Paraesophageal Hiatal Hernia Research Articles

Influence of Wrap Fixation Technique on the Results of Fundoplication.

Different techniques of wrap fixation in laparoscopic Nissen fundoplication (LNF) have been proposed with of the aim to reduce the complications, but the optimal technique is yet to be determined. The aim of our prospective study was to evaluate several techniques of wrap fixation and determine whether the application of a combined approach to perform wrap fixation reduces the failure rate in short-term and long-term follow-up. One hundred two patients with sliding or paraesophageal hiatal hernia (type I or type II), who underwent antireflux surgery were randomized into 2 groups. In group I, LNF was supplemented with suturing the wrap to the diaphragmatic crura (35 patients) or to the body of stomach (16 patients). This was dependent on the strength of the crura (defined as weak or strong). The control group (51 patients) underwent LNF without wrap fixation. All patients were assessed using a validated symptom and quality of life (gastroesophageal reflux disease-Health Related Quality of Life) questionnaire, 24-hour impedance-pH monitoring, and barium swallow. At the 48-month follow-up, the overall rate of complications was not significantly different between the 2 groups; however, there was a tendency toward a lower frequency of reoperations in the first group (P=0.059). Fixation of the fundoplication of wrap was noted to lead to significantly lower rates of postoperative dysphagia (P<0.05). These patients (group I) were also found to have significant improvement in gastroesophageal reflux disease-Health Related Quality of Life score (from 19.3±13.2 to 4.3±3.9 vs. from 18.7±11.9 to 9.3±7.7). Fixation of the Nissen fundoplication wrap has been shown to have a positive impact on the reduction of postoperative dysphagia and leads to an improvement in disease-specific quality of life.

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

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

Right paraesophageal hiatus hernia associated with complete situs inversus

Right paraesophageal hiatus hernia associated with complete situs inversus

Acute paraoesophageal hiatal hernia following laparoscopic sleeve gastrectomy

Anti-obesity surgery is the most effective therapy available for significant weight loss in patients with morbid obesity. Obesity in consider a major independent risk factor for Hiatal hernia (HH) and it is present in about 37%-50% of morbidly obese patients undergoing bariatric surgery.1,2,3 It might be overlooked or under looked especially if the patient was asymptomatic and no pre-operative endoscopy or radiological workup. Denovo closure of the hiatal defect in case of an intraoperative finding of HH strongly recommended preventing such acute postoperative complications. Herein we report a rare and acute post laparoscopic sleeve gastrectomy with gastric herniation were uneventfully diagnosed and interfered early to prevent a catastrophic outcome.

What Is the Reality of Hiatal Hernia Management?-A Registry Analysis.

Introduction: To date, the guidelines for surgical repair of hiatal hernias do not contain any clear recommendations on the hiatoplasty technique with regard to the use of a mesh or to the type of fundoplication (Nissen vs. Toupet). This present 10-years analysis of data from the Herniamed Registry aims to investigate these questions.Methods: Data on 17,328 elective hiatal hernia repairs were entered into the Herniamed Registry between 01.01.2010 and 31.12.2019. 96.4% of all repairs were completed by laparoscopic technique. One-year follow-up was available for 11,280 of 13,859 (81.4%) patients operated during the years 2010–2018. The explorative Fisher's exact test was used for statistical calculation of significant differences with an alpha = 5%. Since the annual number of cases in the Herniamed Registry in the years 2010–2012 was still relatively low, to identify significant differences the years 2013 and 2019 were compared.Results: The use of mesh hiatoplasty for axial and recurrent hiatal hernias remained stable over the years from 2013 to 2019 at 20 and 45%, respectively. In the same period the use of mesh hiatoplasty for paraesophageal hiatal hernia slightly, but significantly, increased from 33.0 to 38.9%. The proportion of Nissen and Toupet fundoplications for axial hiatal hernia repair dropped from 90.2% in 2013 to 74.0% in 2019 in favor of “other techniques” at 20.9%. For the paraesophageal hiatal hernias (types II–IV) the proportion of Nissen and Toupet fundoplications was 68.1% in 2013 and 66.0% in 2019. The paraesophageal hiatal hernia repairs included a proportion of gastropexy procedures of 21.7% in 2013 and 18.7% in 2019. The recurrent hiatal hernia repairs also included a proportion of gastropexies 12.8% in 2013 and 15.1% in 2019, Nissen and Toupet fundoplications of 72.7 and 62.7%, respectively, and “other techniques” of 14.5 and 22.2%, respectively. No changes were seen in the postoperative complication and recurrence rates.Conclusion: Clear trends are seen in hiatal hernia repair. The use of meshes has only slightly increased in paraesophageal hiatal hernia repairs. The use of alternative techniques has resulted in a reduction in the use of the “classic” Nissen and Toupet fundoplication surgical techniques.

S2918 Giant Paraesophageal Hernia and Gastric Volvulus: An Uncommon Etiology of Vomiting and Upper Gastrointestinal Bleeding

INTRODUCTION: Paraesophageal hiatal hernia is a rare type of hiatal hernia, which occurs mostly in the elderly population after the age of 70, and accounts for less than 5% of all hiatal hernias. Here we report a rare case of a large paraesophageal hiatal hernia and gastric volvulus as an uncommon cause of vomiting and upper gastrointestinal bleeding. CASE DESCRIPTION/METHODS: A 46-year-old female with a past medical history of anemia and GERD presents with one day history of coffee ground emesis and melena. She has no history of previous gastrointestinal bleeding and denies NSAID use. She has been off PPI agents for one year due to the improvement of acid reflux disease after weight loss of 40 lbs. Etiology of anemia was not found during the previous GI workup including an upper endoscopy completed locally. Upon presentation, her hemoglobin was checked low at 9.3 g/dl from her baseline of 11.0 g/dl. She underwent a repeat upper endoscopy which revealed a large paraesophageal hernia (7 cm) with multiple linear erosions/ulcerations, suggestive of Cameron's lesions. The insufflation of the stomach was abnormal, with a distorted antrum located at an eccentric angle concerning for gastric volvulus. Further workup with computerized tomography (CT) scan of the chest and abdomen showed findings of a large type 3 hiatal hernia with organoaxial volvulus, and no evidence of ischemia or obstruction. She subsequently underwent laparoscopic repair of her paraesophageal hernia and Nissen fundoplication with resolution of anemia after the surgery. DISCUSSION: Paraesophageal hernia with gastric volvulus is a rare entity that can manifest with vomiting due to partial or complete gastric outlet obstruction, and gastrointestinal bleeding due to mucosal ischemia or Cameron's lesions. It is critical for gastroenterologists to recognize paraesophageal hiatal hernias during upper endoscopy evaluation, due to its association with gastric volvulus leading to incarceration and life-threatening strangulation. Emergency surgery is required for acute ischemic gastric volvulus. Otherwise, elective surgery can be offered to symptomatic patients and laparoscopic surgery is the mainstay of treatment approaches.Figure 1.: Giant Paraesophageal hiatal hernia: Retroflexion (A) and forward view (B) revealed giant hiatal hernia with Cameron lesions. C: Chest/abdominal CT confirmed large type 3 paraesophageal hernia with gastric volvulus.

Magnetic Sphincter Augmentation in Patients with Paraesophageal Hernia vs Large Sliding Hiatal Hernia: Comparison of Clinical Outcome and Complexity of the Surgery

Magnetic Sphincter Augmentation in Patients with Paraesophageal Hernia vs Large Sliding Hiatal Hernia: Comparison of Clinical Outcome and Complexity of the Surgery

S2978 Intrathoracic Gastric Incarceration Following Laparoscopic Nissen Fundoplication

INTRODUCTION: Nissen fundoplication is the most performed surgical treatment for GERD. Given the complex anatomy of the EG junction, structural complications occur in up to 30% of cases following fundoplication. Our case is that of post fundoplication paraesophageal hernia with intrathoracic gastric incarceration. CASE DESCRIPTION/METHODS: A 57yo F with PMHx of GERD and type III paraesophageal hiatal hernia who had undergone laparoscopic surgery with primary diaphragm repair and Nissen fundoplication 7mo prior presented with acute onset of dysphagia and epigastric pain. CT revealed superoposterior migration of the Nissen wrap above the diaphragm and a well-circumscribed pouchlike sac to the left of the Nissen fundoplication containing an air-fluid level, without evidence of perforation. GI was consulted and the patient underwent EGD revealing a tight Nissen wrap that was barely traversable. The gastric mucosa was congested, inflamed, and ulcerated from the GE junction to the gastric body concerning for acute incarceration and necrosis. Surgery was urgently consulted, and the patient underwent emergent exploratory laparoscopy which revealed incarcerated herniation of the previously performed fundoplication into the chest. The fundus and upper body of the stomach were necrotic. Laparoscopic subtotal linear gastrectomy with mediastinal abscess drainage and closure of the diaphragmatic defect was performed followed by intraoperative EGD. The patient was discharged a few days later and is currently doing well. DISCUSSION: Nissen fundoplication is a widely accepted and commonly performed anti reflux surgical procedure. The gastric fundus is wrapped around the intraabdominal esophagus, after mobilizing the esophagus and reducing the hiatal hernia, if present. The rate of serious complications has been documented as less than 5%. Incarceration post fundoplication is usually a late diagnosis as it presents with non-specific symptoms of abdominal pain, nausea, and vomiting. EGD with comprehensive retroflexed examination of the fundoplication and barium esophagram are the primary tests to assess for structural complications. Paraesophageal hernia is one of the complications reported after laparoscopic Nissen fundoplication, and it requires emergency operation when associated with incarceration, obstruction, or strangulation of the stomach. There should be high index of suspicion for complications in patients with history of Nissen fundoplication for early detection, prompt treatment, and satisfactory outcomes.Figure 1Figure 2Figure 3

S3041 Primary Gastric Synovial Sarcoma: A Rarity Tucked Within

INTRODUCTION: Synovial sarcoma (SS) is a rare tumor, accounting for about 10% of soft tissue sarcomas. The most common sites are the extremities. GI tract involvement is uncommon. We present a rare case of Primary Gastric SS. Based on our literature review, there are less than 20 reported cases. CASE DESCRIPTION/METHODS: 77 y.o. Female with hx of Hiatal Hernia and Chronic GERD presented with upper abdominal discomfort, loss of appetite and 12 lb unintentional weight loss. She denied melena or vomiting. Physical exam was unremarkable. Labs revealed new anemia with Hgb 9.8 g/dl from baseline 13 g/dl. CT abdomen showed a large paraesophageal hiatal hernia that had increased in size from imaging 8 yrs ago. EGD showed a very large hiatal hernia containing the fundus, cardia and body of the stomach. A large, polypoid, ulcerated, partially circumferential mass with no bleeding was seen in the gastric body within the hiatal hernia. Multiple biopsies were taken with cold forceps. Biopsy showed malignant spindle cell neoplasm. Immunohistochemical staining was highly suspicious for synovial sarcoma. FISH study was positive for SS18 (SYT) gene rearrangement, which was consistent with a diagnosis of Synovial Sarcoma. Staging scans showed no evidence of metastatic disease. She underwent near total gastrectomy and primary hiatal hernia repair. Surgical pathology showed a 9.5 cm spindle cell, histologic grade 3, synovial sarcoma. Resection margins were negative for tumor and there was no lymphovascular or omental involvement. She received no adjuvant therapy, and there has been no evidence of local recurrence or distant metastasis for 5 months after surgery. Oncology recommends serial surveillance imaging and EGD at 1 year. DISCUSSION: Primary gastric SS is rare and difficult to diagnose. It is important to distinguish from other common GI mesenchymal tumors, such as GIST, leiomyoma, leiomyosarcoma and schwannoma. Immunohistochemical staining and molecular analysis are useful tools. Much of the management is guided by case reports. The mainstay of treatment for gastric SS is surgical resection. Data on the role of adjuvant radiation or chemotherapy is sparse. Based on the available data, size greater than 5cm have a high rate of recurrence. However, given the small number of cases, prognosis of gastric SS remains unclear. The rare diagnosis of primary gastric SS makes our case unique. Currently, very few cases of gastric SS exist in the literature and more data is necessary to understand the natural history of this disease.Figure 1.: Gastric Mass seen on EGD.Figure 2.: H&E: Momomorphic cellular spindle cell neoplasm infiltrating the stomach wall extending into mucosa. Arrows point to the residual gastric foveolar glands. There is background acute inflammation caused by erosion of the lesion in the stomach.Figure 3.: Immunohistochemical stain : Tumor cells display strong patchy CK7 and diffuse TLE1 positivity. A FISH study demonstrates SS18 gene rearrangement supporting synovial sarcoma diagnosis (not shown).

S1474 Acute Pancreatitis as an Early Complication of Laparoscopic Sleeve Gastrectomy

INTRODUCTION: Bariatric surgery remains a safe and effective long term solution to help curb the growing obesity problem worldwide. Laparoscopic sleeve gastrectomy (LSG) is the most common surgical intervention performed. Acute pancreatitis (AP) is a rarely reported complication. Herein we present a case of AP within 30 days of LSG. CASE DESCRIPTION/METHODS: A 27-year-old morbidly obese female underwent LSG and paraesophageal hiatal hernia repair after complete outpatient evaluation. On post-op day (POD) 2, she was discharged home upon tolerating a liquid diet. She presented to the Emergency Department (ED) four days later with multiple episodes of diarrhea and lethargy. Stool studies did not reveal any infection. She was hydrated and discharged home. On POD 16, she returned with nausea and inability to tolerate solid food but denied any abdominal pain. Her lipase was elevated at 511 U/L. However, CT Abdomen with contrast was normal. She was advised to stay hydrated and discharged with antiemetics. She was re-evaluated twice more for similar complaints and on her 5th ED visit on POD 26, she was admitted for severe nausea and poor oral intake. Patient still denied abdominal pain but endorsed some regurgitation. She appeared dehydrated and her abdominal exam was benign. Labs revealed WBC 12000/µL, Creatinine 0.8 mg/dL, normal bilirubin/liver enzymes, and Lipase 687 U/L. Repeat CT Abdomen showed inflammation of the posterior pancreas and a normal gallbladder. Esophagogastroduodenoscopy revealed Hill Grade III gastroesophageal flap valve and gastritis at the junction of the gastric body and antrum without stricture or leak. Patient was aggressively hydrated the first day and subsequently started on total parenteral nutrition. Her lipase peaked at 785 U/L but she clinically improved and was discharged home 3 days later. She did well on follow-up without any sequelae. DISCUSSION: AP is an under-recognized complication associated with any bariatric surgery. In a retrospective study by Hussan et al, they reported a 2-fold increase in AP risk within 6 months after LSG when compared to other bariatric surgeries. There are many hypotheses for this potentially life-threatening complication including gallstones, postprandial peak of cholecystokinin promoting the release of pancreatic enzymes, peripancreatic tissue adhesion intraoperatively, or compromised pancreatic microcirculation. As the number of LSG performed annually continues to increase, a high index of suspicion should remain for AP as a potential early complication.

569 LAPAROSCOPIC REPAIR OF A VOLUMINOUS SYMPTOMATIC HIATAL HERNIA USING AN ABSORBABLE SYNTHETIC MESH

Abstract In symptomatic voluminous paraesophageal hiatal hernias not only a laparoscopic surgical approach, but also the use of mesh can be considered too. The use of surgical protesis in hiatal henia repair was a debated surgical topic in the last years A laparoscopic repair of a symptomatic type III hiatal hernia by plastic of the hiatus, fundoplicatio and use of an absorbable glycolic acid/trimethylene carbonate synthetic mesh is showed. Methods The patient was a 59 years old male suffering from recurrent aspiration pneumonias. Surgery was performed by a standardized tecnique in a high volume laparoscopic surgical centre. The hernia sac was removed and the plastic of the esophageal hiatus was performed. After the mesh placement a Nissen fundoplicatio was performed. No drain was placed. Results In the postoperative period a contrat-soluble swallow was performed and it resulted in a good transit witout any sign of recurrence. The patient was discharged with an appropiate oral intake. One year after surgery the patient is asymptomatic and in good conditions. Conclusion A voluminous symptomatic hiatal hernia can be successfully treated in a high-volume and long-term experienced laparoscopic surgical. The use of an absorbable, handily positionable and synthetic mesh can help to gain a lower rate of recurrence without any risk for the patients. The technical skill and all the surgical steps never are renounceable because of the presence of the mesh. Further studies with a longer-term follow-up and a international live debate are necessary. Video https://www.dropbox.com/s/384ujzm3rnoqe0a/Hiatal%20Hernia%20Dr.%20Cocozza%20ISDE%202020.mp4?dl=0

Type IV paraesophageal hiatal hernia and organoaxial gastric volvulus

Organoaxial gastric volvulus occurs when the stomach rotates on its longitudinal axis connecting the gastroesophageal junction to the pylorus. With that, the antrum of the stomach usually rotates in the opposite direction in rela-tion to its fundus (1). This phenomenon has often been known to be associated with diaphragmatic defects (2) Importantly, abnormal rotation of the stomach of more than 180° is a life threatening emergency that may create a closed loop ob- struction which may result in incarceration leading to strangulation, and hence, a surgical emergency. We present the case of a middle-aged female who presented with organoaxial gastric volvulus and had an associated Type IV paraesophageal hiatal hernia that was treated electively. Normally an emergent gastric volvulus is diagnosed via Borchardt’s classic triad (epigastric pain, unproductive vomiting and diffculty inserting a nasogastric tube); however in this patient the nasogastric tube (NGT) was passed into the antrum which allowed additional time for resusci-tation with fuids and other symptomatic relief.

Short-Term Outcomes in Patients Undergoing Paraesophageal Hiatal Hernia Repair

Many patients with hiatal hernias (HH) are asymptomatic; however, symptoms may include heartburn, regurgitation, dysphagia, nausea, or vague epigastric pain depending on the hernia type and severity. The ideal technique and timing of repair remains controversial. This report describes short-term outcomes and readmissions of patients undergoing HH repair at our institution. All patients who underwent HH repair from January 2012 through April 2017 were reviewed. Patients undergoing concomitant bariatric surgery were excluded. 239 patients were identified and 128 were included. Eighty-eight were female (69%) and 40 were male (31%) with a mean age of 59 years (range 20–91 years) and a mean BMI of 29.2 kg/m2 (17–42). Worsening GERD was the most common presenting symptom in 79 (61.7%) patients. Eighty-four laparoscopic cases (65.6%) and 44 robotic assisted (34.4%) procedures were performed. Mesh was used in 59 operations (3 polytetrafluoroethylene; 56 biologic). All hiatal hernia types (I-IV) were collected. Majority were initial operations (89%). Techniques included: Toupet fundoplication in 68 cases (63.0%), Nissen fundoplication in 36 (33.3%), Dor fundoplication in 4 (3.7%), concomitant Collis gastroplasty in 4 (3.1%), and primary suture repair in 20 (15.6%). Outcomes between robotic and laparoscopic procedures were compared. Length of stay was reported as median and interquartile range for laparoscopic and robotic: 1.0 day (1.0–3.0) and 2.0 days (1.0–2.5); p = 0.483. Thirty-day readmission occurred in 9 patients, 7 (8.3%) laparoscopic and 2 (4.6%) robotic; p = 0.718. Two 30-day reoperations occurred, both laparoscopic; p = 0.545. Total of 16 complications occurred; 18.6% had a complication with the use of mesh compared to 8.7% without the use of mesh, p = 0.063. There were no conversion to open modality and no mortalities were reported. Hiatal hernia repair can be performed safely with a low incidence of complications.

Evolution From the U-shaped to Keyhole-shaped Mesh Configuration in the Repair of Paraesophageal and Recurrent Hiatal Hernia.

Paraesophageal hernia (PEH) and recurrent hiatal hernia (RHH) are prone to recurrences. One adjunct used to reduce recurrences is mesh reinforcement. The optimal configuration is yet to be determined. We present our evolution from the U-shaped to the keyhole pattern. All patients undergoing PEH/RHH repair with mesh between 2013 and 2019 were reviewed for demographic information, perioperative/intraoperative details, postoperative complications, and recurrences. Of patients undergoing PEH/RHH repair between 2013 and 2019, 138 were repaired using mesh. Of these, 88 were repaired using the U-shaped configuration and 50 using the keyhole configuration. The U-shaped configuration was used for PEH in 72% and RHH in 28%, while the keyhole configuration was used for PEH in 66% and RHH in 34%. Thirty patients suffered postoperative complications, although there was no difference between the groups. Overall, 28 patients in the U-shaped configuration group (31.8%) had a recurrence of their hiatal hernia identified, compared with 7 patients (14.6%) in the keyhole group (P=0.039). The median time to last follow-up was 21 months (range: 1 to 85) in the U-shaped group and 8 months (range: 1 to 23) in the keyhole group. There was no difference in median time to recurrence, postoperative dysphagia, dilations, or strictures. The keyhole pattern mesh was not associated with a higher complication rate compared with the U-shape pattern. Although this study was not a direct comparison between the configurations, it does suggest that the keyhole pattern may lead to fewer recurrences.

Organoaxial Gastric Volvulus

An 84-year-old woman with known history of paraesophageal hiatal hernia presented with acute epigastric pain and vomiting. Laboratory testing revealed no clinically significant derangements. A computed tomography scan was performed, which revealed rotation of the stomach along its long axis with reversal of the greater and lesser curvatures, mimicking an inverted stomach appearance (Figure A). This finding was consistent with organoaxial gastric volvulus. The patient was emergently taken for laparotomy for detorsion of the stomach and gastropexy.

Robotic Fundoplication for Large Paraesophageal Hiatal Hernias.

Purpose:Laparoscopic fundoplication is now a cornerstone in the treatment of gastro-esophageal reflux disease (GERD) with sliding hernia. The best outcomes are achieved in those patients who have some response to medical treatment compared to those who do not. Robotic fundoplication is considered a novel approach in treating GERD with large paraesophageal hiatal hernias. Our goal was to examine the feasibility of this technique.Methods:Seventy patients (23 males and 47 females) with mean age 64 y old (22–92), preoperatively diagnosed with a large paraesophageal hiatal hernia, were treated with a robotic approach. Biosynthetic tissue absorbable mesh was applied for hiatal closure reinforcement. Fifty-eight patients underwent total fundoplication, 11 patients had partial fundoplication, and one patient had a Collis-Nissen fundoplication for acquired short esophagus.Results:All procedures were completed robotically, without laparoscopic or open conversion. Mean operative time was 223 min (180–360). Mean length of stay was 38 h (24–96). Median follow-up was 29 mo (7–51). Moderate postoperative dysphagia was noted in eight patients, all of which resolved after 3 mo without esophageal dilation. No mesh-related complications were detected. There were six hernia recurrences. Four patients were treated with redo-robotic fundoplication, and two were treated medically.Conclusions:The success of robotic fundoplication depends on adhering to a few important technical principles. In our experience, the robotic surgical treatment of gastroesophageal reflux disease with large paraesophageal hernias may afford the surgeon increased dexterity and is feasible with comparable outcomes compared with traditional laparoscopic approaches.

Laparoscopic gastric fundus tamponade: a novel adaptation of the Toupet fundoplication for large paraesophageal hernia repair.

Laparoscopic repair of large paraesophageal hiatal hernia with defects too large to close primarily or greater than 8cm is technically challenging. The ideal repair remains unclear and is often debated. Utilizing the gastric fundus as an autologous patch to obliterate and tamponade large hiatal defects may offer a new solution. The aim of this study was to evaluate the short-term outcomes following partial posterior fundoplication with gastric fundus tamponade. Retrospective chart review and prospective patient follow up was conducted on patients who underwent laparoscopic hiatal hernia repair between 2015 and 2019 by a single surgeon. Basic demographics, pre-operative diagnoses, operative technique, and clinical outcomes were recorded. Fifteen patients underwent the described technique for repair of large paraesophageal hiatal hernia. All procedures were completed laparoscopically with a short post-operative length of stay (mean of 3days) and no 30-day readmissions. The majority of patients reported resolution of their pre-operative symptoms. Only one patient required surgery for emergent indications and the same patient was the only mortality in the study, which was secondary to respiratory failure, necrotizing pneumonia, and sepsis as a result of gastric volvulus and obstruction. Utilizing the gastric fundus as an autologous patch to repair large hiatal hernia may be a safe and efficacious solution with good short-term outcomes. However, further studies should be conducted to elucidate long-term results.

Assessment of short-term outcome with TiO2 mesh in laparoscopic repair of large paraesophageal hiatal hernias

BackgroundLaparoscopic large para-oesophageal hiatal hernia (LPHH) repair using mesh reinforcement significantly reduces postoperative recurrence rates compared to conventional suture repair, especially within short follow-up times. However, the ideal strategy for repairing LPHH remains disputable because no clear guidelines are given regarding indications, mesh type, shape or position. The aim of this study was to survey our short-term results of LPHH management with a biosynthetic monofilament polypropylene mesh coated with titanium dioxide to enhance biocompatibility (TiO2Mesh™).MethodsA retrospective study was performed at Ramon y Cajal University Hospital, Spain from December 2014 to October 2018. Data were collected on 27 consecutive patients with extensive hiatal hernia defects greater than 5 cm for which a laparoscopic repair was performed by primary suture and additional reinforcement with a TiO2Mesh™. Study outcomes were investigated, including clinical and radiological recurrences, dysphagia and mesh-related drawbacks.ResultsTwenty-seven patients were included in our analysis; 10 patients were male, and 17 were female. The mean age was 73 years (range, 63–79 years). All operations were performed laparoscopically. The median postoperative hospital stay was 3 days. After a mean follow-up of 18 months (range, 8-29 months), only 3 patients developed clinical recurrence of reflux symptoms (11%), and 2 had radiological recurrences (7%). No mesh-related complications occurred.ConclusionsTiO2Mesh™ was found to be safe for laparoscopic repair of LPHH with a fairly low recurrence rate in this short-term study. Long-term studies conducted over a period of years with large sample sizes will be essential for confirming whether this mesh is suitable as a standard method of care with few drawbacks.

2763 A Case of Intermittent Organo-axial Gastric Volvulus

INTRODUCTION: Gastric volvulus is a rare clinical entity defined as twisting of the stomach along its long or short axis leading to gastric outlet obstruction (GOO). Commonly symptoms are acute and include retching, abdominal pain, and vomiting. Chronic intermittent manifestations of this entity constitute a diagnostic challenge as conclusive findings in imaging are only present during symptomatic periods and due to the intermittent nature of the disorder, a volvulus may spontaneously resolve before imaging studies are performed. Herein we illustrate a rare case of an intermittent organo-axial gastric volvulus that responded to conservative measures. CASE DESCRIPTION/METHODS: A 92-year-old female presented with intermittent epigastric pain and food intolerance of a few weeks duration. She reported dysphagia one year prior to presentation. Upper gastrointestinal (UGI) series showed gastric organo-axial rotation with no obstruction. Symptoms resolved at that time without any intervention. Physical examination revealed epigastric tenderness. Vitals and laboratory tests were unremarkable. UGI series showed a large para-esophageal hernia, an intrathoracic stomach with a gastric organo-axial rotation and partial obstruction at the level of gastroduodenal junction [Figures 1 and 2]. A contrast computed tomography (CT) scan of abdomen confirmed the same findings [Figure 3]. Endoscopic as well as surgical gastropexy were offered but the patient refused any intervention in view of her poor functional status. She was managed conservatively with intravenous fluids and bowel rest and was discharged 5 days later. DISCUSSION: Gastric volvulus was first described in 1866 as a torsion of the stomach around its short or long axis. Based on the axis of rotation, it was classified into organo-axial, mesentero-axial or combined. Organo-axial volvulus is common in adults, constitutes about 59% of cases and peaks after the 5th decade of life. It is mainly seen in the context of diaphragmatic abnormalities such as para-esophageal Hiatal hernias and diaphragmatic eventration. Diagnosis is challenging due to non-specific presenting symptoms. Contrast CT of abdomen and UGI series are gold standard diagnostic modalities. Endoscopic and surgical gastropexy is the mainstay of therapy. Heightened awareness is warranted in patients presenting with GOO in the setting of UGI tract anatomical abnormalities, since delayed diagnosis and management may lead to life-threatening complications and mortality rates up to 50%.

A162 Investigation of Laparoscopic Sleeve Gastrectomy with and without concurrent Paraesophageal Hiatal Hernia Repair utilizing the ACS MBSAQIP

A162 Investigation of Laparoscopic Sleeve Gastrectomy with and without concurrent Paraesophageal Hiatal Hernia Repair utilizing the ACS MBSAQIP