A 40-year-old man was admitted with acute diarrhoea, 3kg weight loss, and mild fever (up to 38 °C). His medical history included acute necrotising pancreatitis and an axial hiatal hernia. Laboratory tests showed elevated inflammation parameters (C-reactive protein of 188mg/L). A 18 F-FDG-PET/CT scan revealed infected abdominal pancreatic pseudocysts extending to the thoracic region due to the hiatal hernia. Endosonography and transgastric drainage removed 200mL of pus. Klebsiella pneumoniae was identified, and antibiotic therapy with ampicillin and sulbactam was started. A follow-up ultrasound showed significant cyst regression. The patient was discharged in a satisfactory condition with reduced inflammation.

Conventional classifications of T1 adenocarcinoma at the esophagogastric junction (T1-AEGJ) rely on lymph node metastasis patterns and define AEGJ according to the distance between the tumor epicenter and esophagogastric junction (EGJ). However, their significance in T1-AEGJs remains unclear due to the low frequency of lymph node metastasis. Thus, classifications based solely on tumor epicenter may encompass tumors with distinct biological behaviors, particularly those in the stomach. Therefore, we aimed to elucidate the characteristics of T1-AEGJs localized in the stomach. We retrospectively analyzed 266 patients with pT1-AEGJs who underwent endoscopic or surgical resection between 2010 and 2023. Tumors were classified into Groups E (confined to the esophagus or crossing the EGJ) and G (localized in the stomach). Clinicopathological features were compared between the groups, and risk factors for deep submucosal invasion (SM > 500μm) were evaluated using multivariate analysis. Patients in Group G were older and had a higher prevalence of Helicobacter pylori infection (64.9% vs. 30.8%) and intestinal metaplasia (71.6% vs. 43.1%). Conversely, patients in Group E had more incidences of hiatal hernia (42.5% vs. 20.3%), gastroesophageal reflux disease (43.4% vs. 22.4%), Barrett's esophagus (47.6% vs. 9.0%), and deep submucosal invasion (45.4% vs. 27.8%). Tumor size ≥ 20mm, EGJ extension, depressed or protruded morphology, and undifferentiated biopsy histology were identified as independent risk factors for deep invasion. T1-AEGJ tumors in the stomach demonstrate distinct clinicopathological features. Therefore, a classification based on EGJ extension, and not just epicenter, may improve their risk assessment and treatment decisions.

Robotic primary Roux-en-Y gastric bypass is independently associated with increased 30-day mortality: a 2023 MBSAQIP analysis of 50,365 patients.

Persistent heartburn is a common indication for gastroscopy. However, the diagnostic yield and contribution of patient-level factors, including ethnicity, to clinically significant findings (CSFs) remain incompletely defined. This retrospective cohort included 6813 adults who underwent gastroscopy between 2012 and 2023 for persistent heartburn despite prior acid-suppressive therapy. Arab ( n = 1831) and Jewish ( n = 4982) patients were compared in terms of demographics, treatment history, procedural characteristics, and endoscopic outcomes. Multivariable logistic regression identified independent predictors of CSFs. Arab patients were significantly older than Jewish patients (56.2 ± 18.7 vs. 50.2 ± 14.6 years; P < 0.001), with no difference in sex distribution. Pre-endoscopy treatment differed markedly by ethnicity: Arab patients more frequently received antacids only (17.6 vs. 3.2%) or H2-blockers (18.0 vs. 11.5%), whereas Jewish patients were more likely to receive proton pump inhibitors (PPIs), including high-dose and twice-daily regimens. CSFs were more prevalent among Arabs (18.9 vs. 12.3%; P < 0.001), primarily because of higher rates of Barrett's esophagus and severe reflux esophagitis. Multivariable analysis showed that Arab ethnicity, male sex, older age, and presence of hiatus hernia were independently associated with CSFs, while adequate PPI therapy (particularly prolonged or high-dose regimens) was protective. Gastroscopy in patients with persistent heartburn frequently reveals clinically significant esophageal pathology, particularly among Arab patients. Ethnic disparities in pre-endoscopy management and outcomes suggest that tailored therapy may mitigate disease burden and improve endoscopy utilization.

Chronic neurogenic cough (CNC) is prevalent in Otolaryngology settings and impactful. Targeted neuromodulators may offer benefits. This longitudinal study of CNC patients taking pregabalin evaluates success of treatment, duration of treatment, and responses in relation to presence of other trigger conditions. Ninety five patients (73% female, mean age 62y [12.5, SD]) treated with pregabalin for CNC were evaluated by patient-reported outcome measures, ratings of cough improvement and ability to discontinue therapy. Patients presented with mean 3.5 year [2.75 SD] cough duration. Seventy-eight percent of individuals administered pregabalin reported significant cough improvement or resolution, with mean 6.5 weeks [5, SD] of therapy. Significant reduction in HARQ from 32 [11, SD] to 22 [15, SD], [t-4.15, p = 0.0001, d = 0.60], and RSI scores from 21 [8, SD] to 14.4 [8.2, SD], [t = 6.71, p < 0.001, d = 0.75] were seen following treatment, with moderate effect sizes. 17% of patients taking pregabalin did not report improvement, with 1% reporting worsening cough. Side effects requiring discontinuation of therapy were reported in 4% of patients. Presence of hiatal hernia, dysmotility or reflux findings did not change the likelihood of positive response (75% [no findings] vs. 80% [positive findings]). Sex did not affect likelihood of improvement (female 82% vs. male 85%, p = n.s). Pregabalin is a well-tolerated neuromodulator providing relief of CNC symptoms in patients presenting to an Otolaryngology clinic. Treatment duration of 6 weeks provides relief to more than three quarters of patients and response to therapy occurs equally across genders and in those with gastrointestinal comorbidities.

Paraesophageal hernias are a prevalent medical condition often treated with surgical intervention, and decisions regarding hernia sac management are involved. Sac excision during PEH repair has emerged as a viable and safe management strategy, with potential implications for patient outcomes. This study aimed to assess the impact of sac excision on hernia recurrence, reoperation rates, and postoperative gastroesophageal reflux disease (GERD) in patients undergoing hernia repair. A retrospective analysis was conducted on patients who underwent paraesophageal hernia repair between 2014 and 2022. Data on patient demographics, preoperative evaluation, surgical technique, and long-term follow-up were collected and analyzed. Primary outcomes included hernia recurrence, reoperation rates, and postoperative GERD assessed over a mean follow-up of 1.8 years. Analysis of a 1154-patient cohort revealed that sac excision during paraesophageal hernia repair did not significantly affect hernia recurrence (P=0.27). Notably, the reoperation rate was similar between patients with and without sac excision (P=0.28), indicating no significant difference in the need for reoperation. However, sac excision was associated with a lower incidence of persistent postoperative gastroesophageal reflux disease (GERD) (P=0.03). Sac excision during paraesophageal hernia repair does not significantly impact hernia recurrence or reoperation rates but may be associated with a lower incidence of persistent postoperative GERD.

There is a complex relationship between gastroesophageal reflux disease (GORD), hiatus hernia, obesity, and metabolic bariatric surgery. We report the outcomes of laparoscopic hiatus hernia repair (HHR) with BIO-A® mesh in the management of GORD post LSG in patients who developed a hiatus hernia with migration of the proximal gastric sleeve. A retrospective review of 50 patients who previously underwent LSG and revisional surgery (HHR, n = 25; RYGB, n = 25) between 2011 and 2022. The modified DeMeester scoring system was used to assess the severity of the patient's GORD symptoms pre-HHR/pre-RYGB and 6 months post-op. Twenty-five patients underwent HHR with BIO-A® mesh following a previous LSG. The severity of GORD six months post-HHR was significantly lower (0.96 ± 0.84 vs. 2.60 ± 0.50, p = < 0.0001). After HHR, 3/25 (12%) patients had ongoing GORD symptoms that were not medically controlled and underwent conversion to RYGB. In contrast, 25 patients underwent direct conversion to RYGB following a previous LSG. The severity of GORD at 6 months post-RYBG was significantly lower (0.40 ± 0.50 vs. 2.36 ± 0.64, p = < 0.0001). At six months, there was no significant difference in GORD symptoms when HHR was compared with RYGB (3.32 ± 1.6 vs. 3.76 ± 1.54, p = 0.4296). In appropriately selected patients, HHR with BIO-A® mesh appears safe and effective in managing persistent GORD following LSG, within the limits of this study. However further research is needed to explore its role and the long-term outcomes.

ABSTRACTHiatal Hernia—one of the most frequently encountered gastrointestinal conditions that rarely mimics cardiac pathology on imaging. We present a case of an elderly female where a hiatal hernia appeared as a left atrial mass on transthoracic echocardiography, raising concern for a benign cardiac tumor, while chest radiography revealed a retrocardiac air‐fluid level suggestive of a hiatal hernia. Definitive diagnosis was established with contrast‐enhanced computed tomography of the chest. Our goal is to raise awareness of hiatal hernia as an important differential diagnosis when evaluating an apparent cardiac mass on imaging and to emphasize the value of different imaging modalities, especially chest radiography, in preventing misdiagnosis of this rare presentation in resource‐limited health care settings of developing countries like Bangladesh.

Hiatal hernia is common in patients with severe obesity undergoing metabolic bariatric surgery. Although concomitant hiatal hernia repair during laparoscopic sleeve gastrectomy has been widely adopted, long-term data beyond 5 years remain limited, and the clinical relevance of anatomical recurrence is still poorly defined. To evaluate the 10-year recurrence rate, predictors of failure, and clinical outcomes following concomitant sleeve gastrectomy and hiatal hernia repair. This retrospective multicenter cohort study analyzed 111 patients who underwent sleeve gastrectomy with concomitant hiatal hernia repair between 2014 and 2015. Complete-case analysis included only patients with assessable recurrence status at follow-up. The primary outcome was anatomical recurrence (> 2cm transhiatal migration of the gastric sleeve). Secondary outcomes included reintervention, gastroesophageal reflux disease (GERD), and weight loss. Among 111 patients, 108 were analyzed. Mean age was 50.1 ± 11.6 years, 80.6% female, mean baseline BMI 42.7 ± 5.8kg/m², and mean follow-up was 93.0 ± 22.7 months (7.7 ± 1.9 years). Hernia recurrence occurred in 14 patients (13.0%). Among these, 5 (35.7%) underwent reintervention, while 9 (64.3%) were managed conservatively. Freedom from recurrence was 98.1% at 5 years and 68.9% at 10 years, although the 10-year estimate should be interpreted cautiously. Hernia size ≥ 5cm and postoperative GERD were associated with recurrence (OR 5.0; 95% CI 1.2-20.0; P=0.035; OR 4.97; 95% CI 1.56-17.53; p = 0.008). Reintervention was required in 11 patients (10.2%), all with symptomatic GERD. Concomitant sleeve gastrectomy and hiatal hernia repair were associated with acceptable long-term outcomes in this multicenter cohort. Reintervention was more often associated with postoperative reflux-related symptoms than with anatomical recurrence alone, while many anatomical recurrences were managed conservatively.

Studies have demonstrated that Toupet fundoplications (TF) result in equitable reflux control with improved outcomes of gas-bloat compared to Nissen fundoplications (NF). Currently, it is unknown if the advantages of TF remain significant compared to NF of similar gastroesophageal junctiondistensibility post-fundoplication. This study aims to compare TF and NF quality-of-life (QOL) outcomes according to intraoperative endoluminal impedance planimetry (EndoFLIP) distensibility index (DI). A retrospective study was performed on adatabase of patients who received laparoscopic TF or NF with intraoperative EndoFLIP. Patients reported QOL using gastroesophageal reflux disease-health-related quality-of-life questionnaire (GERD-HRQL), reflux symptom index (RSI), gas-bloat score, and dysphagia surveys pre- and postoperatively at 3 weeks, 6 months, 1 year, and 2 years. Statistical analysis was conducted using Wilcoxon rank-sum and chi-square tests. 509 patients received TF (n = 429) or NF (n = 80) between 2018 and 2024 for GERD. Paraesophageal hernias represented81% of cases. Intraoperatively.315 patientsreceivedDI measurement at 30ml fill-volume, (NF n = 65 vs. TF n = 250). 441 patients received measurementsat 40mL fill (NF n = 43 vs. TF n = 398). Average post-fundoplication DI at 30ml was lower after NF with DI 2.6 ± 1.2 mm2/mmHg vs TF DI of 3.3 ± 1.5 mm2/mmHg (p < 0.001), but was not statistically different at 40ml volume(NF 3.5 ± 1.3 vs. TF 3.2 ± 1.3). QOL surveys from patients with DI range < 2.0 mm2/mmHg demonstrated no significant differences in QOL at 3-week, 6-month, or 1-year timepoints. DI at 2.0-3.5 mm2/mmHg and > 3.5mm2/mmHg demonstrated no differences on GERD-HRQL, RSI, gas-bloat, or dysphagia scores at any time point. EndoFLIP can be used for objective measures of LES physiologyafter fundoplication. When compared byDI range, QOL of NF vs. TG are comparable,suggesting outcomes are dependent on post-fundoplication distensibility rather than type of fundoplication.

Partial fundoplication is the most common surgical treatment for gastroesophageal reflux disease (GERD). Our preferred technique is a symmetrical anterior-posterior partial (300°) fundoplication created along the natural axis of the stomach, leaving the bare area on the esophagus along the lesser curvature. We assessed perioperative and long-term outcomes of this technique. We retrospectively reviewed records of all patients who underwent primary elective antireflux surgery by a single foregut surgeon from September 2016 to December 2024. Non-primary and emergency procedures and other techniques (such as Dor) were excluded. Perioperative complications, hiatal hernia recurrence, patient-reported outcomes (PROMs), and patient satisfaction were assessed for up to 7years. We identified 355 patients (254 [71.5%] women; median age, 64years) who underwent primary antireflux surgery (laparoscopic [79.2%], robotic [20.6%], and conversion [0.3%]). The median operative time, estimated blood loss, and length of stay were 90min (IQR 70-110), 25mL (IQR 10-25), and 1day (IQR 1-2). Severe complications (Clavien-Dindo grade ≥ III) occurred in 3 (0.8%) patients. There was no 90-day mortality. GERD health-related quality of life (GERD-HRQL) questionnaires and/or objective assessment using barium esophagram or upper GI endoscopy were completed by 222/355 (62.5%), 134/322 (41.6%), 56/267 (21.0%), 43/166 (25.9%), and 19/90 (21.1%)patients at 1, 2, 3, 5, and 7years, respectively. The median total GERD-HRQL scores improved from 32 (IQR 13-46) preoperatively to 1 (IQR 0-4), 2 (IQR 0-7), 2 (IQR 0-12), 1 (IQR 0-6), and 5 (IQR 1-24) at 1, 2, 3, 5, and 7years, respectively. Over 7years, objective HH recurrence occurred in 22 patients (≥ 2cm in 5 patients). Symmetrical anterior-posterior partial fundoplication is safe and effective, providing sustainable relief from GERD symptoms with high patient satisfaction reported up to 7years. Interpretation of these promising results is limited by the small number of patients with extended follow-up.

To evaluate the effect of obesity on subjective and objective outcomes after antireflux surgery (ARS). Obesity has traditionally been viewed as a relative contraindication to ARS with some guidelines favoring Roux-en-Y gastric bypass in this population. The concern that increased intra-abdominal pressure may compromise durability is physiologically plausible, but supporting clinical evidence is limited. Consecutive patients undergoing primary fundoplication or magnetic sphincter augmentation (MSA) between 2011 and 2024 were analyzed. Patients were stratified by body mass index (BMI) <35kg/m² or ≥35kg/m² (obese). Preoperative characteristics and postoperative outcomes were compared, including symptom control, objective reflux parameters, and anatomic integrity. A total of 2,388 patients were included, of whom 309 (12.9%) had BMI ≥35. Obese patients had larger hiatal hernias (P<0.001) and higher DeMeester scores [48.7 (34.8) vs. 44.1 (35.0), P=0.030]. At 1 year after surgery, GERD-HRQL scores improved in both groups and were comparable [10.7 (12.8) vs. 10.1 (13.0)], as were patient satisfaction (81.6% vs. 83.3%) and PPI independence (85.1% vs. 85.5%) (all P>0.05). These findings remained similar at 3 years. Five-year anatomic integrity (75.8% vs. 78.2%) and revisional surgery rates (4.5% vs. 5.3%) were similar between groups (all P>0.05). However, obese patients undergoing MSA had lower rates of pH normalization (48.1% vs. 71.0%, P=0.001). Patients with BMI ≥35 presented with more advanced reflux but achieved comparable symptom improvement, satisfaction, and PPI independence after ARS. Anatomic integrity and revision rates were similar, with reduced pH normalization observed only in the MSA subgroup. These findings support ARS in obese patients and suggest BMI alone should not determine surgical candidacy.

Neurologically impaired children frequently experience recurrent gastroesophageal reflux symptoms after laparoscopic Nissen fundoplication, even when the fundoplication remains anatomically intact. Esophagogastric dysfunction may contribute to these recurrences but is often underrecognized. To analyze the causes of recurrent gastroesophageal reflux symptoms in neurologically impaired children with an intact Nissen fundoplication attributable to esophagogastric dysfunction and to describe their management and outcomes. We conducted a retrospective descriptive study of neurologically impaired children who underwent laparoscopic Nissen fundoplication between 2010 and 2025 and subsequently developed recurrent gastroesophageal reflux-related symptoms. All patients were evaluated with contrast upper gastrointestinal studies and upper gastrointestinal endoscopy; gastric emptying scintigraphy was performed when gastric atony was suspected. Demographic data, neurological diagnosis, Gross Motor Function Classification System level, nutritional status, symptoms, time to recurrence, imaging findings, treatment, and follow-up were recorded. A total of 124 children were included (96 with cerebral palsy, 18 with traumatic brain injury, and 10 with brain tumors). At 36-month follow-up, 82 patients achieved complete symptom remission. Forty-two children, all with cerebral palsy, developed recurrent symptoms between 10 and 48 months after surgery. Recurrence was due to paraesophageal hernia in 15 patients, all of whom underwent successful laparoscopic redo fundoplication. The remaining 27 children had an anatomically intact fundoplication: 10 presented bile reflux with duodenitis and improved with medical management, and 17 had gastric, pyloric, or duodenal dysfunction requiring laparoscopic pyloroplasty, esophagogastric disconnection, or gastrojejunostomy, with subsequent resolution of symptoms. In neurologically impaired children, esophagogastric dysfunction unrelated to wrap failure is a frequent and surgically treatable cause of recurrent symptoms after Nissen fundoplication.

Objective and subjective outcomes of primary laparoscopic hiatal hernia repair with Toupet fundoplication vs fundopexy.

Hiatal hernia (HH) disrupts the anti-reflux barrier and contributes to gastroesophageal reflux disease (GERD), which is defined objectively by abnormal pH testing. Ambulatory 96-h wireless pH monitoring is widely used for objective GERD assessment, yet the relationship between HH size and abnormal pH results remains ambiguous. We evaluated the association between HH size and pH study positivity in a surgically evaluated cohort. Patients with HH identified on imaging or endoscopy who underwent preoperative pH monitoring between January 1, 2009 and January 1, 2026 were identified from a prospectively maintained institutional database. Patients with prior HH repair or incomplete pH data were excluded. Abnormal pH study was defined according to Lyon Consensus criteria as acid exposure time (AET) ≥ 6% on at least two monitoring days. DeMeester score was analyzed as a secondary measure of reflux severity. HH size was analyzed across predefined strata. Multivariable logistic regression assessed independent predictors of abnormal pH study. A total of 363 patients were included; 65.8% were female and the mean age was 60 ± 14years. Overall, 79.3% had abnormal pH testing. Abnormal pH prevalence increased with HH size (p = 0.002), rising from 60.0% in hernias < 1.0cm to 95.2% in 5.0-5.9cm hernias. In contrast, prevalence decreased to 68.4% in hernias ≥ 6.0cm. In multivariable analysis, HH size remained independently associated with abnormal pH testing, with adjusted odds ratios increasing from 3.71 (95% CI 1.17-11.80) in the 2.0-2.9cm group to 17.44 (95% CI 2.33-130.67) in the 5.0-5.9cm group compared with hernias < 1.0cm. Hernias ≥ 6.0cm were not independently predictive. Increasing HH size was also associated with higher AET%, DeMeester scores, and moderate-to-severe esophagitis. Intermediate-to-large sliding hernias are strong anatomic predictors of abnormal reflux and may inform anatomy-guided preoperative evaluation.

National database studies suggest elective paraesophageal hernia (PEH) repair in octogenarians is safe but provide limited detail on operative strategy and long-term symptom outcomes. We evaluated perioperative outcomes, operative strategy, and post-discharge functional outcomes in octogenarians undergoing PEH repair compared with younger patients in a contemporary institutional cohort. A retrospective review of 2,517 PEH repairs performed at a tertiary academic center from 2010-2023 was conducted. Patients were stratified by age (18-79 vs. ≥ 80years). Demographics, operative characteristics, 30-day complications, recurrence, reoperation, and postoperative symptoms were compared. Multivariable logistic regression identified predictors of composite adverse outcome (CAO), defined as postoperative GERD, dysphagia, recurrence, or reoperation. Of 2,517 patients, 195 (7.7%) were ≥ 80years. Compared with younger patients, octogenarians had lower BMI (26.9 vs. 32.5kg/m2, p < 0.001), higher rates of cardiovascular disease (83.6% vs. 61.0%, p < 0.001), and more frequent ASA ≥ III (93.2% vs. 69.6% p < 0.001). Non-elective surgery was more common in octogenarians (30.6% vs. 6.0%, p < 0.001). Surgeons performed gastropexy more than twice as often in octogenarians (43.6% vs. 17.3%, p < 0.001) and used mesh reinforcement at higher rates (21.5% vs. 13.0%, p = 0.004), while fundoplication rates were similar (33.3% vs. 38.7%, p = 0.12). Thirty-day complications were higher in octogenarians (15.9% vs. 9.1%, p = 0.006), with no significant difference in mortality (1.0% vs. 0.3%, p = 0.15). Hernia recurrence, postoperative GERD, dysphagia, and reoperation were similar between groups (p > 0.05 for all). Age ≥ 80 was not independently associated with CAO (OR 1.05, 95% CI 0.72-1.54, p = 0.79). PEH repair in octogenarians is associated with increased perioperative morbidity but similar PEH-related outcomes compared with younger patients. These findings support consideration of elective repair in appropriately selected symptomatic octogenarians and individualized risk assessment based on comorbidities rather than age alone.

Paraconduit hernia after esophagectomy: Impact of operative technique on its incidence and recurrence.

Gastroesophageal Reflux Disease (GERD) is treated primarily with proton pump inhibitors (PPIs), with surgery reserved for patients refractory to PPIs or with symptomatic hiatal hernias. PPI efficacy depends on metabolism by cytochrome P450 2C19 (CYP2C19) in the liver, which varies with genetic polymorphisms. Rapid (RM) and ultra-rapid (UM) metabolizers may require higher PPI doses for efficacy, while poor (PM) and intermediate (IM) metabolizers respond to lower doses but have higher risk of side effects. This study assesses CYP2C19 phenotype prevalence in medically versus surgically managed GERD. We hypothesized a higher RM/UM rate among surgical patients, suggesting PPI resistance. This was a multi-site retrospective cohort study of adult patients with GERD and CYP2C19 genotyping from 2012 to 2023. Medical patients included those with Barrett's esophagus, LA grade C/D esophagitis, or abnormal pH testing. Surgical patients included those who underwent anti-reflux surgery. CYP2C19 phenotypes were grouped as PM/IM, normal metabolizer (NM), and RM/UM based on the anticipated need for PPI dose adjustment. Descriptive statistics were used for analysis. A total of 261 patients were included in this study: 187 medical (female: 59%, mean age: 57 (SD 15), 77% White) and 74 surgical (female: 69%, mean age: 58 (SD 13), 89% White). Medical patients included the following esophageal pathologies: 52% Barrett's esophagus, 31% abnormal pH testing, and 17% LA grade C/D esophagitis. Surgical patients had a significantly higher proportion of RM/UM phenotypes compared to medical patients (p = 0.018). There was also a significant difference in hiatal hernia size between medical and surgical patients (p < 0.001). Surgical patients have a higher prevalence of hypermetabolizing (RM/UM) CYP2C19 phenotypes compared to medical patients. Dose escalation of PPI should be considered in medical patients with these phenotypes, and if ineffective, a timely referral for anti-reflux surgery should be made.

ACR Appropriateness Criteria® Epigastric Pain.

Background:Recurrent hiatal hernias represent a significant surgical challenge, with recurrence rates of 10.2%–25.5% after conventional repairs. Patients with complex recurrent hernias who have undergone multiple operations have limited therapeutic options due to technical complexity and altered anatomy. This study presents a novel autologous salvage technique using a superiorly pedicled rectus abdominis muscle (RAM) flap for complex recurrent hiatal hernia repair.Methods:Between August 2019 and May 2022, four patients with symptomatic recurrent hiatal hernias underwent RAM flap reconstruction after multiple failed conventional repairs. The superiorly pedicled RAM flap, based on the superior epigastric artery, was harvested laparoscopically or via laparotomy and inserted tension-free into the mediastinal cavity through the esophageal hiatus. Outcomes were assessed using clinical evaluation, radiological imaging (computed tomography scan and barium swallow), and Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaires at medium- and long-term follow-up (>2 y).Results:All procedures were technically successful without major complications. The mean hospital stay was 6.5 days. At mean long-term follow-up of 46.5 months, no hiatal hernia recurrences were observed on imaging. All patients demonstrated significant symptom improvement with mean Gastroesophageal Reflux Disease Health-Related Quality of Life score improvement of −23 points at medium-term follow-up, with continued improvement long-term. Minor complications included abdominal bulging in two patients without functional impairment and one incisional hernia requiring revision.Conclusions:The superiorly pedicled RAM flap represents a promising autologous salvage technique for complex recurrent hiatal hernias in patients who have undergone multiple operations, offering durable reconstruction with excellent symptom relief and no recurrences at long-term follow-up. The technique can be performed laparoscopically in selected cases.