Hiatal Repair Research Articles

Presentation and management of post-esophagectomy or Gastrectomy Hiatal Hernia.

Hiatal hernia may development after esophagectomy or Gastrectomy. Post- esophago-gastric hiatal hernia is a rare but challenging condition. Nearly half of reported cases involve emergent situations, underscoring the urgency of addressing this condition. However, there is currently no consensus on the optimal treatment approach for this type of hernia. All consecutive patients who underwent repair for Post- esophago-gastric hiatal hernia over the past five years were retrospectively reviewed. Patient characteristics and perioperative data were collected. The primary outcomes, repair methods, and surgical results following post-esophago-gastric hiatal repair were analyzed. A total of eight patients with post-esophago-gastric hiatal hernia were included in this study. All patients presented with emergent conditions, specifically bowel obstruction. Laparoscopic repair was successful in four cases, with a conversion rate to open surgery of 50% (4 out of 8). Primary suture was performed in three cases, while biological mesh repair was carried out in four cases, and one case was left unrepaired. Bowel gangrene and perforation occurred in one case. The most notable postoperative complications included wound infection and pleural fluid collection. Importantly, there were no instances of hernia recurrence during the follow-up period, which ranged from 2 to 55 months, with a 100% follow-up rate observed. Post-esophago-gastric hiatal hernia is a rare yet significant condition, often presenting emergently and linked to higher morbidity and mortality rates. Therefore, symptomatic patients warrant surgical repair, and immediate intervention should be provided to those with acute-onset symptoms and clinical signs of bowel obstruction. Primary suture repair, with or without biological mesh, appears to be a durable method of repair.

423. ROBOTIC SURGERY FOR BENIGN ESOPHAGEAL DISEASE: PROMOSING OUTCOMES OF AN EARLY CASE SERIES

Abstract Background Laparoscopic surgery is a well-established approach in the treatment of benign gastroesophageal junction (GEJ) disease. Robotic platforms have only recently been incorporated in surgery for esophageal motility disorders and their exact value remains to be determined. In the present study, we present our initial experience through a case series of patients with benign GEJ disease treated using the DaVinciXi robotic system in our department. Methods Patients undergoing surgery for benign GEJ disease during the last 5 years (01/2029-12/2023) were prospectively collected. Data regarding their perioperative and postoperative course was evaluated. All patients attended regular follow-up appointments. Patients with relapse or deterioration of their symptoms were referred for objective testing using high-resolution manometry or 24-h impedance pHmetry. Results 12 patients with achalasia were subjected to robotic Heller myotomy and modified Dor fundoplication, 13 patients underwent hiatal hernia repair and 2 patients underwent Nissen fundoplication due to severe reflux. Median operative time was 110min (96-150) and no intraoperative or postoperative complications were observed. All patients demonstrated resolution of their symptoms, with a median postoperative Eckardt score of 2 for patients with achalasia and median GERD score of 1 for patients with GERD. 2 patients with achalasia were subjected to impedance manometry due to temporary symptom relapse, without any abnormal findings. Conclusion The incorporation of robotic platforms in the treatment of achalasia, reflux and hiatal repair is safe with excellent perioperative and postoperative functional results, when performed in a high-volume center. Further experience will demonstrate potential advantages and disadvantages of the method and will allow for reliable comparison to the laparoscopic approach.

511. IS IT SAFE TO USE NONABSORBABLE MESH IMPLANTATION FOR HIATAL REINFORCEMENT DURING PRIMARY ANTIREFLUX PROCEDURES?

Abstract Background Laparoscopic Fundoplication (LF) is highly effective in surgical treatment of GERD and the prevention of disease progression. Currently it is the gold standard of treatment and allows to achieve good and excellent postoperative results in majority patients. However, despite the gained experience, failures of primary LF and hiatus repair like hiatal hernia recurrence demonstrate that current surgical techniques are not optimal. One of the decisions is mesh implantation for hiatal reinforcement in GERD. However, due to the different types of complications (mesh erosion, scarring, dysphagia) safety use of mesh are still controversial. Method Laparoscopic Total Fundoplication (LTF) with nonabsorbable and composite light mesh implantation for hiatal reinforcement during 2022 – 2023 years were performed in 71 patients. We use macroporous nonabsorbable polypropylene or composite (polypropylene/monocryl) light mesh repair routinely by own proposed surgical technique. Our decision did not depend on size of hiatal hernia and hiatal surface area. We use U-shaped mesh posteriorly on the approximated crura by previous interrupted suturing not around the esophagus (Fig. 1). The mesh fixes with staples to the muscular and ligamentous structures of crura. We compared our results with the group of LTF without mesh implantation. Result All patients underwent completed validated questionnaires, esophagogasroduodenoscopy, contrast video esophagram, 24-hour impedance-pH monitoring after surgery. Some patients underwent computed tomography. Along with the disappearance of GERD symptoms, no mesh erosion and long (>3 month) postoperative follow-up dysphagia were marked in any patient with mesh repair. There are no significant difference in comparison with these results of LTF without mesh implantation. During the early postoperative period (< 12 months) no recurrence of hiatal hernia was diagnosed in the group with mesh implantation. Conclusion According to our study, in comparison with no-mesh repair, the proposed surgical technique is safe. Nonabsorbable and composite light mesh implantation for hiatal enforcement during primary antireflux procedures may be used routinely to prevent hiatal hernia recurrence effectively. Further, longer-term follow-up will be continued to confirm this position.

Long-Term Outcomes of Magnetic Sphincter Augmentation: A Comparative Study to Nissen Fundoplication

BackgroundMagnetic sphincter augmentation (MSA) demonstrates improvement in gastroesophageal reflux disease (GERD) across multiple short-term studies. Long-term, single-arm studies show durable outcomes, but there is limited comparative data to Nissen fundoplication (NF). MethodsWe performed a retrospective propensity-matched cohort study of patients with GERD undergoing MSA or NF between 2012 and 2018. Patients were matched on age, sex, body mass index, size of hiatal hernia, length of Barrett esophagus, and motility in a 1:1 fashion. A total of 523 patients (177 MSA, 346 NF) underwent surgery and after matching 177 MSA and 177 NF cases were analyzed. ResultsAt 1 year, GERD quality of life scores improved (22 to 5 MSA vs 24 to 5 NF, P = .593). Proton pump inhibitor use was 14% vs 5% (P = .010). pH testing demonstrated improved DeMeester scores (42 to 21 vs 46 to 7, P < .001). At 5 years, GERD quality of life scores were stable (5 to 5 vs 5 to 4, P = .208). Proton pump inhibitor use was 31% vs 26% (P = .474). The incidence of endoscopic dilation was similar between MSA and NF (7% vs 10%, P = .347). Reoperation rates were higher for MSA (10% vs 4%, P = .022) and recurrent hiatal hernias were found in 18% vs 7% (P = .007). Compared to NF, MSA undergoing complete dissection showed no difference in dilation (5% MSA vs 7% NF, P = .527), reoperation (8% MSA vs 6% NF, P = .684) or hernia recurrence (10% MSA vs 6% NF, P = .432). ConclusionsMSA achieves similar improvements in quality of life and freedom from medical therapy compared to NF, especially with complete hiatal repair.

The effectiveness and safety of the anti gastroesophageal reflux system in the treatment of gastroesophageal reflux disease: a single center study of 23 cases

Objective: To evaluate the safety and efficacy of domestically produced magnetic sphincter augmentation (MSA) for gastroesophageal reflux disease. Method: This study is a prospective cohort study. Patients with typical heartburn and reflux symptoms (at least partial response to proton pump inhibitors), abnormal esophageal acid exposure and normal esophageal peristalsis were included, prospectively in the Department of Gastroesophageal Surgery, Rocket Force Characteristic Medical Center from June 2019 to September 2022. Patients with hiatal hernia >2 cm and severe esophagitis were excluded. The MSA was wrapped around the distal esophagus after esophageal hiatus repair by laparoscopy. A postoperative questionnaire survey was conducted to assess the relief of symptom, complications, the discontinuation rate of proton pump inhibitor, and surgical satisfaction. Gastroscopy, high-resolution esophageal pressure measurement, and pH value impedance monitoring were also reviewed. The pre- and postoperative rates were compared using the McNeinar χ2 test. Result: Currently, 23 patients with gastroesophageal reflux disease were enrolled and underwent MSA surgery. There were 20 males and 3 females, aged (M (IQR)) 48 (14) years (range: 25 to 64 years). All cases were successfully implanted with MSA. Subjective indicators were followed for 17 (18) months (range: 14 to 53 months), while objective indicators were followed for 17 (1) months (range: 12 to 23 months). The postoperative gastrointestinal and extraesophageal symptom scores showed a significant decrease compared to preoperative levels as follows: the degree of subjective relief of overall digestive symptoms was 90 (20)% (range:0~100%), the degree of subjective relief of overall respiratory symptoms was 100(10)% (range: 10%~100%), the overall satisfaction rate was 83% (19/23), the proton pump inhibitor discontinuation rate was 70% (16/23). The proportion of esophagitis has decreased from 44% (10/23) to 9% (2/23) (κ=0.169, P=0.039), The Hill grade of gastroesophageal valve morphology improved from 1 case of grade Ⅰ, 5 cases of grade Ⅱ, 10 cases of grade Ⅲ, and 7 cases of grade Ⅲ preoperative to 22, 1, 0, and 0 cases postoperative. The proportion of lower esophageal sphincter pressure below normal has decreased from 70% (16/23) to 35% (8/23) (κ=0.170, P=0.012). There were 21 patients who restored normal esophageal acid exposure. Eleven patients had mild long-term dysphagia, but it didn't affect their daily life. No postoperative device migration, erosion, or secondary surgical removal occurred. Conclusions: Laparoscopic implantation of the MSA device was safe and well tolerated. It can effectively control the symptoms of gastroesophageal reflux disease, reduce medication, restore normal cardia morphology and function, and esophageal acid exposure. The main postoperative complication was dysphagia, but it was relatively mild.

Functional results after hiatal repair and gastropexy without fundoplication in patients with paraoesophageal hernia

PurposeParaoesophageal hernias (PEH) are associated with a high complication rate and often occur in elderly and fragile patients. Surgical gastropexy without fundoplication is an accepted alternative procedure; however, outcomes and functional results are rarely described. Our study aims to evaluate short-term outcomes and the long-term quality of life after gastropexy as treatment for PEH.MethodsSingle center cohort analysis of all consecutive patients who underwent gastropexy for PEH without fundoplication. Postoperative outcomes and functional results were retrospectively collected. Reflux symptoms developed postoperatively were reported using the validated quality of life questionnaire: GERD-Health Related Quality of Life Qestionnaire (GERD-HRQL).ResultsThirty patients (median age: 72 years (65–80)) were included, 40% classified as ASA III. Main PEH symptoms were reflux (63%), abdominal/thoracic pain (47%), pyrosis (33%), anorexia (30%), and food blockage (26%). Twenty-six laparoscopies were performed (86%). Major complications (III-IVb) occurred in 9 patients (30%). Seven patients (23%) had PEH recurrence, all re-operated, performing a new gastropexy. Median follow-up was 38 (17–50) months. Twenty-two patients (75%) reported symptoms resolution with median GERD-HRQL scale of 4 (1–6). 72% (n = 21) reported operation satisfaction. GERD-HRQL was comparable between patients who were re-operated for recurrence and others: 5 (2–19) versus 3 (0–6), p = 0.100.ConclusionGastropexy without fundoplication was performed by laparoscopy in most cases with acceptable complications rates. Two-thirds of patients reported symptoms resolution, and long-term quality-of-live associated to reflux symptoms is good. Although the rate of PEH recurrence requiring a new re-intervention remained increased (23%), it does not seem to affect long-term functional results.

Medium term (> 12 months) outcomes after laparoscopic hiatal hernia repair without conventional fundoplication using PH4B-mesh implant (Phasix™) in 176 reflux patients: experience and technique.

Hiatal mesh repair remains a controversial topic among anti-reflux surgeons. Biosynthetic mesh cruroplasty may prevent early recurrence while avoiding late esophageal erosion and strictures associated with non-resorbable materials. So far, medium-term results on hiatal PH4B (Poly-4-Hydroxybutyrate) mesh repair from high-volume centers are lacking. We analyzed the medium-term efficacy and safety of PH4B mesh cruroplasty in 176 consecutive patients (≥ 18years) with symptomatic hiatal hernias. Treatment failure was defined as the clinical recurrence of reflux symptoms. Patients could choose between mesh augmented hiatal repair (combined with a modified anterior hemifundoplication and fundophrenicopexy), Nissen fundoplication, and magnetic sphincter augmentation at their discretion. We also describe the surgical approach to mesh augmented hiatal repair used at our center. On average, patients were 55 (± 14) years old and followed up for 22 (± 7; sum: 3931) months. Treatment failed in 6/176 (3%, 95% CI: 2-7%) patients. The 24-month Kaplan-Meier failure estimate was 2.8% (95% CI: 0.4-5%). Each centimeter in hernia size increased the risk of failure by 52% (p = 0.02). Heavier patients (BMI > 27) had an 11% higher probability of clinical symptom recurrence (p = 0.03). The dysphagia and bloating/gas rate were 13/176 (7%), each. 8 (5%) patients required endoscopy due to dysphagia but without intervention. No serious complications, including mesh infection and erosion, or fatalities, occurred. Augmented PH4B mesh cruroplasty without conventional fundoplication shows excellent intermediate-term results in patients with reflux disease due to hiatal hernia. Around one in thirty patients experience treatment failure within 2years of surgery. Hernia size and overweight are key determinants of treatment failure.

Laparoscopic proximal sleeve gastrectomy as an alternative for management of giant hiatal hernias

Background and aim: Large anatomic defects of the diaphragmatic hiatus known as giant hiatal hernias could be associated with reflux esophagitis disease (GERD) and other life-threatening complications such as gastric volvulus, ischemia and perforation, thus surgical repair is warranted. Although usually the key steps to surgical repair are reduction of the herniated stomach, complete excision of the sac, hiatus repair, and an antireflux procedure, surgery in these cases is associated with a great rate of anatomic and functional failure, therefore different techniques have been described since the original description of Collis gastroplasty designed to lengthen the short esophagus. Methods: We report here the technique and results performing proximal vertical gastrectomy or proximal sleeve gastrectomy (PSG) as an alternative in cases in which the possibility of recurrence of the hiatal hernia (HH) is high. Results: After years of follow-up after surgery, all the case patients presented here are free of gastroesophageal reflux or dysphagia symptoms, with no necessity for acid suppression medication, and no side effects of the surgery. Conclusion: The treatment of giant HH is a complex and challenging disorder to treat. PSG seems to be a good surgical alternative for the treatment of some special cases of giant HH minimizing the GERD symptoms and possible recurrences.

Laparoscopic Sleeve Gastrectomy Lacks Intrasurgeon and Intersurgeon Agreement in Technical Key Points That May Affect Gastroesophageal Reflux Disease After the Procedure.

Gastroesophageal reflux disease (GERD) after sleeve gastrectomy (SG) may be related to surgical technique. The fact that there is a lack of technical standardization may explain large differences in GERD incidence. The aim of this study is to evaluate auto- and hetero-agreement for SG technical key points based on recorded videos. Ten experienced (minimum of 5years performing bariatric surgery, minimum of 30 SG per year) bariatric surgeons (9 (90%) males) were selected. Participants were invited to send an unedited video with a typical laparoscopic SG (first round of the Delphi process). Videos were cropped into small clips comprising 11 key points of the technique. All anonymized clips (including their own) were returned to all surgeons. Individuals were asked to agree or not with the technique demonstrated (second round). The percentage of agreement was presented to the entire group that was asked for a second vote (third round). Agreement was poor/fair for all points except hiatal repair that had a very good agreement in the second round. For the third round, there was a slight increase in agreement for distance esophagogastric junction/proximal stapling and gastric mobilization for stapling and a slight decrease in agreement for gastric tube final shape. Only 1 (10%) surgeon recognized that he evaluated his own video. Five (50%) surgeons disagreed with themselves on 1 or more points. SG lacks intrasurgeon and intersurgeon agreement in technical key points that may justify significant differences in GERD incidence after the procedure.

OGBN P39 Feasibility and Safety of Laparoscopic Anti-Reflux Surgery at a District General Hospital: Matching National Standards and Improving Patient Quality of Life

Abstract Background Gastro-oesophageal Reflux Disease (GORD) affects a substantial proportion of adults in the UK, with surgery offering superior short-to-medium term benefits compared to medical management alone. However, there is significant variation in surgical practice nationwide. This study aimed to assess the feasibility and safety of laparoscopic anti-reflux surgery (LARS) at a District General Hospital (DGH) by aligning outcomes with the national standards set by AUGIS (Association of Upper Gastrointestinal Surgeons). Methods Prospective data from patients who underwent LARS between May 2022 and May 2023 were collected and recorded locally as well as on the National Hiatal Surgery Register (NHSR). Pre-operative symptoms and investigations, intraoperative findings, post-operative short and medium-term outcomes, and patient-reported outcome measures (PROMs) were analyzed. Quality of life (QoL) questionnaires, administered by the NHSR, were collected at 6 months to 1 year post-surgery. AUGIS standards, including a minimum of 5 procedures per year by 2 surgeons, conversion rate below 5%, 30-day return to theatre below 5%, and 30-day readmission rate below 10%, were utilized for comparison. Results In one year, two surgeons performed 41 LARS procedures: 31 Nissen, 4 Toupet, and 2 Dor wraps, with 2 redo surgeries. Minor complications occurred in 3 patients, requiring no intervention. One surgery was converted to open due to bleeding, and hiatal repair performed. Wrap migration led to re-do after 10 months. The 30-day return to theatre rate was 0%, readmission rate 2% (n=1, unremarkable CT scan). One patient discharged as a day case, average stay 4 days. Out of 23 eligible patients, 15 completed post-op questionnaires, showing significant QoL improvement. Additionally, 55% no longer needed anti-reflux meds at 6-month follow-up. Conclusions We significantly increased the number of LARS procedures performed while meeting the national standards set by AUGIS and we observed a significant improvement in our patients' quality of life following surgery. Experienced laparoscopic Upper GI surgeons can safely and effectively offer anti-reflux surgery in a DGH setting. Our commitment to prospective data collection for audit and research purposes has been a major strength. Future objectives include further consolidation of our work and expanding the range of procedures, such as magnetic sphincter augmentation (LINX), to improve day-case rates.

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.

Role of Mesh in the Reinforcement of the Primary Repair of Large Hiatal Hernia

Abstract Background The incidence of hiatal hernias increases with age. Approximately 55%-60% of individuals over the age of 50 have a hiatal hernia. However, only about 9% have symptoms, and it depends on the type and competency of the lower esophageal sphincter. Aim of the Work In our study, an objective observational study was made regarding post operative short term mesh related complications possible to develop in patients underwent hiatal repair of large hiatal hernia with mesh rienforcement. Patients and Methods An observational cohort (retrospective and prospective) study regarding the post operative mesh related complications in patients who underwent Large diaphragmatic hernia repair with mesh application. The study was conducted at Ain Shams University Hospitals, Al-Demerdash, Department of General surgery. Approval of the research ethics Committee of medicine and general surgery department at faculty of medicine, Ain Shams University as well as a written informed consent from all participants was obtained. The study was conducted on 15 patients over a period of six months, starting from date of approval of the protocol by the faculty and the university committee at 10/7/2021. Results Five patients (33.3%) complained about dysphagia postoperatively. In one case, the symptoms declined spontaneously within 6 months was grade 1. Another patient successfully underwent esophageal dilatation of a stenosis 2 months postoperatively was grade 2. Up to this date, two patients (13.3%) still report mild dysphagia but maintain normal body weight were grade 3. Three cases report persistent intraabdominal discomfort without weight loss described as bloating. Two patients experienced heartburn, while another patient reported respiratory compromise in the form dyspnea due to already huge hiatal defect with lung collapse present preoperatively. Conclusion Laparoscopic large hiatal/paraesophageal hernia repair with prosthetic meshes as well as laparoscopic antireflux surgery with prosthetic hiatal closure are safe and effective procedures to prevent hiatal hernia recurrence and/or postoperative intrathoracic wrap migration, with low complication rates and mesh fixation is indicated in patients with large hiatal hernial defect &amp;gt; 5 cm.

HIATAL HERNIA, PANORAMIC REVIEW OF DIAGNOSIS AND MANAGEMENT

Introduction: Hiatal hernia (HH) occurs frequently in the population, characterized by various non-specific symptoms, however most of these symptoms are found to be related to gastroesophageal reflux disease. A hiatal hernia is said to be a medical condition in which the upper portion of the stomach or other internal organ protrudes through an opening in the diaphragm. Objective: to detail current information related to hiatal hernia, description, etiology, classification, diagnosis, differential, prognosis, management and complications. Methodology: a total of 38 articles were analyzed in this review, including review and original articles, as well as clinical cases, of which 27 bibliographies were used because the other articles were not relevant for this study. The sources of information were PubMed, Google Scholar and Cochrane; the terms used to search for information in Spanish, Portuguese and English were: hiatal hernia, hiatal repair, diagnosis, management. Results: The incidence of symptomatic cases of hiatal hernia is related to the diagnosis of gastroesophageal reflux disease (GERD). The incidence of hiatal hernias increases with age. About 55%-60% of individuals over 50 years of age have a hiatal hernia. However, approximately 9% have symptoms and it depends on the type and competence of the lower esophageal sphincter (LES). The largest percentage of these hernias are type I sliding hiatal hernias. Type II, paraesophageal hernias, represent approximately 5% of hiatal hernias in which the LES remains stationary, with the stomach protruding superiorly to the diaphragm. There is also a high prevalence in women, attributable to increased intra-abdominal pressure during pregnancy. The estimated overall 30-day mortality rate in relation to antireflux surgery is approximately 0.19%. Conclusions: Hiatal hernia (HH) is relatively common in the general population. It is caused by increased intra-abdominal pressure, leading to protrusion of the stomach and other abdominal viscera into the mediastinum. Hiatal hernias can be congenital or acquired. The current anatomical classification of hiatal hernias consists of four types or categories, each with its different characteristics. Diagnosis of hiatal hernia can be challenging because of the change in the anatomy of the esophagogastric junction on swallowing, breathing and movement. The pre-surgical study of the individual supports the diagnosis and the exclusion of other pathologic entities to properly direct the surgical intervention. The success of hiatal hernia surgery can be measured by the improvement of symptoms, such as esophageal acid exposure, complications and the requirement for reoperation. Complications of surgery are usually mild and are not directly linked to the surgery itself. KEY WORDS: surgery, hernia, hiatus, diagnosis, management.

10 Critical Steps of Hiatal Hernia Repair and Anti-Reflux Surgery: An Expert Consensus and Literature Review

Background: There is significant variability in the treatment of hiatal hernias, which has led to various perspectives regarding the proper manner of dissection, repair, and reconstruction. We sought to evaluate and analyze expert opinions, survey data, and the literature to define the critical steps in hiatal hernia repair. Methods: A focus group ( focus) of expert foregut surgeons defined and agreed upon a sequence of critical steps of a hiatal hernia repair. Using the data from the focus group, an anonymous survey was compiled and distributed to members of the American Foregut Society (AFS). The survey data ( survey) was then compared to the focus for agreement. The compiled focus and survey data was interpreted as expert recommendation ( expert). A literature review ( literature) was then conducted and compared to expert data for agreement and evaluation of discordance. This was used to define the critical steps of hiatal hernia repair. Results: Of the 10 identified critical steps, there was agreement on 9 of 10 steps between focus and survey. The 1 step with discordance was supported by the literature. Conclusions: Ten critical steps have been identified to help produce a succinct and reproducible approach to hiatal hernia repair. It is believed that adherence to these steps will allow the surgeon to achieve a safe and successful hiatal repair.

Outcomes and Functional Results after Gastropexy without Fundoplication in Patients with Paraoesophageal Hernia

Abstract Background Paraoesophageal hernias (PEH) are associated with a high complication rate and often occur in elderly and fragile patients. Gastropexy without fundoplication, in which the stomach is attached to the anterior abdominal wall is an accepted alternative procedure and considered a low-risk intervention. However, outcomes and functional results are hardly described in literature. Aims Our study aims to evaluate short-term outcomes and the long-term quality of life of patients that underwent a gastropexy as treatment for PEH. Methods Single center cohort analysis of all consecutive patients who underwent hiatal repair and gastropexy for PEH without fundoplication from 2015 to 2021. Postoperative outcomes and functional results were retrospectively collected via chart review of postoperative routine follow-up. Reflux symptoms developed postoperatively were reported using the published and validated quality of life questionnaire: GERD-Health Related Quality of Life Questionnaire (GERD-HRQL). Postoperative complications were reported according to Clavien-Dindo complication grade. Results Thirty patients (median age: 72 years (65-80)) were included, 40% classified as ASA III. Main PEH symptoms were reflux (63%), abdominal/thoracic pain (47%), pyrosis (33%), anorexia (30%), and food blockage (26%). Twenty-six laparoscopies were performed (86%). Major complications (III-IVb) occurred in 9 (30%). Seven patients (23%) had PEH recurrence, all re-operated, performing a new gastropexy. Median follow-up was 38 (17-50) months, one patient was lost. Twenty-two patients (75%) reported symptoms resolution with median GERD-HRQL score of 4 (1-6). 72% (n=21) reported operation satisfaction. GERD-HRQL was comparable between patients who were re-operated for recurrence and others: 5 (2-19) versus 3 (0-6), p=0.100. Conclusions Gastropexy without fundoplication was performed by laparoscopy in the majority of cases with acceptable complications rates. Two-thirds of patient's report symptoms resolution, and long-term quality-of-live associated to reflux symptoms is good. Although the rate of PEH recurrence requiring a new re-intervention remains increased (23%), it does not seem to affect long-term functional results.

Anterior reconstruction of the esophageal hiatus: a novel approach for the repair of large diaphragmatic hernias

Introduction: Paraesophageal hernias (PEH) often require surgical repair. The standard approach, primary posterior hiatal repair, has been associated with a high recurrence rate. Over the past few years, we have developed a new approach for repairing these hernias, which we believe restores the original anatomy and physiology of the esophageal hiatus. Our technique includes anterior crural reconstruction with routine anterior mesh reinforcement and fundoplication. Objective: To determine the safety and the clinical success of anterior crural reconstruction with routine mesh reinforcement. Material and methods: Data were collected retrospectively on 178 consecutive patients who had a laparoscopic repair of a symptomatic primary or recurrent PEH between 2011 and 2021 using the above technique. The primary outcome was clinical success, and the secondary outcome was 30 days of major complications and patient satisfaction. This was assessed by imaging tests, gastroscopies, and clinical follow-up. Results: Mean follow-up was 65 (SD 37.1) months. No intraoperative or 30 days postoperative mortality or major complications were recorded. Recurrence rate requiring a re-operation was 8.4% (15/178). Radiological and gastroenterological evidence of minor type 1 recurrence was 8.9%. Conclusion: This novel technique is safe with satisfactory long-term results. The outcome of our study will hopefully motivate future randomized control trials.

Management of paraesophageal hiatus hernia: recommendations following a European expert Delphi consensus

AimsThere is considerable controversy regarding optimal management of patients with paraesophageal hiatus hernia (pHH). This survey aims at identifying recommended strategies for work-up, surgical therapy, and postoperative follow-up using Delphi methodology.MethodsWe conducted a 2-round, 33-question, web-based Delphi survey on perioperative management (preoperative work-up, surgical procedure and follow-up) of non-revisional, elective pHH among European surgeons with expertise in upper-GI. Responses were graded on a 5-point Likert scale and analyzed using descriptive statistics. Items from the questionnaire were defined as “recommended” or “discouraged” if positive or negative concordance among participants was > 75%. Items with lower concordance levels were labelled “acceptable” (neither recommended nor discouraged).ResultsSeventy-two surgeons with a median (IQR) experience of 23 (14–30) years from 17 European countries participated (response rate 60%). The annual median (IQR) individual and institutional caseload was 25 (15–36) and 40 (28–60) pHH-surgeries, respectively. After Delphi round 2, “recommended” strategies were defined for preoperative work-up (endoscopy), indication for surgery (typical symptoms and/or chronic anemia), surgical dissection (hernia sac dissection and resection, preservation of the vagal nerves, crural fascia and pleura, resection of retrocardial lipoma) and reconstruction (posterior crurorrhaphy with single stitches, lower esophageal sphincter augmentation (Nissen or Toupet), and postoperative follow-up (contrast radiography). In addition, we identified “discouraged” strategies for preoperative work-up (endosonography), and surgical reconstruction (crurorrhaphy with running sutures, tension-free hiatus repair with mesh only). In contrast, many items from the questionnaire including most details of mesh augmentation (indication, material, shape, placement, and fixation technique) were “acceptable”.ConclusionsThis multinational European Delphi survey represents the first expert-led process to identify recommended strategies for the management of pHH. Our work may be useful in clinical practice to guide the diagnostic process, increase procedural consistency and standardization, and to foster collaborative research.

617. OESOPHAGO-GASTRIC JUNCTION-PLASTY: PARAESOPHAGEAL HERNIA REPAIR + ANTI REFLUX SURGERY REVISITED

Abstract VIDEO DESCRIPTION: Our technique for large paraoesophageal hernia repair and gastropexy shown step by step. This approach takes components of a series of historical anti-reflux operations and can be seen as a hybrid of Hill, Toupet and Nissen with anterior and posterior hiatus repair. 1. Sac approached infero-posteriorly on the right crus after phreno-esophageal ligament identified and separated at the V. 2. Sac separated from the pleura in the mediastinum. 3. Sac dissected from right to left along the edge of the hiatus. 4. Short gastric taken, posterior component of the sac dissected. 5. Sac reduced and completely excised. 6. OGJ identified. 7. Hiatus repair: posterior and (mainly) anterior. 8. Mobilised fundus slid behind the oesophagus. 9. Angle of His reconstituted. 10. Lateral and posterior fundo-pexy (Toupet). 11. Mediastinal drain. SEE DESCRIPTION: Esophago-Gastric Junction-plasty with anterior and posterior hiatal repair is an anatomical anti-reflux procedure which can be performed for large paraoesophageal hernias.

502 Emergency Giant Hiatus Hernia Surgery: Experiences with Post-Operative Complications

Abstract Aim Patients with giant hiatus hernias can present acutely with volvulus or strangulation. Early emergency surgical intervention with reduction of the hernia and hiatal repair is shown to reduce the mortality rate. However, surgery is not without risk or complications. This study assessed the rate of complications and length of hospital stay in patients requiring emergency surgery. Method A retrospective study was done looking at all patients who underwent emergency hiatal hernia surgery at a tertiary oesophagogastric centre. Over an eight-year period, 80 patients were identified. Their clinical course was evaluated from medical records, collecting data on their length of stay, complications, and mortality. Results Of the 80 patients, 30 patients (37.5%) had no documented complications from the surgery. 62.5% did have complications, of which respiratory complications were the most frequent (43%). 10% of patients had symptomatic recurrence of the hiatus hernia that required operative correction either during index admission or a subsequent admission. Median length of hospital stay was 8 days (IQR 5–16). There was a positive correlation between number of complications and length of stay. Post-operative mortality was 9%. Conclusions Emergency surgery for hiatus hernias has a high morbidity rate, as expected for an emergency procedure in acutely unwell patients. Despite the high rate of post-operative complications, the length of hospital stay was relatively short with low mortality, showing emergency surgery to be an effective lifesaving treatment.

TU8.9 Emergency Giant Hiatus hernia repair, Single Centre Experience

Abstract Aim Patients with giant hiatus hernias can present acutely with volvulus or strangulation. Early emergency surgical intervention with reduction of the hernia and hiatal repair reduces the mortality rate. However, surgery is not without risk or complications. This study assessed the rate of complications and length of hospital stay in patients requiring emergency surgery. Method A retrospective study looked at all patients who underwent emergency hiatal hernia surgery at a tertiary oesophagogastric centre. Over an eight-year period, 80 patients were identified. Their clinical course was evaluated from medical records, collecting data on their length of stay, complications and mortality. Results Of the 80 patients, 30 patients (37.5%) had no documented complications from the surgery. 62.5% did have complications, of which respiratory complications were the most frequent (43%). 10% of patients had a symptomatic recurrence of the hiatus hernia that required operative correction during index admission or subsequent admission. The median length of hospital stay was eight days (IQR 5–16). There was a positive correlation between the number of complications and length of stay. Post-operative mortality was 9%. Conclusion Emergency surgery for hiatus hernias has a high morbidity rate, as expected for an emergency procedure in acutely unwell patients. Despite the high rate of post-operative complications, the length of hospital stay was relatively short with low mortality, showing emergency surgery to be an effective lifesaving treatment.