Hiatal Hernia Research Articles

545. HIATAL HERNIA RECURRENCE: IS OBSTRUCTIVE SLEEP APNEA A RISK FACTOR?

Abstract Background A plausible mechanism explaining how obstructive sleep apnea (OSA) triggers gastroesophageal reflux disease (GERD) through hiatal hernia (HH) has been proposed but also ignored in clinical practice. We sought to determine if there were differences in the prevalence of OSA between patients undergoing redo-HH repair and a matched cohort undergoing primary HH repair. Methods After IRB approval, we conducted a single-center retrospective cohort study. A prospectively maintained database was queried to retrieve clinical information of all the patients who underwent HH repair by a foregut surgeon between September 2016 and July 2023. The first group included patients who underwent redo-HH repair due to HH recurrence, and the second group included patients who underwent primary HH repair. Matching was performed in a 1:2 ratio using a propensity-score method based on age, sex, body mass index (BMI), history of chronic respiratory conditions other than OSA, history of smoking, and alcohol abuse. Results During the study period, 63 patients underwent redo-HH repair, and 370 underwent primary HH repair. After matching, 57 patients in the redo-HH repair and 114 in the primary HH repair were included, and all covariates showed adequate balance (Table 1). Patients undergoing redo-HH repair had a slightly higher prevalence of OSA compared to those who underwent primary repair (22.8% [CI95:11.91-33.7%] vs. 14.0% [CI95:7.7-20.4%], χ2 = 2.076, p=0.150). Conclusion Despite not reaching statistical significance, a relatively higher prevalence of OSA among patients undergoing redo-HH was found. Our study was limited by the retrospective design and inability to characterize the severity of OSA as well as patient compliance to treatment. Future prospective studies assessing this potential causality should be undertaken.

507. LONG BARRETT´S ESOPHAGUS IN MONOZYGOTIC TWINS WITH ADENOCARCINOMA DEVELOPMENT

Abstract Background Familial aggregation of Barrett's esophagus (BE) and esophageal adenocarcinoma (EA) suggests a genetic pattern in fewer than 10% of patients with the former diseases. In 1983, BE was described in identical twins, underlining the hereditary influence on the development of mucosal dysplasia in some patients with this epithelial alteration. At present, some studies have attempted to identify chromosomal alterations among patients with familial aggregation of BE or EA, but there is not a clear pattern. Methods Description of the case report of a male patient who underwent esophagectomy due to EA on a long BE, who had a monozygotic twin without gastroesophageal reflux symptoms and no upper GI endoscopies before. Results A 53-year-old man was diagnosed with EA and a long BE (8 cm length) in 2017. He underwent CROSS neoadjuvant treatment and minimally invasive Ivor-Lewis esophagectomy. The pathological report indicated a GI T3N1M0 adenocarcinoma. Unfortunately, the patient developed lung metastases and passed away in 2019. Before that, the patient recalled that he had an identical twin brother with no gastroesophageal reflux symptoms, but we decided to scope him in 2017. The gastroscopy report revealed a 2 cm hiatal hernia with a long BE (C4M6 Prague Classification) but with no dysplasia. Nowadays, the twin patient is under close follow-up with proton pump inhibitors (PPI) and has not developed dysplasia. Conclusion Monozygotic twins provide a perfect model to study the possible influence of genetic predisposition to develop BE and EA. The development of EA in a patient guided us to diagnose and treat a long BE in his asymptomatic identical twin. More studies should be done to find the possible genetic alterations linked to familial aggregation of BE and EA.

613. LAPAROSCOPIC MANAGEMENT OF TYPE IV HIATAL HERNIA WITH MESH AUGMENTATION CRUROPLASTY - EXPERIENCE AT A TERTIARY CARE CENTRE

Abstract Background Type IV para-esophageal hernias, which are characterized by herniation of other organs in addition to stomach, are rare - comprising only 2-5% of all para-esophageal hernias. They are associated with life-threatening complications such as strangulation or perforation of stomach. Laparoscopic treatment of these hernias requires excellent advanced laparoscopic suturing and dissecting skills. Although laparoscopic approach is now universally accepted, the role of mesh augmentation remains debated. Methods Case records of patients who underwent Laparoscopic mesh augmentation cruroplasty for Type IV hiatal hernia since 2012 were retrospectively analyzed. Results Out of 340 patients who underwent hiatal hernia repair, 7 patients (3males, 4females) fulfilled the selection criteria. Median age was 64(53-89) years. Median duration of symptoms was 2months (15days-6months). All patients complained of heartburn. Vomiting was present in 5(71%) patients; only 1(14%) patient had persistent vomiting with dysphagia. Respiratory symptoms were present in 2(29%) patients. No patient had features of peritonitis or sepsis. One patient had undergone laparoscopic heller’s cardiomyotomy twice before. All patients underwent MDCT which confirmed type IV paraesophageal hernia. Median operating time was 150(100-280) minutes. Median blood loss was 150(50-400) ml. 6(85%) patients had herniation of omentum in addition to stomach while 1 patient had herniation of omentum and transverse colon. No patient had ischemia/perforation of stomach. Median hiatal defect was 6(5-8) cm. Sac was excised completely in all cases following reduction of contents. Crural repair was done with1-0 polyester interrupted sutures. In some patients, anterior cruciate ligament repair was done to avoid tenting of esophagus. Rectangle shaped Composite mesh with key-hole slit in upper border was placed. Mesh was anchored with interrupted 1-0ethilon sutures. Fundoplication (Nissen’s/Toupet) was done in all patients, none required esophageal lengthening procedure. Median post-operative stay was 5(2-8) days, median ICU stay was 1(0-4) days. Oral liquids were started on 2 nd (1-3) post-op day and solids on 4 th (2-5) day. 2(29%) patients had post- operative complications - atrial fibrillation and transient respiratory failure respectively. Median follow-up was 14(1-40) months. No patient had symptomatic recurrence. OGDscopy at 6months was normal in 5 patients. No mesh related complication was observed. Discussion Wide hiatal defects were noted in all patients. This necessitated mesh augmentation of crural repair. Both short-term (morbidity, mortality) and long-term outcomes (recurrence, patient satisfaction) were excellent.

353. INNOVATIVE SURGICAL TECHNIQUES TO REDUCE RECURRENCE IN LAPAROSCOPIC RADICAL TREATMENT OF GIANT HIATAL HERNIA

Abstract Background In Japan, there is an increasing trend in the number of esophageal hiatal hernia (EHH) surgeries performed in elderly patients. EHH in the elderly patients are associated with surgical invasiveness and complications, but safe surgery can contribute to improving quality of life (QOL). We report on the safe surgical technique and treatment results for giant hiatal hernia. Methods The most important point to be careful of when suturing the esophageal hiatus is damage to the diaphragm leg. If the esophageal hiatus is large, reducing the pneumoperitoneum pressure as much as possible will reduce the tissue resistance during suturing, allowing suture closure without placing excessive tension on the diaphragm legs. If the esophageal hiatus is large, the pneumoperitoneum pressure should be kept as low as possible to reduce tissue resistance during suturing and prevent damage to the diaphragm legs. Surgery is usually performed with a high pneumo-abdominal pressure of 10 mmHg, but if suture closure of the esophageal hiatus is difficult, suturing is performed with a low pneumo-abdominal pressure of 6 mmHg. We underwent 103 cases of EHH surgery between 2012 and 2022. There were 73 cases (70.8%) of over 75 years old patients, and 71 cases (68.9%) of giant mixed type EHH. We compared the surgical outcomes in the early group up to 2018, in which surgery was performed with high pneumo-abdominal pressure during hiatal closure, and the latter group, from 2019 onwards, in which surgery was performed with low pneumo-abdominal pressure during hiatal closure. Results 67 cases in the early group: 23 cases with sliding type/44 cases with mixed type (65.6%), 36 cases in the latter group: 8 cases with sliding type/27 cases with mixed type (75.0%), the proportion of mixed type was higher in the late group. Mesh was used in 1 case in the early group and 0 cases in the latter group. The recurrence rate was 7 cases (10.4%) in the early group and 1 case (2.8%) in the late group, and although the proportion of mixed type cases was higher in the latter group, the recurrence rate was lower. Reoperation for recurrence was performed in 1 patient in the early group. In one case of recurrent surgery in the early group, the type of recurrence was that the muscle bundle of the diaphragm leg on one side was torn, the hiatus was dilated, and the transverse colon was invaginated into the mediastinum. From this experience, I reaffirmed the importance of reliably suturing the esophageal hiatus without damaging tissue in order to reduce recurrence of giant hiatal hernia surgery. Although there are differences in observation periods, in recent years, appropriate management of intraoperative pneumoperitoneum pressure has been able to reduce recurrence and complications, and it has also been possible to safely improve QOL in elderly patients. Conclusions In giant hiatal hernia surgery, appropriate control of intraoperative pneumoperitoneum pressure can reduce recurrence.

Outcomes of Transoral Incisionless Fundoplication (TIF 2.0): A Prospective, Multicenter Cohort Study in Academic and Community Practices (with video)

BACKGROUND AND AIMSTransoral incisionless fundoplication (TIF) is an established safe endoscopic technique for the management of GERD but with variable efficacy. In the last decade, the TIF technology and technique have been optimized and more widely accepted but data on outcomes outside clinical trials are limited. We tracked patient-reported and clinical outcomes of GERD patients after TIF 2.0. METHODSPatients with BMI < 35, hiatal hernia < 2cm, and confirmed GERD with typical and/or atypical symptoms from 9 academic and community medical centers were enrolled in a prospective registry and underwent after TIF 2.0 performed by gastroenterologists and surgeons. The primary outcomes were safety and clinical success (response in >2 of 4 endpoints). Secondary endpoints were symptom improvement, acid exposure time (AET), esophagitis healing, proton pump inhibitor (PPI) use, and satisfaction. Outcomes were assessed at last follow-up within 12 months. RESULTS85 patients underwent TIF 2.0, 81 were included in the outcomes analysis. Clinical success was achieved in 94%, GERD-HRQL scores improved in 89%, and elevated RSI score normalized in 85% of patients with elevated baseline. Patient satisfaction improved from 8% to 79% (p <0.0001). At baseline, 81% were taking at least daily PPI, while 80% were on no or occasional PPI after TIF 2.0 (p<0.0001). Esophageal AET was normal in 72%, greater with an optimized TIF 2.0 valve >300 degree circumference, >3cm length (94% vs 57%, p=0.007). There were no TIF 2.0-related serious adverse events. CONCLUSIONTIF 2.0 is a safe and effective endoscopic outpatient treatment option for select patients with GERD.

420. MESH REINFORCEMENT IN HIATAL HERNIA REPAIR: CLINICAL RESULTS OF OUR EARLY EXPERIENCE

Abstract Background Approximately one-third of the population develops diaphragmatic hernias among which only 10% are symptomatic. Restoration of the normal anatomy, hiatus closure and fundoplication are effective methods in the surgical treatment of diaphragmatic hernia repair. Placement of absorbable meshes to cover the hiatal closure emerges as a new, albeit controversial in the literature, technique for reinforcement. This study aims to assess the quality of life of patients diagnosed with hiatal hernia who underwent Nissen or Toupet fundoplication with absorbable biosynthetic mesh placement covering the suturing of the hiatus as an additional step during the laparoscopic or robotic hiatal hernia repair. Methods Data of all patients who underwent Nissen or Toupet fundoplication with absorbable mesh reinforcement at the hiatus between 2020-2023 at our specialised unit was collected and analysed. Thirteen patients who had completed their 6-month and 1-year postoperative follow-up, were interviewed. GERD score, PPI use and postoperative endoscopy were evaluated. Results Occasional use of PPI was reported by one patient, whereas those who had already undergone endoscopy of the upper gastrointestinal tract presented no signs of esophagitis, recurrence of hernia or Barrett esophagus. One patient reported symptom improvement after the operation with a GERD score of 13, while the rest of the patients had a GERD score of 0 (12/13). Conclusion The treatment of diaphragmatic hernias with Nissen or Toupet fundoplication using absorbable mesh reinforcement of the hiatus after closure with sutures seems to be an effective therapeutic method with a success rate over 90% in our case series provided that the rest of the surgical steps are identical between the cases through a well-established technique by our surgical team. However, further studies with larger number of patients and longer follow-up are mandatory aiming to further investigate the potential benefits when mesh reinforcement is applied.

811. POOLED 1-YEAR SAFETY AND QUALITY-OF-LIFE DATA AFTER REFLUXSTOP SURGERY AT TWO LARGE HOSPITALS IN SWITZERLAND: A RETROSPECTIVE CHART ANALYSIS

Abstract Background The standards of care in reflux disease management are proton pump inhibitor (PPI) therapy and conventional antireflux surgery, however, both options carry the caveats of medication irresponsiveness and troublesome postoperative sequelae, respectively. More specifically, PPIs respond inadequately in up to 40% of cases and Nissen fundoplication is associated with postoperative dysphagia in a significant proportion of patients. RefluxStop is an innovative technology that was adopted at our two respective institutions following promising safety and effectiveness data from its CE mark trial. We present the pooled safety and quality-of-life data of our 1-year experience with RefluxStop surgery. Methods Between September 2018 and August 2023, RefluxStop surgery was performed on 121 patients as part of routine clinical care at two hospitals, both of which are high-volume centers for antireflux surgery. The procedure involves crural repair with hiatal hernia reduction, reconstruction of the flap valve and angle of His, narrow esophagogastric (90-110°) plication, and device implantation in an external pouch on the gastric fundus (Figure 1). A retrospective chart analysis was conducted to document perioperative adverse events (AEs) and quality-of-life improvements via Gastroesophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) score. Higher GERD-HRQL scores are indicative of more severe disease. Results Baseline patient characteristics included mean age 54.7 years, female sex (52.9%), body mass index 27.2±4.1 kg/m2, large hiatal hernia &amp;gt;3 cm (46.3%) of median (IQR) size 3 (2-5) cm, abnormal esophageal motility (60.3%), and Barrett’s esophagus (27.3%). At 1-year follow-up, patients experienced a median (IQR) reduction of 90.5% (81.4-100%) in total GERD-HRQL score. Intraoperative AEs included conversion to laparotomy for adhesiolysis with bleeding (n=1), bleeding short gastric arteries leading to return to the operating room the next day (n=1), and esophageal perforation repaired intraoperatively (n=1). Postoperative AEs are summarized in Table 1. Conclusion The results of this pooled retrospective chart analysis support the promising early data of the RefluxStop CE mark trial. Few and predictable AEs occurred during the study period while significant improvements in quality of life were observed, as evidenced by 90.5% (81.4-100%) reductions in GERD-HRQL score. Notably, this pooled cohort of patients was comprised of substantial proportions of difficult-to-treat patients (i.e., abnormal esophageal motility in 60.3%, large hiatal hernia &amp;gt;3 cm in 46.3%), providing evidence for wider implementation of RefluxStop surgery in real-world settings. Additional evaluation is required to further delineate the role of this promising innovative antireflux surgery.

461. BARRETT'S ESOPHAGUS POST-ABLATION TRANSORAL INCISIONLESS FUNDOPLICATION (TIF) WITH OR WITHOUT HIATAL HERNIA REPAIR (CTIF):A PROSPECTIVE FEASIBILITY TRIAL

Abstract Transoral incisionless fundoplication without (TIF) or with concomitant hiatal hernia repair(cTIF) are treatment options for GERD. Lifelong PPI therapy is recommended for BE patients, even after endoscopic eradication therapy (EET), but concern for adverse effects of chronic PPI use has increased. Full barrier surgical therapy (Nissen fundoplication, magnetic sphincter augmentation) is a highly effective treatment for GERD but is associated with dysphagia and gas-bloat. We hypothesized that TIF/cTIF may be reasonable alternatives. AIM: We studied the safety and efficacy of TIF/cTIF in post-EET BE patients with refractory GERD symptoms or esophagitis despite PPI, and those averse to chronic PPI. METHODS: We prospectively enrolled BE patients with BMI &amp;lt;35 after successful EET (EMR, RFA, cryoablation) who underwent TIF (HH &amp;lt; 2cm, Hill grade ≤2) from Nov 2017-2020 or cTIF (HH ≥2cm, Hill grade ≥3) from Nov 2020-2022. Preoperative evaluation included baseline standardized GERD questionnaires, EGD, and selective pH testing and manometry. The primary outcome was GERD/LPRD symptom control. Secondary outcomes were presence of esophagitis, PPI use, patient satisfaction (rated as satisfied/neutral/dissatisfied), average duration of symptom control off PPI, failure rate, BE recurrence, and adverse events. RESULTS: To date, 30 patients have had TIF or cTIF (Table 1) after EET for LGD/HGD/ImCA (n=19) or no dysplasia + family history of BE/ECA, n=11). Median follow-up to date is 3 years (IQR 2-4, range 0.5-6). 22/30(76%) were asymptomatic on once/twice daily PPI at baseline but PPI averse. All TIFs/cTIFs were completed without serious adverse events. At 6 months post TIF/cTIF, GERD/LPRD symptom control was 86% (GERD-HRQL score) and 93% (Reflux Symptom Index score) (Fig 1B), esophagitis was absent in all patients, PPI discontinued or reduced to occasional use in 83% (Fig 1B), and acid exposure time was normal in 74%. At last follow-up, GERD and LPRD symptoms remained controlled in 93% and 96%, respectively, esophagitis absent in 95%, PPI discontinued or reduced in 71% (Fig 1D). Overall, the mean duration off PPI from TIF/cTIF was 30.4 months (range 4.4-72.5). Patient satisfaction improved from 43% at baseline, to 69% at 6 months, to 79% at last follow-up (Fig 1C). TIF/cTIF failure (defined as resumption of daily/twice daily PPI, symptom recurrence, and/or abnormal AET) was 9(32%), greater in TIF (50%) than cTIF (8%) (p=0.039). Median recurrent hiatal hernia length was 1(IQR 0-1.5). Nondysplastic BE recurrence noted in 1 patient treated with APC and TIF (3.3%). Dysphagia (10%) and gas bloat (7%) improved from baseline (37% and 20%, respectively). CONCLUSION: Transoral partial fundoplication is a safe and effective alternative to chronic PPI or full barrier surgical therapy in BE patients after EET. Surgical hiatal hernia repair (cTIF) provides added durability.

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

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

Abstract ID: 33 FLIP Measurements and Esophageal Opening Classifications in Hiatal Hernia

Abstract ID: 33 FLIP Measurements and Esophageal Opening Classifications in Hiatal Hernia

532. OPERATIVE TRENDS AND CLINICAL OUTCOMES OF OPEN, LAPAROSCOPIC AND ROBOTIC APPROACHES TO HIATAL AND PARAOESOPHAGEAL HERNIAS-A STUDY OF 1834 PATIENTS

Abstract Background Indications for repair of hiatal and paraesophageal hernia (HH/PEH) repair evolved significantly over the past two decades, impacted by the increasing application of minimally invasive surgical (MIS) approaches. This transition underscores the importance of evaluating the operative trends and clinical outcomes associated with open (open), laparoscopic (lap), and robotic surgeries especially in cases of giant hernias (over 50% intrathoracic stomach). Understanding these dynamics is crucial, especially as MIS becomes increasingly prevalent in managing complex cases, including giant hernias. The aim of this study is to assess critical outcomes achieved during the evolution from open to lap to robotic HH/PEH repair in a high volume center. Methods This is a retrospective review of 1834 patients undergoing open (958), lap (390), and robot (486), consecutive HH/PEH repairs prospectively entered into an IRB approved database from 2000 to 2023 at a high-volume center. Patient demographics, operative techniques, and top three most common presenting symptoms were studied overtime. Impact of operative technique, hernia type and size, operative outcomes including length of stay (LOS), radiographic recurrence (esophagram at 3 and 12 months), revisional surgery, on post-operative symptom resolution was evaluated. Results Annual volume increased overtime, with 418 repairs (78% robotic) in the last two years. Average hernia size decreased over the study period. The majority of patients (99.1%) presented with symptoms (Fig 1) and robotic repair had significantly better symptomatic resolution than open surgery (p&amp;lt;0.05). This advantage persists with symptoms in giant hernias (p&amp;lt;.001) LOS decreased over the study period (Fig 1). Overall radiographic recurrence (8.6%) and reoperative rate (2.4%) did not differ among operative techniques, however robotic repair had higher radiographic recurrence rate in case of giant hernia (18%, p&amp;lt;.001). Conclusion The operative volume of HH/PEH repair has increased overtime associated with the increased application along with advancements in MIS and robotic operative techniques. Surgical interventions markedly ameliorate HH/PEH symptoms, with greater improvement observed in large hernia cases. Significant improvement in LOS and at least equivalent clinical results favors MIS, particularly robotic surgery. Although the incidence of anatomic recurrent hernia and reoperation is relatively low continued assessment of especially robotic operations to decrease this incidence further is warranted.

280. MANOMETRIC FINDINGS IN PATIENTS WITH GIANT HIATAL HERNIA: OESOPHAGEAL PHYSIOLOGY APPEARS TO IMPROVE WITH SURGERY

Abstract Background High resolution manometry (HRM) is a gold standard test of oesophageal physiology. The use of HRM in patients with giant hiatus hernia (GHH) is limited by historical technical challenges as well as unclear clinical implications of the findings. The aim of this study is to demonstrate feasibility of HRM in patients with GHH and study effect of surgery on oesophageal physiology of patients undergoing GHH repair. Methods Data was extracted from a prospectively populated database of patients with giant (&amp;gt;30% stomach above diaphragm) hiatus hernias. All patients that underwent HRM before and after surgery were included. Manometric findings before and after surgery were analysed and compared. Patient symptoms were correlated with manometric findings. Results Inclusion criteria were met by 30 patients: 83% female, average age 74 (range 51-86), 93% had type III hernia containing on average 55% of stomach. All operations but one were performed laparoscopically. Pre-operatively average LOS length was 1.89cm which improved significantly to 2.19cm after surgery (p&amp;lt;0.05). Nine patients had ineffective oesophageal motility on index study which normalised post operatively in 4 patients. Lower oesophageal sphincter integrated relaxation pressure (IRP) increased post-operatively from 9.07mmHg to 11.52mmHg (p&amp;lt;0.05). Distal contractility improved post-operatively, however this was not significant. Most common presenting symptoms were dyspnoea, anaemia, retrosternal pain, and dysphagia. There was no association between dysphagia and manometric findings before or after surgery. Conclusion This study provides an insight into HRM findings in patients with GHH before and after surgery. Majority of the physiological parameters improved with surgery. There was no correlation of symptom of dysphagia with manometric findings.

254. QUANTIFYING PERIOPERATIVE RISKS FOR ANTIREFLUX AND HIATUS HERNIA SURGERY: A MULTICENTER COHORT STUDY OF 4301 PATIENTS

Abstract Background Predicting perioperative risks for fundoplication and hiatus hernia repair will inform treatment decision-making, hospital resource allocation, and benchmarking. However, available risk calculators do not account for hernia anatomy or technical aspects of surgery in estimating perioperative risk. Using a comprehensive Australian cohort, we quantified the incidence and determined the independent predictors of intraoperative and postoperative complications associated with antireflux and hiatus hernia surgeries. Additionally, we performed an in-depth analysis to understand the complication profiles associated with each independent risk factor. Methods Retrospective analysis of all elective antireflux and hiatus hernia surgeries in 36 Australian hospitals over 10 years. Hierarchical multivariate logistic regression analyses were performed to determine the independent predictors of intraoperative and postoperative complications accounting for patient, surgical, anatomical, and perioperative factors. Results A total of 4301 surgeries were analyzed. Of these, 1569 (36.5%) were large/giant hernias and 292 (6.8%) were revisional procedures. The incidence rates of intra- and postoperative complications were 12.6% and 13.3%, respectively. The Charlson Comorbidity Index, hernia size, revisional surgery, and baseline anticoagulant usage independently predicted both intraoperative and postoperative complications. These risk factors were associated with their own complication profiles. Finally, using risk matrices, we visualized the cumulative impact of these four risk factors have on the development of intraoperative, overall postoperative, and major postoperative complications. Conclusions This study has improved our understanding of perioperative morbidity associated with antireflux and hiatus hernia surgery. Our findings group patients along a spectrum of perioperative risks that informs care at an individual and institutional level.

493. EFFECTIVENESS OF TRANSORAL INCISIONLESS FUNDOPLICATION (TIF) WITHOUT OR WITH HIATAL HERNIA REPAIR (CTIF) IN PATIENTS WITH GERD AND CHRONIC COUGH

Abstract Background GERD is a common cause of chronic cough. Although barrier therapy with laparoscopic fundoplication is highly effective for typical GERD symptoms, the response rates are variable for chronic cough. We hypothesized that transoral incisionless fundoplication (TIF) or TIF with hiatal hernia repair (cTIF) may be a suitable alternative for medically refractory cough associated with GERD. Aim We prospectively s studied the effectiveness and safety of TIF/cTIF in patients with chronic cough and proven GERD. Methods Patients with GERD and extra-esophageal symptoms from 10 academic and community medical centers (TIF Registry), elevated GERD-HRQL score +/- Reflux Symptom Index (RSI) &amp;gt;13 and pathologic reflux by esophageal pH-metry, or erosive esophagitis/Barrett’s esophagus were evaluated before and after a minimum 6 months post TIF/cTIF performed by gastroenterologists and surgeons. Patients with history of prior foregut/bariatric surgery, chronic obstructive or interstitial lung disease, or prior lung transplant were excluded. The primary outcome was improvement in RSI score at last follow-up compared to baseline. Secondary outcomes were: 1) normalization of RSI (&amp;lt;13), 2) improvement in cough sub-scores of RSI (decrease ≥ 2 points or to 0 on a 5-point scale), 3) GERD symptom improvement (&amp;gt;50% decrease in GERD-HRQL, or &amp;lt; 2 in all sub-scores) 4) discontinuation of proton pump inhibitor (PPI), and 5) overall patient satisfaction. We further analyzed response in patients with cough-predominant phenotype (chief complaint of cough and RSI troublesome cough subscore ≥2). Results 198 patients with cough and GERD successfully underwent TIF/cTIF (Table 1) without serious adverse events. Greater than 6-month follow-up was available for 177 patients at a median of 12 months [IQR 6,12]. Median RSI score decreased from 18 [IQR 13, 27] to 5 [IQR 2, 11] (p &amp;lt; 0.0001), median change 11 [IQR5,11]. 83% of patients with elevated baseline RSI normalized their scores. 75% of patients had improvement of cough when lying down (median: 1 point [IQR 0,3]), and 72% of patients had improvement of troublesome cough (median: 1 point [IQR 1,3]). 83% of patients successfully discontinued or decreased PPI to occasional use. Patient satisfaction improved from a baseline of 5.6% to 68.8% (p &amp;lt;0.0001). Compared to patients without cough-predominant symptoms, cough-predominant patients (n=108) experienced an additional 4.2-point decrease in in RSI score (p = 0.01) and 1.5-point decrease in troublesome cough sub-scores (p&amp;lt;0.0001). Patients with regurgitation phenotype were more likely to have a favorable cough response at 6 months (p&amp;lt;0.0001). In appropriately selected patients, cTIF and TIF were comparable for cough, GERD-HRQL, RSI, and PPI responses. Conclusion TIF/cTIF are effective and safe alternative barrier therapies for patients with pH-positive cough-predominant GERD.

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

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

213. A NEW MANOMETRIC TOOL TO EVALUATE THE EFFICACY OF LAPAROSCOPIC ANTIREFLUX SURGERY

Abstract Background High resolution manometry (HRM) has been proven able to describe the pathophysiological pathway leading to gastroesophageal reflux disease (GERD). Recently, a new manometric tool, the Milan Score (MS), has been introduced and validated to evaluate the risk of pathologic GERD, defined as Acid Exposure Time (AET) &amp;gt;6% at pH-study. Aim of this study is to validate this score in the post-operative assessment after laparoscopic antireflux surgery (LARS). Methods All patients who underwent HRM after LARS between October 2020 and May 2023 were included. The MS was calculated assessing four manometric variables: esophagogastric junction (EGJ) type, EGJ contractile integral (EGJ-CI), ineffective esophageal motility (IEM) and response to the straight leg raise (SLR) manoeuvre. The MS was considered pathologic if ≥137 (risk of GERD ≥50%). The risk of GERD was categorized into six classes, according to the MS score. The MS was compared with validated questionnaires for reflux symptoms, including GERD Questionnaire (GERD-Q), GERD Health-Related Quality of Life (GERD-HRQL) and Reflux Symptom Index (RSI), and with postoperative endoscopy findings. Results A total of 160 patients were included (63% males, age: 53 years, time from surgery: 30 months). Surgical techniques included magnetic sphincter augmentation in 54% of patients, Toupet fundoplication in 29% and Nissen or Dor fundoplication in 17%. The proportion of patients with MS ≥137 among those with pathologic questionnaires was 73% for GERD-Q (p&amp;lt;0.001), 75% for GERD-HRQL (p&amp;lt;0.001) and 78% for RSI (p&amp;lt;0.001). The rate of pathologic questionnaires increased for higher MSs. A MS ≥137 was related to recurrent hiatal hernia (23%, p=0.046) and esophagitis (21%, p=0.007) at endoscopy. Clinical and manometric outcomes were similar among different surgical techniques. Conclusions The MS is an efficient tool to assess the efficacy of LARS. Various surgical techniques have similar distribution in the different risk classes for GERD identified by MS, and similar clinical results. HRM with MS represent an easy and feasible assessment of surgical outcomes after LARS, providing an objective evaluation of the antireflux barrier after surgery.

274. ROBOTIC REVISIONAL HIATAL HERNIA REPAIR (R-RHR): DOES IT MAKE SENSE?

Abstract Background The gastroesophageal reflux disease (GERD) is increasing among our population and Nissen Fundoplication still remains as the most widely performed technique. The robotic approach to the hiatal hernia repair has been proven to be safe and feasible. Precision and comfort seem to be some reasons that it makes, at least, comparable to the laparoscopic approach. Revisional hiatal hernia is a challenging situation to the operator due the adhesions and fibrosis of the tissues so our concern is that the best technology available is needed. Methods From June 2019 to November 2023 our division performed 14 cases of Robotic Revisional Hiatal Hernia Repair (R-RHR). Demographic items such as Gender, Age, Body Mass Index (BMI), Previous surgery, Time from first surgery and Postoperative outcomes as Operation Time, Length of stay (LOS), Mesh use, Complications and Readmissions were recorded. Results 10 women and 4 men were recruited. In all cases the DaVinci robotic platform X and Xi (Intuitive) was used. Mean age resulted in 63.5 years old (sd 12.25). Mean BMI was 26.97 (sd 3.52). In 71.4% cases the Previous HH Surgery was Nissen Fundoplication. 49.3 months was the mean time from the first surgery to the revisional procedure. 163.5 (sd 83.7) minutes was the mean operation time. Mean Lenght Of Stay resulted in 3.4 days (sd 1.4). There were no conversions to the laparoscopic approach. In 5 patients (35.8%) a mesh was placed. Pleural effusion was the only postoperative complication reported (1/14) and it was managed non-operatively. No other complications were recorded and mortality rate was 0. Conclusions To the authors knowledge, this is Spain’s largest Robotic - Revisional Hiatal Hernia Repair (R- RHR) series. The results lead us to conclude that the robotic approach, even the complexity of the surgery, is safe and feasible in trained teams with similar outcomes from the primary surgery that are published.

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&lt;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