Hiatal Hernia Research Articles

482. REFLUXSTOP PROCEDURE IN THE LAPAROSCOPIC REPAIR OF HIATAL HERNIA

Abstract The video demonstrates laparoscopic anti-reflux surgery with the RefluxStop procedure, first introduced in 2016 and now offered in multiple centers across Europe. As this tertiary level hospital was among the first to offer this treatment to patients in clinical practice, this video provides unique insight to the lessons learned from the early experience of this surgery, with regard to optimizing effectiveness and safety. In light of the promising clinical outcomes that are emerging as follow-up data become available, the number of surgeons performing this this technique is likely to continue to increase. The RefluxStop procedure addresses all 3 components of the anti-reflux barrier as follows: 1) laparoscopic hiatal hernia repair, 2) high mediastinal dissection to achieve 4-6 cm intraabdominal length of esophagus, allowing the LES to be brought into an optimal intraabdominal position, and 3) recreation of the flap valve at the angle of His though creation of a 90-degree esophago-gastric plication. The 22mm round silicone RefluxStop device is then positioned high-up and close to the esophagus in a fundic pocket, to maintain the correct position of the repair. https://drive.google.com/file/d/1hlXXRUUMkDPmheW_mgPM_g1wWCu2R_Y3/view

Plummer-Vinson syndrome: Clinical, therapeutic and evolutionary aspects: a Moroccan case series

Plummer Vinson syndrome (PVS) is a rare entity characterized mainly by upper dysphagia, irondeficiency anemia, and the presence of an esophageal ring on endoscopic examination. We conducted a retrospective study over a period of 18 years describing the epidemiological and clinical profile, endoscopic management and the medium and long-term evolution. A total of 96 patients were enrolled, with a median age of 41,5 years and a clear female predominance (19/77). dysphagia was present in almost all our patients (97,9%), and an anemic syndrome in half the cases (52%). Female gender was significantly associated with PVS occurrence (p=0.002). The frequency of the disease was significantly higher after the age of 30 years with a peak in frequency in the 4th decade (p<0.034). Upper endoscopy found a membranous ring located in the cervical area in all cases. 1 patient had, in addition to the plummer vinson ring, a lower esophageal membranous called Schatzki ring with a small sliding hiatal hernia. PVS was associated with other autoimmune diseases mostly represented by celiac disease and autoimmune thyroiditis. Treatment was based on iron supplementation followed by endoscopic dilatation with Savary dilators in 91,6% (n=88) and balloons for 8,3% of cases (n=8). long-term outcome was favorable in 79.1% of patients with no clinical recurrence. 20,8% patients relapsed after a median of 29,2 months [2-72 months] requiring a second dilation. PVS was complicated by squamous cell carcinoma in 5,2% (n=5).

Initial Experience of Laparoscopic Crural Closure in the Management of Hiatal Hernia in Obese Patients Undergoing Sleeve Gastrectomy

Initial Experience of Laparoscopic Crural Closure in the Management of Hiatal Hernia in Obese Patients Undergoing Sleeve Gastrectomy

Laparoscopic revisional antireflux and hiatal hernia surgery results in a higher rate of complications and severity at 90 days than primary surgery

ObjectiveData on graded complications and their frequency after laparoscopic revisional antireflux and hiatal hernia surgery compared with primary surgery are lacking. We describe 30- and 90-day morbidity using the Clavien-Dindo classification. MethodsA total of 298 patients underwent revision surgery between 2003 and 2020 and were propensity matched to primary surgeries (1:2 ratio) based on age, sex, body mass index, American Society of Anesthesiology classification, Los Angeles grade esophagitis, presence of Barrett's, and indication for surgery. Complications were graded using the Clavien-Dindo classification, with the highest grade of complication reported per patient. ResultsAfter matching, both groups had a majority of female patients, with a median age of 60 years and a median body mass index of 29.5 kg/m2. Most were healthy, with nonerosive esophagitis and modest levels of Barrett's esophagus. A laparoscopic Nissen fundoplication was most common; however, a partial fundoplication was more common in revisions. Mesh, relaxing incisions, and Collis were more common in revisional surgery. At 30 days, total complications were similar (23.5% [70/298] vs 20.6% [123/596], P = .373) with 1 death in each group. Minor complications (less than Clavien-Dindo 3A) were comparable. Patients undergoing revisional surgery experienced Clavien-Dindo 3B complications (4.7% [14] vs 0.8% [5], P > .001) more frequently, with esophageal obstruction requiring revision and esophageal/gastric leak being most common. Grade Clavien-Dindo 4 A/B complications were comparable in both groups. At 90 days, patients undergoing revisional surgery experienced overall complications (7.1% [21] vs 2.0% [12], P = .003), and Clavien-Dindo 3B complications (1.0% [3] vs 0, P = .037) more frequently, with intra-abdominal abscess washout being the most common Clavien-Dindo 3B complication. ConclusionsRevisional surgery results in similar total complications at 30 days, but additional complications can occur out to 90 days.

Abstract ID: 94Quantifying Changes at the Hiatus at Different Timepoints During a Concomitant Hiatal Hernia Repair with Endoscopic Fundoplication (c-TIF) Procedure Using EndoFLIP

Abstract ID: 94Quantifying Changes at the Hiatus at Different Timepoints During a Concomitant Hiatal Hernia Repair with Endoscopic Fundoplication (c-TIF) Procedure Using EndoFLIP

546. ESOPHAGEAL FUNCTION TESTS BEFORE AND AFTER LAPAROSCOPIC SLEEVE GASTRECTOMY FOR SEVERE OBESITY

Abstract Background Gastroesophageal reflux disease is common in patients with severe obesity. However, changes in esophageal motility and gastroesophageal reflux in patients undergoing sleeve gastrectomy have not been well-studied. In this study, we evaluated the effects of sleeve gastrectomy on esophageal function. Methods All patients undergoing laparoscopic sleeve gastrectomy (LSG) at our institution are entered into a prospectively maintained database. We queried this database to identify patients who underwent pre- and post-LSG esophageal function tests (ie, high-resolution manometry [HRM] and 24-hour pH monitoring). Post-operative was esophageal function tests done at 12 months after surgery. Results A total of 44 patients underwent LSG between Jul. 2018 and Dec. 2022, of which 11 patients underwent both pre and post-LSG esophageal function tests. The study cohort had a mean age of 65.4 years with 5 males. BMI was significantly decreased after LSG (40.0 vs. 27.4 kg/m2，p=0.004). Manometric hiatal hernia was increased post-LSG (0% vs. 45.5% [n=5/11]), though this difference did not reach statistical significance (p=0.063). Esophagogastric junction contractile integral (EGJ-CI), thoraco-abdominal pressure gradient, and distal contractile integral (DCI) were similar between the two groups (p=0.155, p=0.154, and p=0.131, respectively). Post-LSG 24-hour pH monitoring showed higher acid exposure time (0.4% vs. 11.2%, p=0.005) and DeMeester score (3.5 vs. 33.2, p=0.003). Conclusions Gastroesophageal reflux was significantly exacerbated post-LSG, although esophageal motility and EGJ pressures were preserved after LSG. This may indicate that the change in EGJ morphology and disruption of the angle of His have an important role in mechanism of LSG-related GERD.

324. A RETROSPECTIVE SINGLE CENTRE PROPENSITY-MATCHED ANALYSIS OF TRANSTHORACIC VERSUS TRANSABDOMINAL PROCEDURES FOR GIANT HIATAL HERNIAS

Abstract Background Transthoracic open procedure (TTO) was historically the preferred approach for treatment of giant hiatal hernias. However, the last decades transabdominal laparoscopic procedures (TAL) became the standard approach in many centres. The aim of the study was to compare short-term and midterm outcomes, as well as patient-reported outcome measures (PROMs, between TTO and TAL for giant hiatal hernias. Methods A retrospective analysis was conducted on all primary surgeries performed for giant hiatal hernias between 2008 and 2022. Patients who underwent TAL were propensity-matched (n= 36) to those who underwent TTO based on: age, gender, Charlson Comorbidity Score and hernia type. The two groups were compared in terms of surgery duration, length of stay (LOS), Clavien-Dindo score, intrahospital reoperation, hernia recurrence and need for reinterventions. PROMswere compared between total of TTO (n= 187) and TAL (n= 48): for symptom score, QoL-score, overall satisfaction and wound pain. Median clinical follow-up was 365.5 days. Median PROMsfollow-up was 55.3 months. Results Surgery duration (224 vs 177min, P<0.001) and LOS (11 vs 4days, P<0.001) were longer in TTO. Clavien-Dindo scores were alike (P= 0.260). Intrahospital reoperation was not statistically different (8.3% vs 0%, P= 0.239). Midterm recurrence rates suggested a non-significant trend towards lower recurrence in TTO (2.8% vs 16.7%, P= 0.107). Reintervention rates were alike (16.7% vs 11.1%, P= 0.735). QoL-score was inferior for TTO (0.705 vs 0.355, P= 0.036). Wound pain scores were higher in TTO (1 vs 0, P <0.001). Symptom score and satisfaction scores were alike, respectively 0.685 vs 0.760, P= 0.688 and 9 vs 9, P= 0.421. Conclusions TAL for giant hiatal hernias showed superior results compared to TTO for duration of surgery, length of hospital stay, QoL-score and wound pain scores. However, midterm results showed a noticeable trend towards higher recurrence rates for TAL. TAL should be considered when proceeding with surgery for giant hiatal hernias but a possible higher risk of recurrence must be taken into account. Further long-term clinical follow-up and comparison to PROMscould guide future decision-making.

Abstract ID: 92Patient outcomes of robot-assisted laparoscopic hiatal hernia repair with mesh vs primary suture repair

Abstract ID: 92Patient outcomes of robot-assisted laparoscopic hiatal hernia repair with mesh vs primary suture repair

806. MINIMALLY INVASIVE REVISION FUNDOPLICATION, IS IT SAFE AND FEASIBLE? SINGLE CENTER EXPERIENCE

Abstract Introduction Laparoscopic fundoplication has become standard of care for patients with refractory gastroesophageal reflux disease, large and symptomatic hiatal hernia. Failure rate for laparoscopic fundoplication was between 2 to 17%. Doing Revisional Antireflux surgery is technically difficult. Our aim is to analyse symptomatic improvement post surgery, safety and durability of procedure in patients who underwent revision fundoplication at our centre Patients and Methods 22 patients underwent Minimally invasive revision fundoplication between January 2019 to January 2022 were taken into study, of them 12 gentlemen and 10 women were noted. Modified DeMeester score was calculated in all patients preoperatively and on 6 months follow up. Results All patients underwent primary surgery laparoscopically. 14 patients (63.6%)had recurrent reflux symptoms and 8 patients (36.3%) had severe dysphagia. Revision fundoplication was done laparoscopically in 20 patients and 2 patients Robotic surgery was done. Intraoperatively 11 patients had wrap migration, 8 patients had tight wrap, 3 patients had twist of wrap. In the re-do anti-reflux surgery (ARS) procedure, floppy Nissen fundoplication was performed in 86.4% of the patients, which amounts to 19 patients., and 3 patient underwent a 270-degree Toupet fundoplication. In 2 patients, additional composite mesh reinforcement was employed. 13.6 % of patients had intraoperative complications, 9.09 % of patients had pleural injury, 4.7 % had intraoperative bleeding, 9.09% of patients had gallstone disease, for which cholecystectomy was done. All patients anterior and posterior vagus identified and preserved. On follow up 80% of patients had resolution of symptoms, 18% needed intermittent PPI. At a median follow up of 18 months, no surgical failure was noted in endoscopy. Conclusion Laparoscopic revision fundoplication is a safe procedure when operated in a high volume centre by an expert surgeon.

808. ROUX-EN- Y GASTRIC BYPASS FOR REFRACTORY SEVERE GERD AFTER PROXIMAL GASTRECTOMY

Abstract Roux-en- Y gastric bypass for refractory severe GERD after proximal gastrectomy Category Gastro-esophageal reflux and hiatal hernia Background This is the case of a 27-year-old male diagnosed with achalasia. During dilation of the gastroesophageal junction a iatrogenic esophageal perforation occurred. Therefore, a polar gastrectomy with stapling of the lesser curvature and resection of the distal esophagus with esophagogastric anastomosis was performed. After the surgery the patient experienced symptoms of severe reflux unresponsive to PPI. Therefore, a subtotal gastrectomy with pouch construction and Roux-en-Y gastrojejunostomy was indicated. Methods We present an intraoperative video showing the surgical technique. Results The postoperative period was uneventful, with favorable response to gradual reintroduction of oral intake. The patient was discharged on the 9th POD. After a 12-month follow up the patient remains asymptomatic. Conclusions Surgery is currently the gold standard treatment for refractory reflux. In this case, the creation of a gastric pouch with Roux-en-Y bypass ensures the resolution of the symptoms of GERD as well as the gastric delay. Preservation of the gastroepiploic vessels to ensure an optimal gastric pouch perfusion is mandatory https://we.tl/t-kLUqi4AqqB

495. LAPAROSCOPIC FUNDOPLICATION IMPROVES ESOPHAGEAL MOTILITY IN PATIENTS WITH GERD A HIGH VOLUME SINGLE CENTER CONTROLLED STUDY IN HIGH-RESOLUTION MANOMETRY ERA

Abstract Background Pathophysiology of GERD is complex and esophageal motility disorders are frequently contributing to the disease. Most of the existing literature demonstrates that Laparoscopic Fundoplication (LF) is safe in the setting of ineffective or weak peristalsis, however the effect of the wrap on esophageal motility is still debated. This study aimed to assess how a functioning and effective fundoplication could impact the esophageal motility in patients with GERD. Methods We analyzed prospectively collected data on patients who underwent laparoscopic Nissen (LN) or Toupet (LT) fundoplication for GERD between 2010-2022. We selected patients who have been treated with LF according to the GERD international guidelines. The exclusion criteria were: patients with a giant hiatal hernia and patients with a proof of a too-tight LF. Patients were evaluated with the GerdQ questionnaire, barium-swallow, endoscopy and HRM and 24-hour pH-Impedance before and after surgery. The HRM were reviewed by 2 experts (Chicago Classification v4.0). LF failure was recorded in case of an abnormal postoperative pH-MII using the Lyon 2.0 criteria. Results We recruited 124 patients (M:F=89:35). Fifty-eight LN and 66 LT were recorded. A good outcome at the 24-hour pH-Impedance was registered in 103 patients (GLF) and a failure in 21 patients (FLF). As shown in Figure 1, in GLF patients, 29 had a preoperative motility disorder (24 IEM and 5 DES), and postoperatively 22 (76%) of these patients had a normalization of the esophageal motility. Ten FLF patients had a preoperative motility disorder (9 IEM and one DES); 4 (40%) of them showed normal motility after LF. There was a significant association between GLF and normalization of esophageal motility (p<0.05). Conclusion This study demonstrates that LF is an effective and functioning treatment in patients with GERD associated with an esophageal motility disorder. Moreover, our results indicate that LF could determine a normalization of the disordered esophageal motor function in patients with GERD.

333. TECHNICAL CONSIDERATIONS IN UPPER-GI RECONSTRUCTION – A CASE SERIES

Abstract Background Oesophageal reconstruction post-oesophagectomy is performed for both benign and malignant pathologies. Generally, the stomach is the conduit of choice due to its simplicity, requiring only one anastomosis. However, in some cases the stomach may not be a viable option immediately or at all, and alternatives must be considered. We describe a case where the stomach was not immediately viable and two cases where alternative conduits were sought. Furthermore, we discuss techniques such as ‘supercharging’ and ‘superdrainage’ which enhance arterial flow and venous drainage respectively, in order to prevent ischaemia and related complications of the anastomosis site. Methods and Results Case 1 presents a 72-year-old with an incarcerated para-oesophageal hernia leading to necrosis of the distal oesophagus and proximal stomach. After resection, a feeding jejunostomy and a loop oesophagostomy in the neck was created. Months later, the oesophagostomy was closed, and the residual stomach was carefully mobilised into the thorax while preserving the gastro-epiploic arcade, and oesophago-gastric anastomosis was performed. Case 2 involves a 68-year-old female who had elective Nissen fundoplication for a hiatus hernia, which recurred early with strangulation of the distal oesophagus and proximal stomach requiring emergency oesophago-gastrectomy. She later underwent a colonic interposition using the left colon, with superdrainage through an anastomosis between a branch of the middle colic vein to the left external jugular vein. Case 3 describes a 61-year-old male with a gastro-oesophageal adenocarcinoma treated with an Ivor-Lewis oesophagectomy. A year later, he suffered from a strangulated diaphragmatic hernia causing necrosis of the gastric conduit. This was replaced with an isoperistaltic colonic interposition using the transverse and left colon with super drainage. Unfortunately, three years later, this was again complicated with pancreatitis and perforated gall bladder with associated ischaemia of the colonic conduit. A re-do of the colonic interposition using the right colon was done with an arterial graft between the right transverse cervical artery and branch of ileal artery and super drainage via a branch of the ileal and right external jugular veins. Conclusion Primary and in particular secondary re-constructions of the UGI tract are complex procedures and individual approaches are needed as residual anatomy varies. Consequently, such cases require meticulous planning and a multidisciplinary approach involving the cardio-thoracic, plastic and vascular surgeons and adequate support by the anaesthetic and intensive care team. Although associated with significant morbidity and mortality, reestablishment of a swallowing passage is often desired by patients to maintain quality of life.

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

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

363. REFLUX MICRO-ASPIRATION: WHAT HAVE WE LEARNED

Abstract Background The accurate diagnosis of gastro-oesophageal reflux pulmonary microaspiration has only become possible recently with the introduction of a novel technique of reflux micro-aspiration scintigraphy study combined with single photon emission computed tomography (SPECT) combined with x-ray tomography (CT) in a hybrid instrument. This has allowed the accurate diagnosis of pulmonary and airway contamination with refluxate. Previously only patients with large volume symptomatic reflux aspiration were diagnosed clinically (Mendelson syndrome) or by 2-dimentional barium meal or an older plantar (2 dimensional) technique of scintigraphic aspiration studies. The concept of reflux micro-aspiration has been implicated in multiple pulmonary diseases but without absolute proof from an adequate diagnostic test. Little was known about the natural history, physiology, and response to treatment amongst patients with silent reflux micro-aspiration. The aim of this presentation is to summarise a series of research projects studying the natural history of the disease, common presenting symptoms, pathophysiology and response to treatment. Methods A prospectively populated database of patients referred to a tertiary specialist reflux diagnostic service with atypical and/or treatment resistant reflux was evaluated. The database contained records of consecutive patients including demographic information, presenting symptoms, investigations including imaging, upper gastro-intestinal physiology studies and novel reflux micro-aspiration scintigraphy studies. Treatment details including medical and surgical treatment and post treatment clinical information and investigations. Multiple studies were conducted using the information from the database and findings are summarised in this presentation. Results The novel reflux micro-aspiration scintigraphy with SPECT/CT was compared with other studies (multichannel intraluminal impedance and 24-hour pH monitoring) and was found to be sensitive to reflux occurring outside the oesophagus. Patients with reflux micro-aspiration can present a wide variety of symptoms, commonly a combination of typical symptoms of gastro-oesophageal reflux disease (heartburn and regurgitation) and respiratory symptoms. Reflux micro-aspiration was associated with reduced lower oesophageal sphincter pressure, severe ineffective oesophageal motility (IOM), and pharyngeal contamination with refluxate on reflux scintigraphy. Delayed liquid gastric emptying was not associated with reflux micro-aspiration, however gastroparesis with solids is associated with micro-aspiration. Micro-aspiration was common in patients with giant hiatus hernias and mostly resolved with surgery. Anti-reflux surgery resulted in resolution of aspiration in the majority of patients, however severe IOM was associated with lesser rates of microaspiration resolution. Conclusion Reflux micro-aspiration appears to be a more common manifestation of GORD than previously thought. The work summarised in this presentation discusses the presentation, physiological associations, and treatment of patients with reflux micro-aspiration.

Complex Hiatal Hernia with Gastric Volvulus Successfully Managed by Hiatal Plasty and Nissen Fundoplication: A Case Report

Background: Hiatal hernias, particularly those complicated by gastric volvulus, represent a rare but potentially life-threatening condition. Prompt diagnosis and surgical intervention are crucial to prevent severe complications such as strangulation and ischemia of the stomach. This case report details the presentation, diagnosis, and successful surgical management of a Type IV hiatal hernia with an associated gastric volvulus using hiatal plasty and Nissen fundoplication. Case Presentation: We present the case of a 65-year-old male with a history of recurrent epigastric pain, nausea, and postprandial vomiting, who was diagnosed with a Type IV hiatal hernia complicated by an organoaxial gastric volvulus. Imaging studies confirmed the diagnosis, revealing significant herniation of the stomach into the thoracic cavity. The patient underwent elective surgical repair involving a hiatal plasty to restore the diaphragmatic hiatus, followed by a Nissen fundoplication to prevent recurrence. Postoperative recovery was uneventful, with resolution of symptoms and no recurrence at a six-month follow-up. Conclusion: This case underscores the importance of timely recognition and appropriate surgical management of hiatal hernias complicated by gastric volvulus. The combined approach of hiatal plasty and Nissen fundoplication provides effective relief and prevents recurrence, contributing to favorable long-term outcomes.

Association of gastroesophageal junction laxity and gastroesophageal reflux disease.

Gastroesophageal reflux disease is a prevalent condition with significant clinical variability, complicating its evaluation and treatment. The gastroesophageal flap valve is a fundamental evaluation method, but have shown limitations in specificity and reliance on subjective endoscopists' experience. Recent insights suggest that gastroesophageal junction laxity may offer an objective and quantifiable measurement for the presence of gastroesophageal reflux disease. This retrospective study analyzed data from 401 patients who underwent comprehensive evaluations, including a symptom questionnaire, endoscopy, pH-impedance monitoring, high-resolution manometry, and treatment directions, between January 1, 2022 and October 31, 2023. Gastroesophageal junction laxity was assessed using a modified approach based on endoscopic image analysis, with the diameter of endoscope as reference to estimate the long diameter of the laxity ring. The independent association of gastroesophageal junction laxity with pathologic acid exposure, esophagitis, and hiatal hernia were assessed by adjusting with age and sex. The mean age was 44.5 ± 5.5years old, and 49.9% (200/401) were male. The most common symptoms (≥ 1 point) were acid regurgitation (333/401, 83.0%), heartburn (315/401, 78.6%), belching (278/401, 69.3%), bloating (241/401, 60.1%), and globus sensation (241/401, 60.1%). The gastroesophageal junction laxity was significantly associated with pathologic acid exposure, esophagitis, hiatal hernia, and lower esophageal sphincter resting pressure. Notably, with the increase in gastroesophageal junction laxity, the rates of pathologic acid exposure, esophagitis, and hiatal hernia increased gradually, the lower esophageal sphincter resting pressure decreased gradually. The gastroesophageal junction laxity was independent associated with pathologic acid exposure (OR = 2.33, 95%CI 1.77-3.07, p < 0.001), esophagitis (OR = 2.10, 95%CI 1.62-2.73, p < 0.001), and hiatal hernia (high-resolution manometry: OR = 3.39, 95%CI: 2.46-4.67, p < 0.001) (endoscopy: OR = 21.65, 95%CI 11.70-40.06, p < 0.001). The gastroesophageal junction laxity was significantly associated with the indicators of pathophysiology in gastroesophageal reflux disease.

LAPAROSCOPIC TECHNIQUE FOR MEASURING THE ESOPHAGEAL HIATUS AREA

Introduction. The measurement of the esophageal hiatus (EH) area is critical for the choice of the method of hernioplasty for EH hernias. Aim. The objective of this study was to develop a laparoscopic method and tools for measuring the EH area and to compare it with existing methods in type III paraesophageal hernias (PEH). Materials and methods. Laparoscopic hernioplasty was performed on 63 patients with type III PEH – 41.3% males and 58.7% females, with an average age of 53.8±10.8 years, at the surgical clinic of the Bogomolets National Medical University. Irreducible PEH was present in 54 (85.7%) patients, partially reducible in 9 (14.3%). Cardia-fundal PEH was found in 42 (66.7%) patients, subtotal in 20 (31.7%), and total in 1 (0.6%) patient. The average volume of the hernial sac, according to multispiral computed tomography (MSCT), was 235±130.7 cm³ (ranging from 90 cm³ to 863 cm³). In all patients, the EH area was measured using the developed laparoscopic method (DLM) and tools; the Granderath method; the rhomboid area determination method (RAD); and MSCT. The authors evaluated the differences in the mean value and mean percentage difference (MPD) of EH area measurements between the mentioned methods. Results. The esophageal hiatus area measured using the DLM was statistically smaller than that measured by MSCT: 9.66±0.22 cm² versus 13.01±3.04 cm², respectively, and larger than the measurements from the Granderath method and the RAD: 8.16±1.71 cm² and 8.72±1.67 cm², respectively. The MPD between the MSCT data and the Granderath and RAD methods were 40.1±7.5% and 68.8±9.6%, respectively; between MSCT and DLM, it was 28.8±7.4%. The percentage difference in the esophageal hiatus area between the MSCT data and DLM, MSCT and Granderath, and MSCT and RAD showed a significantly positive correlation with the volume of the hernial sac, respectively r=0.687, r=0.601, and r=0.579. This indicates that with an increase in the volume of the hernial sac, the esophageal hiatus area calculated by MSCT increases compared to the intraoperative methods, likely due to the influence of the hernial contents on the area of the hernial orifice. Conclusions. The proposed laparoscopic method for measuring the area of the EH involves the use of a developed device that facilitates the removal of hernial contents from the hernial orifice, placing a ruler in their plane as a reference, transmitting the image to a computer, and calculating the area taking into account the individual shape characteristics. This method provides more accurate data compared to other intraoperative techniques and MSCT. Using the proposed laparoscopic technique for measuring the EH area will allow for a more thorough assessment of the indications for different hernioplasty options, considering the area of the hernial defect.

The impact of obesity on gastroesophageal reflux disease recurrence following re-operative anti-reflux surgery.

Obese patients represent a large proportion of patients experiencing recurrent reflux and re-operations after initial anti-reflux surgery. However, there is a limited data describing the impact of obesity on GERD recurrence following re-operative procedures. A review of patients who underwent re-operative anti-reflux surgery (Re-ARS) between 2012 and 2023. Peri-operative characteristics and post-operative Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) scores were compared across the three BMI categories: (BMI < 25kg/m2, 25 ≤ BMI > 30kg/m2, and BMI ≥ 30kg/m2) over 12 IQR (9-14.9) months follow-up. Impedance planimetry measurements were included when it was utilized intraoperatively. Of 718 patients who underwent robotic ARS, 84 patients (11.6%) underwent Re-ARS, of which 29.7% had a BMI < 25kg/m2, 35.7% were ≤ 25 BMI < 30kg/m2, and 34.5% had a BMI ≥ 30kg/m2. The lower esophageal sphincter distensibility decreased similarly between groups with no differences in post-induction [3.2 ± 2 vs 4.5 ± 3.1 vs 3.9 ± 2.5 mm2/mmHg, p = 0.44] or post-fundoplication values [1 ± 0.6 vs 1.3 ± 0.7 vs 1.2 ± 0.6 mm2/mmHg, p = 0.46]. There was a significant improvement in GERD-HRQL scores postoperatively compared to preoperative levels across the three BMI classes (BMI < 25kg/m2: pre 17 IQR (12-22), post 7.5 (1.5-15), p = 0.04 vs ≤ 25 BMI < 30kg/m2: pre 26 IQR (10-34), post 8 IQR (0-17), p < 0.01 vs BMI ≥ 30kg/m2: pre 44 IQR (26-51), post 5 IQR (3.5-14.5), p < 0.001) during 12 IQR (9-14.9) months follow-up. The rates of hiatal hernia recurrence on barium swallow [5.2 vs 15.7 vs 13.7%, p = 0.32] during 7 IQR (5.2-9.2) months follow-up, and endoscopy [13.3 vs 16.6 vs 7.1%, p = 0.74] during 11.8 (IQR 5.6-17.1) months follow-up period were also similar between groups. GERD-HRQL scores in obese patients are expected to improve similarly compared to non-obese patients. Indicating that Re-ARS may be appropriate for patients across a range of BMIs.

Concurrent Hiatal Hernia, Gastric Polyp, and Lupus Nephritis in an Adolescent: A Case Report

Concurrent Hiatal Hernia, Gastric Polyp, and Lupus Nephritis in an Adolescent: A Case Report

Dynamics of hiatal hernia recurrence: how important is a composite crural repair?

Hiatal hernia recurrence rates vary widely. The true causes of recurrences are not fully understood but likely multifactorial. Surgical approaches and techniques have evolved over time to try and reduce recurrence rates after hiatal hernia repair. Our objective is to provide a current review on the physiology of hiatal hernias and the importance of a composite crural repair on hiatal hernia recurrence rates; more specifically, for this review, a composite repair is defined as a repair requiring more than primary closure of the crura. A recent review of the literature was conducted to identify studies reporting on hiatal hernia pathophysiology, stress, and tension, as well as the role of composite repair. There is a paucity of studies focusing on the pathophysiology of hiatal hernias and recurrence rates. Articles that report on the pathophysiology of the hiatus were found to have alterations of the extracellular matrix, collagen composition, changes in metalloproteinases (MMPs), and differences in genetic composition. The role of composite repair on reducing recurrence rates is not well studied. Hiatal hernias remain a complex problem with no ideal surgical technique. It is likely that the pathophysiology of hiatal hernias is multifactorial, and more studies need to be done to better understand the potential underlying mechanisms for hiatal hernias so this may also further identify the ideal surgical repair.