Recurrent Hiatal Hernia Research Articles

Proton Pump Inhibitor Use After Hiatal Hernia Repair: Inhibitor of Recurrent Symptoms and Potential Revisional Surgery

BackgroundHiatal hernia recurrence after hiatal hernia repair (HHR) is often underdiagnosed and underreported but may present with recurrent gastroesophageal reflux disease (GERD) symptoms. Because of their availability, proton pump inhibitor (PPI) use is common and may mask patients who would benefit from revisional surgery, which has been shown to improve symptoms and quality of life. MethodsA retrospective analysis was performed to evaluate recurrence patterns of patients who underwent HHR, specifically for the indication of GERD, from 2007 to 2015 at a single Veterans Administration Medical Center. Clinicopathologic parameters were reviewed for association with hiatal hernia recurrence, including postoperative PPI use. ResultsSixty-four patients were identified with a median follow-up time of 57.8 mo. Thirty-eight patients developed an anatomic recurrence, which did not demonstrate any associated factors on univariate analysis. Seventy percent of patients remained or were restarted on PPI after their initial surgery. For patients with a documented recurrence, the median time to start a PPI was 224 d, but the time to identify recurrence on imaging or endoscopy was 712.5 d. Eleven (39.3%) patients had a reintervention for anatomic recurrence, of which all had developed recurrent symptoms of GERD. ConclusionsMost patients who developed recurrent hiatal hernia were restarted on PPI without workup for their symptoms. The time of initiation of PPI was much earlier than the time of identification of a recurrent hiatal hernia. The use of PPIs in patients whom have undergone HHR may delay proper workup to identify recurrent hiatal hernia amenable to surgical repair and should be reserved until patients develop recurrent symptoms and have at least begun a diagnostic workup to rule out an anatomic cause for the recurrent symptoms.

Fundic gastropexy for high risk of recurrence laparoscopic hiatal hernia repair and esophageal sphincter augmentation (LINX) improves outcomes without altering perioperative course.

The aim of this study is to show that the addition of a fundic gastropexy to a laparoscopic hiatal hernia repair (HHR) and magnetic sphincter augmentation (MSA) with LINX (Johnson and Johnson, New Brunswick, NJ) in patients with high risk for hiatal hernia recurrence improves outcomes without altering perioperative course. An IRB approved, single institution retrospective review of patient outcomes after hiatal hernia repair with magnetic sphincter augmentation was performed. Data were obtained from the electronic health record and stored in a REDCap database. Using statistical software, the patient data were analyzed and stratified to assess the specific variables of the perioperative and postoperative course focusing on the high risk of hiatal hernia recurrence group (HRHR) and low risk hiatal hernia of recurrence group (LRHR). The HRHR group received a gastropexy and were defined using the following variables: comorbid state increasing abdominal pressure, gastric herniation > 30%, maximum transverse crural diameter > 4cm, age 70years or older, previous hiatal or abdominal wall hernia repair, BMI > 34, heavy weight bearing job/hobby, and/or emergent repair. Hiatal hernia repair with magnetic sphincter augmentation was performed on 137 patients. The HRHR group (N = 86) and the LRHR group (N = 51) were compared and there was a difference observed with acute hernia recurrence, dysphagia (p value=0.008), and number of post-op EGDs (p value=0.005) in favor of the HRHR group. Other postoperative variables observed (i.e., length of stay and PPI use) showed no significant difference between the two groups. Fundic gastropexy for individuals who are considered high risk for recurrence does not appear to alter the perioperative course in our sample of patients. The HRHR group has the same length of stay experience and improved postoperative outcomes with reference to postoperative EGD, dysphagia and a decreasing trend in hiatal hernia recurrence.

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.

Laparoscopic Surgery for Recurrent Hiatal Hernia.

Surgical treatment of hiatal hernia (HH) is well standardized. However, recurrence is observed in 15%-60% of cases, and is challenging to manage. The aim of this study was to analyze the causes of surgical failure and provide some guidelines for treatment. The symptoms of recurrent HH vary widely, and include persistent reflux, dysphagia, and permanent discomfort, leading to a marked change in the quality of life. Morphological and functional pretherapeutic evaluation is necessary to determine whether the symptoms are due to recurrent HH, and to understand the cause of failure. Redo surgery is technically difficult and challenging, and should only be used in symptomatic patients whose symptoms are definitively those of recurrent HH.

Anatomic Observation of Recurrent Hiatal Hernia: Recurrence or Disease Progression?

Recurrence after hiatal hernia repair is common. The causes are uncertain. Our observation is the site of recurrence is primarily the nonsutured or nonreinforced anterior-left lateral portion of the hiatus. Our aim was to assess the distribution of hiatal hernia recurrence location as a basis for developing a theory of recurrence. Consecutive patients who underwent repair of recurrent hiatal hernias from March 2012 to December 2019 were reviewed. Data collected included age, sex, date of operation, location of hiatal hernia recurrence, operative approach, method of hiatal hernia repair, fundoplication performed, need for gastrectomy, and additional procedures. One hundred and eight consecutive patients were studied. The distribution of recurrence locations was as follows: anterior 67%, posterior 12%, and circumferential 21%. Foreshortened esophagus was a contributing factor in 12%. Median time from the original repair to recurrence was 1.5 years (interquartile range 0.9 to 3.75 years) for posterior recurrences, 2.75 years (interquartile range 1.15 to 8.5 years) for circumferential recurrences, and 3.25 years (interquartile range 1.38 to 10 years) for anterior recurrences. Recurrences were repaired in a variety of techniques, depending on the clinical circumstances. Hiatal hernia recurrences due to failure of the crural closure were less common, but early, recurrences. The majority of recurrences were due to stretching of the hiatus anterior and to the left of the esophagus. We theorize that the pathophysiology of late hiatal hernia recurrence is widening of the anterior and left lateral portion of the hiatus secondary to repeated stress from differential pressures that eventually overcomes the tensile strength of the hiatus.

REDO LAPAROSCOPIC ANTIREFLUX SURGERY IN PATIENTS WITH HIATAL HERNIA

Summary. The purpose was to study the features and results of redo laparoscopic antireflux surgery in our clinic.
 Materials and methods. For the period from 2008 to 2019, in our clinic, laparoscopic antireflux operations were performed in 1164 patients. 54 patients underwent laparoscopic reoperation during the study period based on the following indications: recurrence of hiatal hernia (n = 38), recurrent reflux (n = 4), dysphagia (n = 8), severe pain (n = 5). All patients underwent repeated examinations in our clinic, telephone interviews, mailing of special questionnaires. All complaints were recorded, the quality of life was determined according to the GERD-HRQL questionnaire.
 Results. All redo operations were performed laparoscopically without conversion to laparotomy. Intraoperative complications were observed in 11.11 % of patients. Long-term follow up from 6 months to 6 years was observed in 90.74 % of patients. The quality of life of patients according to the GERD-HRQL questionnaire significantly improved in long-term follow-up (p <0.001). Good results were observed in 91.84 % of patients after redo operations. The third operation was needed in 5.6 % of patients.
 Conclusion. Redo laparoscopic antireflux operations are technically difficult surgical interventions, and should be performed by surgeons with big experience in the antireflux surgery.
 Laparoscopic antireflux surgery provide good long-term results in 90 % of patients.

Principles of surgical treatment of recurrent hiatal hernias (review of literature)

Recurrent hiatal hernia is the re-displacement of the abdominal organs into the chest after surgical treatment. Indications for repeated surgical interventions for this pathology are resistant to medical correction gastroesophageal reflux or anatomical disorders, bearing the risk of developing life-threatening conditions. The key task of revision interventions is to identify and address the causes of the failure of the primary operation. The main factors of the recurrence of hernias of this localization are the large size of the hiatal opening, the mechanical weakness of the legs of the diaphragm and the shortening of the esophagus. To increase the reliability of the esophageal aperture plasty in the surgical treatment of recurrent hiatal hernias, prosthetic materials are widely used. When the esophagus is shortened, it is possible to increase its length by creating a gastric stalk (gastroplasty) or fixing the stomach to the anterior abdominal wall (gastropexy). The disadvantage of both methods is the occurring functional impairment. An alternative approach is the formation of a fundoplication wrap in the chest with the closure of the esophageal opening only with its own tissues. To eliminate or prevent the development of gastroesophageal reflux, antireflux reconstruction is an essential component of operations for recurrent hiatal hernias. The option of fundoplication is selected in accordance with the contractility of the esophagus. With normokinesia, circular fundoplication was preferred, with impaired motor skills – free reconstructions.

Quality of life after anti-reflux surgical interventions: possible solutions to the problem

The article presents the results of a prospective controlled parallel clinical study of a new modification of laparoscopic antireflux surgery in the treatment of gastroesophageal reflux disease in combination with a hiatal hernia compared with laparoscopic Nissen fundoplication in terms of assessing quality of life after surgery. Clinical and instrumental examination of patients was carried out a year after surgical interventions. In accordance with the results of instrumental examination after surgery, the proposed modification of laparoscopic partial fundoplication is not inferior to laparoscopic Nissen fundoplication both, in terms of relief of reflux esophagitis symptoms and in relation to the recurrence of hiatal hernia. Clinical monitoring indicates a significantly higher quality of life for patients after the modified antireflux surgery, which is associated with a number of factors. The implementation of this fundoplication led to a decrease in the number of patients with complaints of dysphagia, the development of which is directly related to the surgery performance, as well as to a statistically significant reduction of bloating in the upper abdomen. Another advantage of the modified surgery is a significantly smaller number of cases of gas-bloat syndrome. In addition, the disorders developing in the framework of the gas bloat syndrome after laparoscopic Nissen fundoplication are more severe.

Robotic Recurrent Hiatal Hernia Repair, Collis Gastroplasty, and Nissen Fundoplication

Abstract Introduction: Recurrent hiatal hernia repair may be indicated in cases wherein symptoms are uncontrolled with medications coupled with an anatomic recurrence.1,2 Up to 15% of patients may ...

Manometric Esophageal Length to Height (MELH) Ratio Predicts Hiatal Hernia Recurrence.

The shortened esophagus is poorly defined and is determined intraoperatively, as there exists no objective test to identify a shortened esophagus before surgical hiatal hernia repair. We devised a unique manometric esophageal length to height (MELH) ratio to define the presence of a shortened esophagus and examined the role of esophageal length in hiatal hernia recurrence. A retrospective review identified 254 patients with hiatal hernia who underwent preoperative esophageal manometry and either an open hernia repair with Collis gastroplasty and fundoplication (with Collis) or laparoscopic repair and fundoplication without Collis gastroplasty (without Collis) from 2005-2016. The MELH ratio was calculated by measuring the upper to lower esophageal sphincter distance divided by the patient's height. Of 245 patients, 157 underwent repair with Collis, while 97 underwent repair without Collis. The Collis group had a shorter manometric esophageal length (20.2 vs. 22.4 cm, P<0.001) and lower MELH (0.12 vs. 0.13, P<0.001). The Collis group had fewer hernia recurrences (18% vs. 55%, log-rank P<0.001) and fewer reoperations for recurrence (0% vs. 10%, log-rank P<0.001) at 5 years. A 33% decrease in risk of hernia recurrence was seen for every 0.01 U increment in MELH ratio (hazard ratio: 0.67; 95% confidence interval: 0.55-0.83, P<0.001) while repair without Collis (hazard ratio: 6.1; 95% confidence interval: 3.2-11.7, P<0.001) was associated with increased risk of hernia recurrence. MELH ratio is an objective predictor of a shortened esophagus preoperatively. Lower MELH is associated with increased risk of recurrence and the risk associated with shortened esophagus can be mitigated with an esophageal lengthening procedure such as Collis gastroplasty.

Gastroesophageal reflux after laparoscopic hiatal hernia repair in patients with axial hiatal hernia

To find out significance of the main locking mechanisms of lower esophageal sphincter in the relapse of GERD in patients with axial hiatal hernia after previous antireflux laparoscopic surgery. There were 103 patients with GERD and axial hiatal hernia who underwent original circular laparoscopic esophagofundoplication with correction of hiatal opening dimensions by crural and hiatal repair. Depending on generalized DeMeester index (within the normal range or its excess), all patients were divided into two groups - without relapse (group 1, n=88) and with recurrent GERD (group 2, n=15). Both groups were comparable by the main characteristics and postoperative follow-up period (mean - 6 years). Antireflux function was investigated by X-ray examination and endoscopy, manometry of the esophageal-gastric passage, intra-esophageal 24-hour pH-monitoring. Processing and graphical presentation of data was carried out using Statistica v.10.0 Rus software (StatSoft, USA) and Microsoft Office Excel 2013 (USA). Abnormal gastroesophageal reflux was detected in 14.56±3.48% of patients after laparoscopic anti-reflux surgery. Recurrent hiatal hernia occurred in 20±10.33% of these patients, malfunction of lower esophageal sphincter - in 80±10.33%. Failure of cardia was caused by shortening of its length by 30.43% and decrease of tone by 6.78% with significantly (61.09%) increased tone of the stomach. Failure of cardia was manifested by increase of generalized DeMeester index in the lower third of the esophagus by 3.2 times, acidic gastroesophageal refluxes, reflux index and index reflux values. Preserved esophageal motility combined with shortening of time of esophageal clearance in patient's lying position was associated with reduced incidence of reflux-esophagitis by 77.26% even in case of recurrent GERD. Abnormal reflux after antireflux laparoscopic surgery due to GERD with axial hiatal hernia is caused by recurrent hiatal hernia in every fifth patient while the main reason is failure of LES cuff with increased intragastric pressure.

Difficulties of differential diagnosis and treatment of achalasia cardia after previous hiatal hernia repair

Esophagocardiomyotomy followed by anterior fundoplication is a standard treatment of achalasia cardia, whereas cruroraphy with complete or partial posterior fundoplication is carried out for hiatal hernia and gastroesophageal reflux disease. The most common postoperative complications of hiatal hernia repair are dysphagia due to malformed cuff, phenomenon of 'telescope' and slow gastric emptying syndrome. Recurrent hiatal hernia is observed in 3-15% of cases. Currently, there are a lot of reports devoted to redo antireflux procedures in patients with hiatal hernia. The goal of the study is to demonstrate difficulties of diagnosis and treatment in a patient with achalasia cardia after previous hiatal hernia repair.

SURGICAL TREATMENT OF RECURRENT HIATAL HERNIAS

OBJECTIVE. Hiatal hernias are the most common type of visceral anatomy disorder. The unresolved problem of surgical treatment of this pathology remains the high frequency of its relapse. Currently, it is believed that repeated surgical interventions for hiatal hernia are technically difficult, carry a high risk of complications and have unsatisfactory long-term results.MATERIAL AND METHODS. In the period from 2015 to 2019, 55 patients with this pathology were operated. In 52 (94.5 %) cases, the revision operation was performed laparoscopically, in 3 (5.5 %) – through left-side thoracotomy. The technique of the operation implied the removal of hiatal hernia and the implementation of antireflux reconstruction. In five (9.9 %) patients with a shortened esophagus, the fundoplication wrap was originally created in the chest; in 50 (90.1 %), normal anatomy was restored.RESULTS. Long-term results ranging from 12 to 48 months were evaluated in 53 (96.4 %) cases. The natural position of the esophagus and stomach in relation to the diaphragm was detected in 43 (81.1 %) patients, relapse of hiatal hernia – in 5 (9.4 %). In 5 patients, the fundoplication wrap formed in the chest was functional. The absence of gastroesophageal reflux was observed in 41 (91.8 % of patients who had GERD before surgery). In 4 (8.8 %) cases, including one patient with antireflux reconstruction in the chest, a relapse of the disease occurred.CONCLUSION. The presented results allowed the surgical treatment of recurrent hiatal hernias reasonable and effective.The authors declare no conflict of interest.The authors confirm that they respect the rights of the people participated in the study, including obtaining informed consent when it is necessary, and the rules of treatment of animals when they are used in the study. Author Guidelines contains the detailed information.

P6 HIATAL HERNIA REPAIR BY TENSION-FREE MESH CLOSURE OR SIMPLE SUTURING OF THE DIAPHRAGMATIC HIATUS

Abstract Aim To assess the anatomical and functional results of the use of a mesh for the repairing of hiatal hernia in patients with gastro-esophageal reflux disease (GERD) Background &amp; Methods In hiatal hernia repair during antireflux surgery, less focus has traditionally been directed towards the restoration of the diaphragmatic hiatus. In other types of hernia repair, the use of a mesh-reinforced, tension-free technique has been shown to be associated with reduced recurrence rates. Patients (n=159) undergoing Nissen fundoplication for gastro-esophageal reflux disease were randomized to closure of the diaphragmatic hiatus with either crural sutures alone (n=77) or tension-free closure with a non-absorbable mesh (Crurasoft®, n=82). Primary outcome was radiologically verified recurrent hiatal hernia. Secondary outcomes were intra-and postoperative complications and courses, symptomatic recurrence, use of PPI, postoperative oesophageal acid exposure and Quality of Life. Results At 3 years recurrence rates were 12 % and 9 % in the mesh and suture groups respectively (p=0,61). Control of GERD symptoms, use of PPI and oesophageal acid exposure did not differ between groups. At the same time obstructive eating complaints were reduced in both groups compared to the preoperative setting (p&lt;0.05) but more patients scored dysphagia for solid food after mesh closure (p=0,027). Quality of life scores were significantly improved throughout the follow up without differences between groups. Conclusion Tension-free crural repair with non-absorbable mesh does not reduce the incidence of recurrent hiatal hernia compared to crural sutures alone in GERD patients undergoing total fundoplication. This, together with the finding of increased dysphagia at 3 years postoperatively, suggests that mesh closure cannot be recommended for routine use in laparoscopic hiatal hernia repair for GERD.

Laparoscopic repair of hiatal hernia.

Laparoscopic hiatal hernia repair is a complex surgery typically performed by general abdominal surgeons because it typically involves an abdominal approach. Here, we report our experiences on laparoscopic repair of hiatal hernia as thoracic surgeons. Based on our experience of minimally invasive esophageal surgery (MIES) for esophageal cancer, we began performing laparoscopic repair of hiatal hernia in 2009. We analyzed the surgery-related data and postoperative outcomes of 18 consecutive patients we operated on from 2009 to 2017. There were 1 male and 17 female patients with a median age of 73 years (range, 37-81 years). Ten of 14 symptomatic patients experienced reflux symptoms, such as heartburn. Four patients had a history of prior abdominal surgery. Hiatal hernia types I, II, III, and IV were observed in 3, 9, 5, and 1 patients, respectively. Two (11.1%) laparoscopic procedures required conversion. Modified Collis gastroplasty was used as an esophageal lengthening procedure in 5 patients (27.8%). Mean operation time was 213.8±70.1 minutes and mean hospital stay was 6.2±1.5 days. There were no postoperative complications. At the last follow-up, 15 patients (83.3%) were asymptomatic; however, 3 (16.7%) complained of reflux or dysphagia. Recurrent hiatal hernia was detected on an esophagogram in only 1 patient at 3.5 years after laparoscopic surgery. Laparoscopic repair of hiatal hernia is a feasible technique with a satisfactory surgical outcome. Importantly, it can be performed by thoracic surgeons who are experienced in the laparoscopic approach.

Minimally invasive Roux-en-Y reconstruction as a salvage operation after failed nissen fundoplication.

Conversion of Nissen fundoplication to Roux-en-Y (RnY) anatomy may be indicated in patients with post-surgical complications or who fail to achieve durable control of their disease. Herein we describe the largest series of patients at a single institution who underwent minimally invasive conversion of Nissen fundoplication to RnY reconstruction. All patients with prior Nissen fundoplication which were converted to RnY anatomy at our institution from March 2009 through November 2017 were retrospectively reviewed and analyzed. Patients were identified based on CPT codes and the description of the operation performed. All cases with attempted minimally invasive approach were included for analysis. Fifty patients underwent conversion from prior Nissen fundoplication to RnY anatomy during the study period. The cohort was 84.0% female with a mean age of 53.5years and a median body mass index of 36.7kg/m2. Thirteen patients (26.0%) had multiple prior foregut operations. Complications from fundoplication that warranted revision included recurrent hiatal hernia (n = 16), post-surgical gastroparesis (n = 10), and mechanical complications from the wrap (n = 8). An additional fourteen patients underwent conversion to RnY for metabolic disease. The mean operative time and estimated blood loss were 266min and 132mL, respectively, with all but one (98.0%) completed with a minimally invasive approach. The median length of stay was 5days. Complications included marginal ulcer (n = 2), superficial surgical site infection (n = 2), anastomotic leak (n = 2), and one case each of pulmonary embolism, small bowel obstruction, and gastrointestinal bleeding. There were no mortalities at a median follow-up of 12.4months. Conversion of prior Nissen fundoplication to RnY anatomy is technically challenging, although it is safe and feasible even in the setting of multiple prior foregut operations. A minimally invasive approach should be offered to patients by surgeons with experience in revisional foregut and bariatric surgery.

Mesh erosion after hiatal hernia repair: the tip of the iceberg?

Primary repair of large hiatal hernia is associated with a high recurrence rate, which has led to the use of mesh for crural repair. However, severe mesh-related complications, including esophageal or gastric erosion, have been observed. In the present study, we made a thorough identification of all published reports on the esophageal or gastric mesh erosion or migration after hiatal hernia repair. The incidence, site, mesh type, latent interval, consequence and treatment methods of mesh erosion were summarized and analyzed. A total of 50 cases of esophageal or gastric mesh erosion or migration after hiatal hernia repair were reported since 1998. A higher erosion rate was observed in recurrent hiatal hernia repair. The most common erosion site was esophagus (50%), followed by stomach (25%) and gastric-esophageal junction (GEJ) (23%). The most common mesh types reported in this series were PTEF andpolypropylene. The duration from the hernia repair to the identification of erosion varied greatly, and 79% of the erosion occurred within 2years after the hernia repair. Various treatment methods were reported, including endoscopic mesh retrieval (15.7%), laparoscopic mesh removal (11.8%), surgical mesh removal (19.6%); however, distal esophageal resection and gastric resection were reported in 19.6% and 5.9%, respectively. Some patients had to receive tube feeding. The true incidence of mesh erosion after hiatal hernia repair may be higher than previously reported, and the erosion is more prone to occur after recurrent hiatal hernia repair. Mesh erosion can result in severe morbidity and sometimes require complex organ resection. Different kinds and shapes of prosthetic meshes can cause erosion; therefore, mesh should be used very selectively for hiatal hernia repair. The patient should be informed about the mesh placement and the possible mesh-related complications.

Magnetic sphincter augmentation (MSA) in patients with hiatal hernia: clinical outcome and patterns of recurrence

IntroductionMagnetic sphincter augmentation (MSA) is an effective treatment for patients with gastroesophageal reflux disease. In early studies, patients with a hiatal hernia (HH) ≥ 3 cm were excluded from consideration for implantation and initially the FDA considered its use as “precautionary” in this context. This early approach has led to an attitude of hesitance among some surgeons to offer this therapy to patients with HH. This study was designed to evaluate the impact of HH status on the outcome of MSA and to report the rate of HH recurrence after MSA.Methods and proceduresThis is a retrospective review of prospectively collected data of patients who underwent MSA between June 2013 and August 2017. Baseline clinical and objective data were collected. Patients were divided into four groups based on HH status: no HH, small HH (< 3 cm), large HH (≥ 3 cm), and paraesophageal hernia (PEH). Patient satisfaction, GERD–HRQL and RSI data, freedom from PPI, need for postoperative dilation, length of hospitalization, 90-day readmission rate, need for device removal, and HH recurrence was compared between groups.ResultsThere were 350 patients [60% female, mean (SD) age: 53.5 (13.8)] who underwent MSA. There were 65 (18.6%) with no HH, 205 (58.6%) with small HH (< 3 cm), 58 (16.6%) with large HH (≥ 3 cm) and 22 (6.2%) with PEH. At a mean follow-up of 13.6 (10.4) months, the rate of outcome satisfaction was similar between the groups (86%, 87.9%, 92.2% and 93.8%, p = 0.72). This was also true for GERD–HRQL total score clinical improvement (79.1%, 77.8%, 82% and 87.5%, p = 0.77). The rate of postoperative dysphagia (p = 0.33) and freedom from PPIs (p = 0.96) were similar among the four groups. Duration of hospitalization was higher among those with a large HH or PEH, and only PEH patients had a higher 90-day readmission rate (p = 0.0004). There was no difference between the need for dilation among groups (p = 0.13). The need for device removal (5% overall) was similar between the four groups (p = 0.28). HH recurrence was 10% in all groups combined, and only 7 of 240 (2.9%) patients required reoperation; the majority of these patients underwent a minimal dissection approach (no hernia repair) at the index operation. The incidence of recurrent HH increased in direct correlation with the preoperative HH size (0%, 10.1%, 16.6 and 20%, p = 0.032).ConclusionIn the largest series of MSA implantation, we demonstrate that the excellent outcomes and high degree of satisfaction after MSA are independent of the presence or size of HH. Despite higher rates of hernia recurrence in large HH and PEH patients, the rates of postoperative endoscopic intervention, and device removal is similar to those with no or small HH. The minimal dissection approach to MSA should be abandoned.

Su1139 – Hiatal Location of Recurrent Hiatal Hernia: A Lesson to Where Repair and Reinforcement Attention Should Be Directed?

Su1139 – Hiatal Location of Recurrent Hiatal Hernia: A Lesson to Where Repair and Reinforcement Attention Should Be Directed?

Perioperative Outcomes and Quality of Life after Repair of Recurrent Hiatal Hernia are Compromised Compared with Primary Repair

Paraesophageal hernia repair (PEHR) is burdened by high recurrence rates that frequently lead to redo PEHR. Revisional surgery, because of higher complexity, higher risk of injury, and the intrinsic risk of recurrence, has increased likelihood of higher complication rates and decreased quality of life (QOL) postoperatively. We aimed to compare perioperative outcomes and QOL after revisional and primary PEHR. A retrospective review of all patients who underwent PEHR for a recurrent hernia between January 2011 and July 2016 was completed. These were matched with a contemporary cohort of patients who underwent primary PEHR by age, gender, and BMI. Perioperative measures were compared. The patients were invited to complete the Gastrointestinal Quality of Life Index (GIQLI) to assess response to surgical intervention. There were 24 patients (group 1) who underwent revisional PEHR, and they were matched to 48 patients (group 2) who had a primary hernia repair. Thirteen patients in group 1 responded to the survey (54%), whereas 21 patients' responses were received from group 2 (44%). Conversion rates, LOS, and mean Gastrointestinal Quality of Life Index scores were significantly different between the two groups. Reoperative procedures for paraesophageal and hiatal hernias are burdened by higher conversion rates and length of stay, with similar overall complication rates. Patients who are undergoing repair of a recurrent hernia should be preoperatively counseled, and should have realistic expectations of their GI QOL after surgery.