent upper gastrointestinal symptoms should undergo upper GI endoscopy managed accordingly.

S0421 Lower Esophageal Sphincter Pressures Are Significantly Reduced in Patients With a Hiatal Hernia but No Major Abnormality on Esophageal Manometry

INTRODUCTION: A hiatal hernia (HH) eliminates the normal alignment of the lower esophageal sphincter (LES) and crural diaphragm (CD), separating the two components of the esophago-gastric junction high pressure zone (EGJHPZ). This separation may affect parameters measured during high resolution esophageal manometry (HREM), including measurements of resting lower esophageal sphincter (LES) pressure. The effect of a HH on LES relaxation, as measured by integrated relaxation pressure (IRP), is less well studied. The aim of this study was to determine how a HH affects HREM parameters. METHODS: HREM performed at a large referral-based motility center between 2013 and 2019 were reviewed. Patients with any major/minor peristaltic disorder based on Chicago Classification version 3.0 (CC3), or where the catheter did not traverse the LES, were excluded. Key manometric parameters including LES resting pressure and IRP, distal contractile integral (DCI), contractile front velocity (CFV), distal latency (DL) and esophageal length were collected. Patients were further subdivided into 3 groups according to HH size on HREM for analysis: no HH, HH 0.1–1.9cm, and HH ≥ 2 cm. RESULTS: A total of 1330 HREM reports were reviewed, with 479 studies not showing a CC3 abnormality. These patients had no HH (189, 39.5%), HH 0.1–1.9 cm (172, 35.9%), and HH ≥ 2 cm (118, 24.6%) (Figure 1). Analysis demonstrated that the presence of a HH was associated with a significantly lower mean LES resting pressure, IRP, and DCI (all P-values < 0.02, Table 2). Esophageal length was consistently shorter in HH patients (P < 0.01). For all 3 parameters, values decreased as HH size increased. There was no statistical difference between groups with respect to CFV or DL. CONCLUSION: In patients without a CC3 peristaltic abnormality, HH patients show significant decreases in LES resting pressure, IRP, and esophageal length. Separating the CD from the EGJHPZ may be partially responsible for the drop in pressures. However, HREM analysis software is supposed to isolate the LES from any CD contribution. Additional investigation is necessary to determine whether and what HH-related changes to the LES itself are contributing to this significant difference, and if they affect related conditions such as gastro-esophageal reflux. Shorter esophageal length may impact the success of a HH repair. Further studies exploring the outcomes of different surgical approaches in varying esophageal lengths are warranted.Figure 1.: Study Flow Diagram.Table 1.: Baseline Demographic CharacteristicsTable 2.: High Resolution Esophageal Manometry Findings

Is fundoplication advisable in repair of para-oesophageal hernia? “Little operation” or “big operation”?

It has been observed that not all large hiatus hernia patients have heartburn in their symptom profile at the time of their presentation. Therefore, the necessity of an anti-reflux procedure concurrent with the repair of the large hiatus hernia is contentious. A small prospective cohort (21) of consecutive patients diagnosed with giant hiatus hernia were evaluated for symptoms of heartburn and regurgitation at any stage during the history. A pulmonary reflux aspiration scan was additionally performed to detect reflux events objectively. Heartburn or regurgitation was present in the symptomatic history of 75% (15) of patients. The pulmonary reflux aspiration scan confirmed the occurrence of reflux events in 86% (13) of patients. These data support the case for routine fundoplication when repairing hiatus hernia, unless otherwise contraindicated. Probably due to the configuration of para-oesophageal hiatus hernias, there is a diminution of reflux symptoms as the hernia progresses. Despite this presentation there is a high level of reflux symptomology and a high level of regurgitation shown objectively by scintigraphy, often culminating in pulmonary aspiration.

P6 HIATAL HERNIA REPAIR BY TENSION-FREE MESH CLOSURE OR SIMPLE SUTURING OF THE DIAPHRAGMATIC HIATUS

Abstract Aim To assess the anatomical and functional results of the use of a mesh for the repairing of hiatal hernia in patients with gastro-esophageal reflux disease (GERD) Background &amp; Methods In hiatal hernia repair during antireflux surgery, less focus has traditionally been directed towards the restoration of the diaphragmatic hiatus. In other types of hernia repair, the use of a mesh-reinforced, tension-free technique has been shown to be associated with reduced recurrence rates. Patients (n=159) undergoing Nissen fundoplication for gastro-esophageal reflux disease were randomized to closure of the diaphragmatic hiatus with either crural sutures alone (n=77) or tension-free closure with a non-absorbable mesh (Crurasoft®, n=82). Primary outcome was radiologically verified recurrent hiatal hernia. Secondary outcomes were intra-and postoperative complications and courses, symptomatic recurrence, use of PPI, postoperative oesophageal acid exposure and Quality of Life. Results At 3 years recurrence rates were 12 % and 9 % in the mesh and suture groups respectively (p=0,61). Control of GERD symptoms, use of PPI and oesophageal acid exposure did not differ between groups. At the same time obstructive eating complaints were reduced in both groups compared to the preoperative setting (p&lt;0.05) but more patients scored dysphagia for solid food after mesh closure (p=0,027). Quality of life scores were significantly improved throughout the follow up without differences between groups. Conclusion Tension-free crural repair with non-absorbable mesh does not reduce the incidence of recurrent hiatal hernia compared to crural sutures alone in GERD patients undergoing total fundoplication. This, together with the finding of increased dysphagia at 3 years postoperatively, suggests that mesh closure cannot be recommended for routine use in laparoscopic hiatal hernia repair for GERD.

Prognostic Significance of Hiatal Hernia in Patients with Gastric Cancer Located within the Upper-Third of the Stomach.

Gastric cancers located within the upper-third of the stomach (UGC), especially the esophagogastric junction GC (EGJGC), have distinct clinicopathological features due to their potential for multidirectional lymphatic spread. In this study, we investigated the clinical significance of hiatal hernias (HH) in patients with UGC, including EGJGC. In this retrospective study, we assessed status of HH in 147 patients with UGC who underwent curative resection at our hospital and examined the correlation between the presence of HH (+) and multiple clinicopathological factors. Thirty-four patients (23%) were HH (+). However, we found no significant correlation between HH (+) and clinicopathological factors. HH (+) patients frequently developed lymph node recurrences. Prognosis was significantly better in patients with UGC and HH (-), compared to those with UGC and HH (+). Similarly, EGJGC patients who were HH (-) showed superior survival compared to HH (+) patients. Multivariate analysis found that the HH (+) (p = 0.004), histological type (p = 0.029), and nodal stage (p = 0.034) were independent prognostic factors. The presence of HH might affect lymphatic spread of tumor cells, and consequently prognosis of patients with UGC. Therefore, special attention is needed in developing surgical and postoperative strategies for such patients with UGC who are HH (+).

Is repairing giant hiatal hernia in patients over 80 worth the risk?

Patients with giant hiatal hernia (GHH) are often symptomatic and have significantly reduced quality of life (QoL). Advanced age is a predictor of increased morbidity and mortality in open hiatal surgery, however, outcomes of laparoscopic surgery in patients over the age of 80 are limited to case reports and small case series.Data was extracted from a prospectively maintained database. Consecutive patients over the age of 80 with GHH that have undergone surgery were included. Peri-operative mortality, complications, recurrence rates, use of acid suppressive medication and QoL was analysed. Search of Ryerson index was performed to determined post-operative survival.Inclusion criteria were met by 89 patients. Mean age was 84 (80–93). The mean volume of herniated stomach was 70.9% range 30–100%; SD 27.25). There was one death in this cohort on day 30 from myocardial infarction and one mediastinal collection requiring percutaneous radiological drainage and antibiotics. There were no other major complications (Clavien-Dindo Grade III-IV). Mean post-operative survival was 74.5 months (SD 47.8). GIQLI was reduced pre-operatively (mean 91.8; SD 19.4). There was significant improvement in GIQLI scores at early (mean 101.45; SD 21.2) and late (mean 106.7; SD 19.2) post-operative follow-up (p = 0.005). Pre-operative Visick scores (mean 2.92; SD 0.98) have improved significantly in early (mean 1.94; SD 0.97; p = 0.000) and late (mean 2.03; SD 0.99; p = 0.001) post-operative periods. Satisfaction with surgery was 97% during early and 93.3% during late post-operative follow up.Laparoscopic repair of GHH in appropriately selected elderly patients is safe and results in significant improvement in quality of life.

2715 A Hiatal Hernia Causing Atrial Fibrillation Through Direct Mechanical Irritation

INTRODUCTION: Hiatal hernia (HH) is anatomically classified into four types according to herniated structures. Giant HH refers to a herniation of &gt;50% of the stomach. Atrial fibrillation (AF) is a common arrhythmia, frequently seen in association with cardiovascular diseases. We report a case of AF caused by a giant HH compressing the left atrium. CASE DESCRIPTION/METHODS: A 90+ year-old female with a past medical history of gastroesophageal reflux disease (GERD), was admitted for surgical evaluation of symptomatic HH. During hospital stay the patient developed AF with rapid ventricular response, became hypotensive and lightheaded. EKG (Figure 1) confirmed new onset AF with non-specific ST-T wave changes. Sinus rhythm conversion was achieved by amiodarone drip. Metabolic and endocrine causes of the AF were ruled out. Ischemic etiology of the AF was ruled out by a normal myocardial perfusion imaging study. Computed tomography Angiography of the chest (Figure 2) was only remarkable for persistent giant hiatal hernia. Echocardiogram (Figure 3) showed external material compressing against the heart and the left atrium. At that point, the patient and the surgical team have decided on conservative management for her HH due to her high surgical risk. Patient was discharged home in sinus rhythm on oral anticoagulant and beta blocking agent. DISCUSSION: Gastroesophageal reflux disease (GERD), HH and AF are often seen in association. AF in GERD patients is likely due to local cytokine release from esophageal injury or vagal overstimulation. Such association is supported by reduced AF recurrences by reflux suppression with PPI use or fundoplication. However, the underlying mechanism of AF in HH patients has not been fully understood. In our case, left atrial compression and impingement were seen, which indicates direct left atrial irritation causing atrial arrhythmia. Surgical reconstitution of HH to relieve the cardiac compression would be the definitive treatment. Unfortunately, our patient was not a candidate for such invasive thoracic surgery due to her age. A similar case scenario was previously reported, in which AF was suppressed after laparoscopic surgical repair of a giant paraesophageal hernia. More cases need to be studied to confirm the hypothesized etiology of AF in patients with giant HH.

Role of fundoplication in treatment of patients with symptoms of hiatal hernia

Gastroesophageal reflux disease (GERD) is often associated with hiatal hernia (HH). However, the need for fundoplication during hiatal hernia repair (HHR) remains controversial. The objective of this study was to evaluate the effect of HHR with concomitant laparoscopic Nissen fundoplication (HHR-LNF) in HH patients. A total of 122 patients with symptomatic HH were randomized to receive either HHR (n = 61) or HHR-LNF (n = 61). The measures of evaluating outcomes included DeMeester scores (DMS), complications, Reflux Diagnostic Questionnaire and patients’ satisfaction 24 months following surgery. Despite comparable values in both groups at randomization, the DMS, total numbers of reflux episodes and percentage of time with pH < 4 were significantly higher in HHR group than in HHR-LNF group (P = 0.017, P = 0.002 and P = 0.019, respectively) at 6 months after surgery. One months postoperatively, complications were higher in the HHR-LNF group than in the HHR group (all P < 0.001), and there was no difference between the two groups at 6 months. By the end of the 2-year follow-up, HHR-LNF group showed a significantly lower reflux syndrome frequency-intensity score and greater percentage of satisfaction compared with HHR group (all P < 0.001). Laparoscopic HHR should be combined with a fundoplication in GERD patients with HH. HHR-LNF is safe and effective, not only improve reflux-related symptom, but also reduce the incidence of complications.

Magnetic sphincter augmentation (MSA) in patients with hiatal hernia: clinical outcome and patterns of recurrence

IntroductionMagnetic sphincter augmentation (MSA) is an effective treatment for patients with gastroesophageal reflux disease. In early studies, patients with a hiatal hernia (HH) ≥ 3 cm were excluded from consideration for implantation and initially the FDA considered its use as “precautionary” in this context. This early approach has led to an attitude of hesitance among some surgeons to offer this therapy to patients with HH. This study was designed to evaluate the impact of HH status on the outcome of MSA and to report the rate of HH recurrence after MSA.Methods and proceduresThis is a retrospective review of prospectively collected data of patients who underwent MSA between June 2013 and August 2017. Baseline clinical and objective data were collected. Patients were divided into four groups based on HH status: no HH, small HH (< 3 cm), large HH (≥ 3 cm), and paraesophageal hernia (PEH). Patient satisfaction, GERD–HRQL and RSI data, freedom from PPI, need for postoperative dilation, length of hospitalization, 90-day readmission rate, need for device removal, and HH recurrence was compared between groups.ResultsThere were 350 patients [60% female, mean (SD) age: 53.5 (13.8)] who underwent MSA. There were 65 (18.6%) with no HH, 205 (58.6%) with small HH (< 3 cm), 58 (16.6%) with large HH (≥ 3 cm) and 22 (6.2%) with PEH. At a mean follow-up of 13.6 (10.4) months, the rate of outcome satisfaction was similar between the groups (86%, 87.9%, 92.2% and 93.8%, p = 0.72). This was also true for GERD–HRQL total score clinical improvement (79.1%, 77.8%, 82% and 87.5%, p = 0.77). The rate of postoperative dysphagia (p = 0.33) and freedom from PPIs (p = 0.96) were similar among the four groups. Duration of hospitalization was higher among those with a large HH or PEH, and only PEH patients had a higher 90-day readmission rate (p = 0.0004). There was no difference between the need for dilation among groups (p = 0.13). The need for device removal (5% overall) was similar between the four groups (p = 0.28). HH recurrence was 10% in all groups combined, and only 7 of 240 (2.9%) patients required reoperation; the majority of these patients underwent a minimal dissection approach (no hernia repair) at the index operation. The incidence of recurrent HH increased in direct correlation with the preoperative HH size (0%, 10.1%, 16.6 and 20%, p = 0.032).ConclusionIn the largest series of MSA implantation, we demonstrate that the excellent outcomes and high degree of satisfaction after MSA are independent of the presence or size of HH. Despite higher rates of hernia recurrence in large HH and PEH patients, the rates of postoperative endoscopic intervention, and device removal is similar to those with no or small HH. The minimal dissection approach to MSA should be abandoned.

Su1140 – Prevalence of Hiatal Hernia in Patients with Achalasia

Su1140 – Prevalence of Hiatal Hernia in Patients with Achalasia

Association between cholelithiasis and hiatus hernia in patients with dyspepsia: a prospective study

Background: An association between hiatus hernia and cholelithiasis has been suspected for a long time but has never been adequately documented. Cholelithiasis is an asymptomatic disease. The precise incidence of hiatus hernia is not known. In current era as the practise is getting result oriented not diagnosing Hiatus hernia and persistence of symptoms is considered as failure in case of surgery. Coexistence if diagnosed preoperatively is of great help in management of the patient. The purpose of the study is to study association of Hiatus hernia with cholelithiasis in patients with dyspepsia.Methods: This is a prospective study conducted in DR. D. Y. Patil Medical College, Pune, Maharashtra for a period of two years. 100 patients of dyspepsia were enrolled in the study. All patients of dyspepsia were subjected to USG- abdomen. Patients were divided into diagnosed cholelithiasis (A) and non-cholelithiasis (B) as per USG findings. Both groups were subjected to upper gastro intestinal scopy. Appropriate statistical method was applied to know the incidence of hiatus hernia in cholelithiasis and non -cholelithiasis patients. Comparison was done to know the association between hiatus hernia and cholelithiasis in the patients with dyspepsia.Results: Total 24% patients had both hiatus hernia and cholelithiasis. Whereas 23% patients had neither hiatus hernia nor cholelithiasis on applying chi-square, p-value is 0.58. This is statistically insignificant.Conclusions: There is no obvious association between hiatus hernia and cholelithiasis in patients with complains of dyspepsia.

Long-term outcome of the laparoscopic repair of hiatus hernia

Presently, the improvement in the quality of life of patients who underwent a laparoscopic surgical repair of hiatus hernia and the absence of the gastroesophageal reflux disease (GERD) recurrence are the basic characteristics of the surgical treatment. In this connection, further perfection of the tactics and techniques of the surgical GERD treatment becomes an important problem of modern surgery.&#x0D; Here, we present a comparative analysis of the remote results of the surgical treatment of 159 patients with GERD-complicated hiatus hernia. The patients were divided into two groups, depending on the technique of the performed endosurgical treatment. The first group consisted of patients operated via the standard laparoscopic Nissen fundoplication. In the second group, we included those patients who underwent surgical treatment using a modified procedure of Nissen fundoplication with the formation of a non-tension cuff (RF patent No. 2529415 of 27.09.2014).&#x0D; Evaluation of the results, based on the survey questionnaires Gerd-Q, GSRS, SF-36 and the data of instrumental research methods, was performed 1 to 5 years post-treatment.&#x0D; The treatment of the GERD-complicated hiatus hernia patients with application of the technique of forming a non-hanging fundoplication cuff shows the best long-term results: the incidence of the reflux syndrome and signs of hyperfunction of the fundoplication cuff is lower. The revealed differences coincide with the data of the Gerd-Q and GSRS questionnaires, as well as the life quality estimation by the SF-36 questionnaire. The developed techniques do not require application of sophisticated technical skills and re-equipment and may be recommended for the practical use in the everyday practice in surgical hospitals of all levels.

A291 - Comparison between endoscopic and laparoscopic evaluation of hiatus hernia in patients undergoing weight loss surgery

A291 - Comparison between endoscopic and laparoscopic evaluation of hiatus hernia in patients undergoing weight loss surgery

Valsalva maneuver exacerbates left atrial compression in patients with large hiatal hernia

Hiatal hernia (HH) can cause left atrial (LA) compression and impair LA filling. We evaluated the cardiac effects of preload reduction and abdominal strain induced by Valsalva maneuver (VM) in large HH patients. LA and left ventricular (LV) dimensions were measured using 2D transthoracic echocardiography at rest and during VM in HH patients (n=55, 70±10years) and controls (n=22, 67±6years). Biplane LV volumes (n=39) and mitral inflow pulse-wave Doppler parameters (n=27) were also evaluated. In HH patients, resting LA compression was graded qualitatively (none-mild or moderate-severe). In both controls and HH patients, VM significantly decreased LA (controls, 19±2 vs 16±3mm/m2 ; HH, 16±5 vs 9±5mm/m2 ) and LV diameters (22±3 vs 19±3mm/m2 ; 21±3 vs 17±3mm/m2 ) and LV volume (38±8 vs 26±10mL/m2 ; 31±8 vs 19±9mL/m2 ) (P<.001 for all). VM decreased LA diameter significantly more in HH patients than controls (-42% vs -16%, P<.001). HH patients with none-mild resting LA compression exhibited significantly greater LA diameter reduction than controls (-38±23% vs -16±13% P=.0003) despite similar resting LA diameters. LV volumes were similarly decreased by VM in HH patients and controls irrespective of resting LA compression severity indicating relative preservation of LV filling. LA diameter correlated inversely with early diastolic filling velocity during VM in HH patients (R=-.43, P=.03) but not controls (R=.18, P=.43). VM can markedly exacerbate LA compression in HH patients; however, LV filling is relatively less affected possibly due to augmented early diastolic filling. Conditions associated with decreased preload and increased intra-abdominal pressure may exacerbate the cardiac effects of large HH.

Creative surgery for hiatal hernia

To present an experience of surgical treatment of hiatal hernia. An experience of more than thousand laparoscopic fundoplications in various modifications has been accumulated in the Clinic of Bashkir State Medical University for the period 2001-2016. An original device for intraoperative measurement of hiatal orifice is described. Hiatal orifice repair was indicated in case of its dimension over 3.5 cm. 310 patients underwent hiatal orifice repair including diaphragmocrurorrhaphy in 189 cases, hiatal orifice replacement by using of mesh implant in 121 cases. Simultaneous interventions were performed in 211 cases due to hiatal hernia combined with other abdominal diseases. Thus, selection of hiatal hernia patients for antireflux surgery should be clearly indicated according to clinical and instrumental data in the context of health care system reforming and widespread use of minimally invasive technologies. Laparoscopic operations for hiatal hernia are preferable and contribute to decrease of morbidity and improvement of outcomes.

Laparoscopic Approach to the Management of Achalasia Associated with Large Hiatal Surface Area

Abstract Introduction: Several reports have emphasized the relative rarity of coexistence of hiatal hernia in patients with achalasia.1–4 Nevertheless, clinicians should be aware that esophageal disorders can coexist and may present challenges if not identified early. The esophagus should be fully investigated whenever possible to plan the most appropriate surgical technique from a range of various options. Failure to identify coexistence of achalasia in patients undergoing hiatal hernia surgery may have undesirable outcomes.5 We assume that failure to identify hiatal hernia or predisposition to hiatal hernia in patients undergoing surgery for achalasia may have the same long-term undesirable consequence. A recent study has devised a method to measure in vivo esophageal hiatal surface area using multidetector computed tomography (MDCT) reconstruction.6 Strong correlation between large hiatus and occurrence or predisposition to hiatal hernia has been reported. The normal size range for the hiatal surface a...