Paraesophageal Hernia Repair Research Articles

Comparative analysis between total and partial laparoscopic fundoplication after paraoesophageal hernia repair

The management of paraoesophageal hernia has been a subject to significant debate, particularly regarding the timing and approach of surgical intervention. Objective — to compare postoperative outcomes between Nissen and Dor fundoplication techniques for treating paraoesophageal hernias. Materials and methods. A prospective study was conducted at the Ivano‑Frankivsk Regional Hospital from March 2018 to January 2023, involving 106 patients undergoing either Nissen or Dor fundoplication. Inclusion criteria were patients 18 years or older with paraoesophageal hernias requiring surgery. Exclusions were previous esophageal or gastric surgery, esophageal motility disorders, or contraindications to general anesthesia or laparoscopic surgery. Follow¬up assessments were conducted at 1 and 3 months post‑surgery and included dysphagia rate, need for proton pump inhibitors, comorbidity profiles, duration of surgery, and hospital stay. Results. Both groups were comparable in terms of age, gender, body mass index, and preoperative symptoms, ensuring a fair comparison of surgical outcomes. The Nissen procedure showed a trend towards longer operative times and hospitalization duration, which could be attributed to its technical complexity. The Dor fundoplication group exhibited a more significant reduction in dysphagia symptoms postoperatively. This finding suggests better management of this specific complication compared to the Nissen group. A notable decrease in the need for proton pump inhibitors was observed in the Dor group, indicating more effective control of acid reflux symptoms. Conclusions. Dor fundoplication is associated with less severe postoperative dysphagia and reduced need for proton pump inhibitors compared to Nissen fundoplication. Additionally, Nissen fundoplication tends to involve longer operation times and hospital stays, indicating higher complexity. The study highlights the impact of fundoplication type on postoperative outcomes in paraoesophageal hernia patients.

Short term safety of magnetic sphincter augmentation vs minimally invasive fundoplication: an ACS-NSQIP analysis

PurposeMagnetic Sphincter Augmentation (MSA) is an FDA-approved anti-reflux procedure with comparable outcomes to fundoplication. However, most data regarding its use are limited to single or small multicenter studies which may limit the generalizability of its efficacy. The purpose of this study is to evaluate the outcomes of patients undergoing MSA vs fundoplication in a national database.Materials and MethodsThe 2017–2020 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Registry was utilized to evaluate patients undergoing MSA or fundoplication. Patients requiring Collis gastroplasty, paraesophageal hernia repair, and emergency cases, were excluded. Patient outcomes included overall complication rates, readmissions, reoperations, and mortality.ResultsA total of 7,882 patients underwent MSA (n = 597) or fundoplication (n = 7285). MSA patients were younger (51 vs 57, p < 0.001), and more often male (49.6 vs 34.3%, p < 0.001). While patients undergoing MSA experienced similar rates of reoperation (1.0 vs 2.0%, p = 0.095), they experienced fewer readmissions (2.2 vs 4.7%, p = 0.005), complications (0.6 vs 4.0%, p < 0.001), shorter mean (SD) hospital length of stay(days) (0.4 ± 4.3 vs 1.8 ± 4.6, p < 0.001) and operative time(min) (80.8 ± 36.1 vs 118.7 ± 63.7, p < 0.001). Mortality was similar between groups (0 vs 0.3%, p = 0.175). On multivariable analysis, MSA was independently associated with reduced postoperative complications (OR 0.23, CI 0.08 to 0.61, p = 0.002), readmissions (OR 0.53, CI 0.30 to 0.94, p = 0.02), operative time (RC − 36.56, CI − 41.62 to − 31.49. p < 0.001) and length of stay (RC − 1.22, CI − 1.61 to − 0.84 p < 0.001).ConclusionIn this national database study, compared to fundoplication MSA was associated with reduced postoperative complications, fewer readmissions, and shorter operative time and hospital length of stay. While randomized trials are lacking between MSA and fundoplication, both institutional and national database studies continue to support the use of MSA as a safe anti-reflux operation.

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

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

Fundoplication at the time of paraesophageal hernia repair may not reduce postoperative reflux

Hiatal hernias are observed in approximately 15% to 20% of the population in Western society. Most patients are diagnosed with a sliding-type hiatal hernia, of which gastroesophageal reflux is the predominant driving symptom. Surgical repair of these types of hernias often involves a wrap procedure during the index operation as standard of care. For type 2, 3, and 4 hernias, also known as paraesophageal hernias (PEHs), the symptom complexes vary and often involve symptoms other than reflux, including dysphagia, anemia, shortness of breath, and chest pain. We sought to evaluate whether patients who underwent PEH repair without fundoplication reported different rates of postoperative symptoms compared with those who did.

Malpractice claims after antireflux surgery and paraesophageal hernia repair: a population-based analysis

BackgroundThe complication rate of modern antireflux surgery or paraesophageal hernia repair is unknown, and previous estimates have been extrapolated from institutional cohorts.MethodsA population-based retrospective cohort study of patient injury cases involving antireflux surgery and paraesophageal hernia repair from the Finnish National Patient Injury Centre (PIC) register between Jan 2010 and Dec 2020. Additionally, the baseline data of all the patients who underwent antireflux and paraesophageal hernia operations between Jan 2010 and Dec 2018 were collected from the Finnish national care register.ResultsDuring the study period, 5734 operations were performed, and the mean age of the patients was 54.9 ± 14.7 years, with 59.3% (n = 3402) being women. Out of all operations, 341 (5.9%) were revision antireflux or paraesophageal hernia repair procedures. Antireflux surgery was the primary operation for 79.9% (n = 4384) of patients, and paraesophageal hernia repair was the primary operation for 20.1% (n = 1101) of patients. A total of 92.5% (5302) of all the operations were laparoscopic. From 2010 to 2020, 60 patient injury claims were identified, with half (50.0%) of the claims being related to paraesophageal hernia repair. One of the claims was made due to an injury that resulted in a patient's death (1.7%). The mean Comprehensive Complication Index scores were 35.9 (± 20.7) and 47.6 (± 20.8) (p = 0.033) for antireflux surgery and paraesophageal hernia repair, respectively. Eleven (18.3%) of the claims pertained to redo surgery.ConclusionsThe rate of antireflux surgery has diminished and the rate of paraesophageal hernia repair has risen in Finland during the era of minimally invasive surgery. Claims to the PIC remain rare, but claims regarding paraesophageal hernia repairs and redo surgery are overrepresented. Additionally, paraesophageal hernia repair is associated with more serious complications.

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

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

OGBN O07 Factors in recurrence following 862 giant paraesophageal hernia repairs

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

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

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

The value of "diaphragmatic relaxing incision" for the durability of the crural repair in patients with paraesophageal hernia: a double blind randomized clinical trial.

Surgical repair of paraesophageal hernias (PEHs) is burdened with high recurrence rates, and hitherto various techniques explored to enforce the traditional crural repair have not been successful. The hiatal reconstruction in PEH is exposed to significant tension, which may be minimized by adding a diaphragmatic relaxing incision to enhance the durability of the crural repair. All individuals undergoing elective laparoscopic repair of a large PEH, irrespective of age, were considered eligible. PEHs were classified into types II-IV. The preoperative work-up program included multidetector computed tomography and symptom assessment questionnaires, which will be repeated during the postoperative follow-up. Patients were randomly divided into a control group with crural repair alone and an intervention group with the addition of a left-sided diaphragmatic relaxing incision at the edge of the upper pole of the spleen. The diaphragmatic defect was then covered by a synthetic mesh. The primary endpoint of this trial was the rate of anatomical PEH recurrence at 1 year. Secondary endpoints included symptomatic gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular and pulmonary symptoms, and patient satisfaction in the immediate postoperative course (3 months) and at 1 year. Postoperative complications, morbidity, and disease burden were recorded for each patient. This was a double-blind study, meaning that the operation report was filed in a locked archive to keep the patient, staff, and clinical assessors blinded to the study group allocation. Blinding must not be broken during the follow-up unless required by any emergencies in the clinical management of the patient. Likewise, the patients must not be informed about the details of the operation. ClinicalTrials.gov, identification number NCT04179578.

Hiatal Hernia Repair: Can We Predict the Need for Mesh?

Introduction: The use of mesh for paraesophageal hernia repair is controversial due to concerns about long-term complications. This study aimed to investigate whether preoperative imaging characteristics of diaphragmatic hernia could predict the need for mesh repair. Methods: The records of all patients who underwent laparoscopic diaphragmatic hernia repair between September 2015 and September 2022 were reviewed. Patients' preoperative computerized tomography (CT) imaging was reviewed and was correlated with mesh repair. Results: A total of 53 patients were included in the study. Volumetric measurements were obtained from preoperative CT scans to assess hiatal defect area (HDA) and hernia sac volume (HSV). Mesh repair was required in 43.4% of cases, all among types II-IV. The mesh repair group had a higher mean hiatal neck height (50.8 ± 16.35 versus 43.22 ± 17.08 mm, P < .032) and higher HSV (708.53 ± 577.6 versus 346.866 ± 321.65 cm3, P < .003). There was also a borderline difference in HDA mean values (23.78 ± 17.22 versus 16.8 ± 10.41 cm2, P < .059). Conclusions: Preoperative HSV on CT scans can be a valuable predictor for the need for mesh repair during hiatal hernia surgery, aiding surgical planning and decision-making. Further research is needed to validate these findings and optimize hernia repair outcomes.

Elective Laparoscopic Paraesophageal Hernia Repair Leads to an Increase in Life Expectancy Over Watchful Waiting in Asymptomatic Patients: An Updated Markov Analysis.

The aim of this study was to perform an updated Markov analysis to determine the optimal management strategy for patients with an asymptomatic paraesophageal hernia (PEH): elective laparoscopic hernia repair (ELHR) versus watchful waiting (WW). Currently, it is recommended that patients with an asymptomatic PEH not undergo repair based on a 20-year-old Markov analysis. The current recommendation might lead to preventable hospitalizations for acute PEH-related complications and compromised survival. A Markov model with updated variables was used to compare life-years (L-Ys) gained with ELHR versus WW in patients with a PEH. One-way sensitivity analyses evaluated the robustness of the analysis to alternative data inputs, while probabilistic sensitivity analysis quantified the level of confidence in the results in relation to the uncertainty across all model inputs. At age 40 to 90, ELHR led to greater life expectancy than WW, particularly in women. The gain in L-Ys (2.6) was greatest in a 40-year-old woman and diminished with increasing age. Sensitivity analysis showed that alternative values resulted in modest changes in the difference in L-Ys, but ELHR remained the preferred strategy. Probabilistic analysis showed that ELHR was the preferred strategy in 100% of 10,000 simulations for age 65, 98% for age 80, 90% for age 85, and 59% of simulations in 90-year-old women. This updated analysis showed that ELHR leads to an increase in L-Ys over WW in healthy patients aged 40 to 90 years with an asymptomatic PEH. In this new paradigm, all patients with a PEH, regardless of symptoms, should be referred for the consideration of elective repair to maximize their life expectancy.

A synopsis of the SAGES ADOPT course for foregut surgery and its positive impact on surgeons' confidence levels.

The Acquisition of Data for Outcomes and Procedure Transfer (ADOPT) program was established by SAGES to develop and expand individual surgeon's comfort with specific, complex operations using hands-on teaching and longitudinal mentoring. The 2022-2023 Foregut (Dominating the Hiatus) section of the course focused on hiatal hernia dissection and gastric fundoplication techniques. Our aim was to describe the experience of surgeons who participated in the course. The hands-on component occurred in March 2022 at the SAGES annual meeting. Each expert mentor was matched to two participants. The mentors guided the surgeons through steps of a laparoscopic paraesophageal (PEH) hernia repair and fundoplication using a cadaveric model. Afterwards, monthly group webinars occurred and participants could receive individual coaching from their assigned mentor for a year. Each participant was given a pre-course survey with 3 and 12-month follow-up questionnaires. The majority of the 16 participants were employed in non-academic settings (87.5%). Years in practice ranged from 1 to 26, and 69% completed a fellowship. 100% completed the pre-course survey, and 53.8% responded to the 12-month post-course survey. Participant-reported effectiveness in performing a PEH hernia repair with fundoplication increased from 37.5% pre-course to 85.7% by the conclusion of the course. Confidence levels for the six core steps of the operation also increased: pre-course only 56-75% were confident with each step, this improved to 100% in four out of six steps. 85.7% said the course has changed their practice. Since inception, the ADOPT program has aimed to provide expert instruction for practicing surgeons to learn new techniques or improve their confidence in performing operations. The data for the 2022 ADOPT Foregut course shows that 1year of participation made a positive impact on these surgeons' practices. This helps to fill in the learning gap that occurs after formal surgical training ends.

Robotic-assisted versus laparoscopic paraesophageal hernia repair: a systematic review and meta-analysis.

The robotic approach offers improved visualization and maneuverability for surgeons. This systematic review aims to compare the outcomes of robotic-assisted and conventional laparoscopic approaches for paraesophageal hernia repair, specifically examining postoperative complications, operative time, hospital stay, and recurrence. A systematic review including thorough research through PubMed, Scopus, and Cochrane, was performed and only comparative studies were included. Studies concerning other types of hiatal hernias or children were excluded. A meta-analysis was conducted to compare overall postoperative complications, hospital stay, and operation time. Ten comparative studies, with 186,259 participants in total, were included in the meta-analysis, but unfortunately, not all of them reported all the outcomes under question. It appeared that there is no statistically significant difference between the conventional laparoscopic and the robotic-assisted approach, regarding the overall postoperative complication rate (odds ratio [OR], 0.56, 95% confidence interval [CI], 0.28-1.11), the mean operation time (t = 1.41; 95% CI, -0.15-0.52; p = 0.22), and the hospital length of stay (t = -1.54; degree of freedom = 8; 95% CI, -0.53-0.11; p = 0.16). Only two studies reported evidence concerning the recurrence rates. Overall, the robotic-assisted method did not demonstrate superiority over conventional laparoscopic paraesophageal hiatal hernia repair in terms of postoperative complications, operation time, or hospital stay. However, some studies focused on cost and patient characteristics of each group. Further comparative and randomized control studies with longer follow-up periods are needed for more accurate conclusions on short- and long-term outcomes.

The effect of frailty and age on outcomes in elective paraesophageal hernia repair.

Paraesophageal hernia repair (PEHR) is a safe and effective operation. Previous studies have described risk factors for poor peri-operative outcomes such as emergent operations or advanced patient age, and pre-operative frailty is a known risk factor in other major surgery. The goal of this retrospective cohort study was to determine if markers of frailty were predictive of poor peri-operative outcomes in elective paraesophageal hernia repair. Patients who underwent elective PEHR between 1/2011 and 6/2022 at a single university-based institution were identified. Patient demographics, modified frailty index (mFI), and post-operative outcomes were recorded. A composite peri-operative morbidity outcome indicating the incidence of any of the following: prolonged length of stay (≥ 3days), increased discharge level of care, and 30-day complications or readmissions was utilized for statistical analysis. Descriptive statistics and logistic regression were used to analyze the data. Of 547 patients who underwent elective PEHR, the mean age was 66.0 ± 12.3, and 77.1% (n = 422) were female. Median length of stay was 1 [IQR 1, 2]. ASA was 3-4 in 65.8% (n = 360) of patients. The composite outcome occurred in 32.4% (n = 177) of patients. On multivariate analysis, increasing age (OR 1.021, p = 0.02), high frailty (OR 2.02, p < 0.01), ASA 3-4 (OR 1.544, p = 0.05), and redo-PEHR (OR 1.72, p = 0.02) were each independently associated with the incidence of the composite outcome. On a regression of age for the composite outcome, a cutoff point of increased risk is identified at age 72years old (OR 2.25, p < 0.01). High frailty and age over 72years old each independently confer double the odds of a composite morbidity outcome that includes prolonged post-operative stay, peri-operative complications, the need for a higher level of care after elective paraesophageal hernia repair, and 30-day readmission. This provides additional information to counsel patients pre-operatively, as well as a potential opportunity for targeted pre-habilitation.

Response to: Comment on "Laparoscopic Paraesophageal Hernia Repair: to Mesh or Not to Mesh".

Response to: Comment on "Laparoscopic Paraesophageal Hernia Repair: to Mesh or Not to Mesh".

Comment on "Laparoscopic Paraesophageal Hernia Repair: to Mesh or Not to Mesh".

Comment on "Laparoscopic Paraesophageal Hernia Repair: to Mesh or Not to Mesh".

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

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

483. INTRAOPERATIVE EVALUATION OF HIATAL HERNIA SIZE AND CANDIDACY IN TIF ELIGIBLE PATIENTS

Abstract Background Transoral incisionless fundoplication (TIF) is gaining prominence in treatment of gastroesophageal reflux disease (GERD) for patients with absent or small hiatal hernia. As TIF gains popularity, appropriate patient evaluation and selection is paramount in establishing anatomical candidacy hence successful outcome. We evaluated patients who were intended to be treated with TIF and underwent a standard evaluation but instead underwent robotic hiatal hernia repair. We compared their preoperative evaluation of hernia size with intraoperative findings. Methods A cohort of seventy-six patients from a single-center database from January 2020 to March 2023 were retrospectively analyzed. All were deemed candidates for TIF based on our inclusion criteria (pH confirmation of GERD, hiatal hernia &amp;lt;2 cm) and underwent preoperative testing with endoscopy, esophagram, pH and manometry. Twenty-seven of these patients either were denied TIF by their insurance company or had personal preference for surgery (daVHH) over endoscopic intervention and underwent robotic assisted paraesophageal hernia repair. We examined intraoperative measurements of hiatal hernia size and EG junction anatomy and compared them to standard preoperative evaluation. Results On pre-operative endoscopy 23 patients were found to have no hiatal hernia, 20 were found to have a small hernia, 3 a medium hernia, and 1 a large hernia. Esophagram evaluation demonstrated no hiatal hernia in 17 patients and a small hernia in 23 patients. The average hiatal hernia size seen during manometry was 0.54 cm (0–2 cm) while the average hernia seen intra-operatively was 3.26 cm (1.5–4.8 cm). There was a significant difference between preoperative hernia size evaluated by manometry and intraoperative hernia size (p-value 0.04). Conclusion Standard preoperative evaluation of patients intended to be treated with TIF appears to have a tendency to underestimate the size of hiatal hernia and omits evaluation of paraesophageal anatomy. This can lead to poor patient selection of failure of this treatment modality. Addition of cross-sectional imaging to the evaluation of patients with small hiatal hernias can facilitate a more meaningful therapeutic decision making for endoscopic, surgical, and combination treatment options.

ThTP2.14 Robot-assisted repair of paraoesophageal hernia: a systematic review

Abstract Aim Laparoscopic repair is quoted as the standard of care for paraoesophageal herniae but limitations include the 2D image, requirement of a trained camera assistant and surgeon fatigue. Robotic-assisted (RA) repair promises improved 3D visualization and ergonomics. However, there is limited data on short and long-term outcomes from RA repair. We aimed to systematically review literature on RA repair of paraoesophageal herniae and post-operative outcomes. Methods A systematic on-line literature search of Embase and Medline identified 200 articles of which 13 relevant studies were selected, including 7 retrospective and 6 prospective studies. Selected articles were assessed by two reviewers to extract relevant demographic and outcome data. Results 1601 patients received RA repair of paraoesophageal herniae with a median age of 62 years and 72% were female. The majority had Hill type 3 paraoesophageal herniae (80.5%). Predominately elective operations (86.4%) they had a mean operative time of 169.7 minutes, used mesh in 44.0% and included a fundoplication in 78.2%. Only one required open conversion. Median length of stay was 2.45 days (1.3-4.5 days). 15.4% had reported complications (dysphagia (9.7%), pneumothorax (0.4%), pneumonia (0.3%) post-operative haemorrhage (0.3%) and thrombosis (0.4%)). There were no post-operative mortalities. Few symptomatic recurrences were reported and there was a 1.8% re-operation rate within this cohort. Conclusion RA paraoesophageal hernia repair offers similar outcomes to those published in recent literature for laparoscopic repair, with potential for improved surgeon ergonomics and visualisation. Carefully designed, prospective trials comparing laparoscopic and robotic repair are required to further delineate the optimal surgical approach.

Resolution and recurrence of anemia following repair of paraesophageal hernias.

Iron deficiency anemia is a common paraesophageal hernia (PEH) symptom and may improve after repair. When present, anemia has also been proposed to be associated with an increase in length of hospital stay, morbidity, and mortality after PEH repair. This study aimed to determine anemia-related factors in patients with PEH, the rate of anemia resolution after PEH repair, and the risk of anemia recurrence when repair failed. We included patients who received a PEH repair between June 2019 and June 2020 and had24months of postoperative follow-up. Demographics and comorbidities were recorded.Anemia was defined as pre-operative hemoglobin values < 12.0 for females and < 13.0 for males, or if patients werereceiving iron supplementation. Anemia resolution was determined at 6months post-op.Length of hospital stay, morbidity,and mortality was recorded. Logistic regression and ANCOVA were used for binary and continuous outcomes respectively. Of 394 patients who underwent PEH repair during the study period, 101 (25.6%) had anemia before surgery. Patients with pre-operative anemia had larger hernia sizes (6.55cm ± 2.77 vs. 4.34cm ± 2.50; p < 0.001). Of 68 patients with available data by 6months after surgery, anemia resolved in 36 (52.9%). Hernia recurred in 6 patients (16.7%), 4 ofwhom also had anemia recurrence (66.7%). Preoperative anemia was associated with a higher length of hospital stay (3.31days ± 0.54 vs 2.33days ± 0.19 p = 0.046) and an increased risk of post-operative all-cause mortality (OR 2.7 CI 1.08-6.57 p = 0.05). Fundoplication type (p = 0.166),gastropexy, or mesh was not associated with an increased likelihood of resolution (OR 0.855 CI 0.326-2.243; p = 0.05) (OR 0.440 CI 0.150-1.287; p = 0.05). Anemia occurs in 1 out of 4 patients with PEH and is more frequent in patients with larger hernias. Anemia isassociated with a longer hospital stayand all-cause mortality after surgery. Anemia recurrence coincided with hernia recurrence in roughly two-thirds of patients.