Recurrent Paraesophageal Hernia Research Articles

IDEAL Phase 2a Results: Posterior Rectus Sheath Flap for Hiatal Augmentation in Complex Paraesophageal Hernias.

To report the developmental phase results of posterior rectus sheath hiatal flap augmentation (PoRSHA), a promising surgical innovation for large and recurrent paraesophageal hernias. Durable hernia repair for large paraesophageal hernias continues to be a surgical challenge. PoRSHA addresses the challenges of current and historical approaches to complex paraesophageal hernias and demonstrates significant promise as a successful alternative approach. Using the IDEAL framework, we outline the technical modifications made over the first 27 consecutive cases using PoRSHA. Outcomes measured included hernia recurrence on routine imaging at 6 months and 2 years, development of a postoperative abdominal wall eventration and incidence of solid food dysphagia. Twenty-seven patients at our single institution with type III (n=12), type IV (n=7), or recurrent (n=8) paraesophageal hernias underwent PoRSHA. Surgery was safely and successfully carried out in all cases. Stability of the technique was reached after 16 cases, resulting in 4 main repair types. At an average follow-up of 11 months, we observed no radiologic recurrences, no abdominal eventrations or hernias at the donor site, and 1 patient with occasional solid food dysphagia that resolved with dilation. PoRSHA can not only be safely added to conventional hiatal hernia repair with appropriate training but also demonstrates excellent short-term outcomes. While the long-term durability with 5-year follow-up is still needed, here we provide cautious optimism that PoRSHA may represent a novel solution to the long-standing high recurrence rates observed with current complex PEH repair.

Anterior reconstruction of the esophageal hiatus: a novel approach for the repair of large diaphragmatic hernias

Introduction: Paraesophageal hernias (PEH) often require surgical repair. The standard approach, primary posterior hiatal repair, has been associated with a high recurrence rate. Over the past few years, we have developed a new approach for repairing these hernias, which we believe restores the original anatomy and physiology of the esophageal hiatus. Our technique includes anterior crural reconstruction with routine anterior mesh reinforcement and fundoplication. Objective: To determine the safety and the clinical success of anterior crural reconstruction with routine mesh reinforcement. Material and methods: Data were collected retrospectively on 178 consecutive patients who had a laparoscopic repair of a symptomatic primary or recurrent PEH between 2011 and 2021 using the above technique. The primary outcome was clinical success, and the secondary outcome was 30 days of major complications and patient satisfaction. This was assessed by imaging tests, gastroscopies, and clinical follow-up. Results: Mean follow-up was 65 (SD 37.1) months. No intraoperative or 30 days postoperative mortality or major complications were recorded. Recurrence rate requiring a re-operation was 8.4% (15/178). Radiological and gastroenterological evidence of minor type 1 recurrence was 8.9%. Conclusion: This novel technique is safe with satisfactory long-term results. The outcome of our study will hopefully motivate future randomized control trials.

Revision Fundoplication: How I Do It?

Recurrent paraesophageal hernia repair is challenging both for the surgeon and the patient, both from a surgical and a recovery standpoint. From adhesions to fusing of organs with complete obliteration of planes between the crus/mesh, hernia sac, esophagus, and gastric wall, often the anatomy is extremely distorted. Surgery requires meticulous dissection to avoid an iatrogenic injury and careful evaluation of final repair to avoid yet another recurrence. Herein, we present our technique of a redo paraesophageal hernia repair and some pitfalls associated with it.

Laparoscopic and robotic paraesophageal hernia repair in United States veterans: Clinical outcomes and risk factors associated with reoperation recurrence

BackgroundDespite surgical advances, rates of paraesophageal hernia recurrence remain high. We evaluate outcomes of paraesophageal hernia repair in United States veterans, safety of robotic technology, and risk factors for reoperation for recurrence. MethodsThe Veterans Affairs Surgical Quality Improvement Program database was queried for patients undergoing laparoscopic or robotic paraesophageal hernia repair from 2010 to 2021. The effect of patient and operative characteristics on outcomes was evaluated. Results2,444 patients underwent paraesophageal hernia repair. 62 (2.5%) had a reoperation for recurrence. Emergent priority (aOR 18.3 [5.9–56.2]) and younger age (aOR 0.7 [0.5–0.9]) were associated with increased risk of reoperation. On comparison of propensity matched cohorts, repairs done robotically took longer (4.17 vs. 3.57 h, p < 0.001) but had 30-day outcomes and rates of reoperation for recurrence equivalent to laparoscopic repairs (p > 0.05). ConclusionEmergent priority and younger age are associated with increased risk of reoperation for recurrent paraesophageal hernia. Robotic approaches take longer but are safe.

THE DIAPHRAGM EVENTRATION UNDER THE GUISE OF RECURRENT PARAESOPHAGEAL HIATAL HERNIA

The clinical case presented in this article illustrates one of the serious iatrogenic complications of Nissen fundoplication: diaphragmatic eventration. A 65-year-old patient was diagnosed with recurrent paraesophageal hiatal hernia. Intraoperatively, it was treated as diaphragmatic eventration. Laparoscopic Nissen refundoplication, suturing of the diaphragm defect was performed. The patient was discharged in satisfactory condition on the 5th day.

Laparoscopic revision paraesophageal hernia repair: a 16-year experience at a single institution.

Laparoscopic paraesophageal hernia repair (PEHr) is a safe and effective procedure for relieving foregut symptoms associated with paraesophageal hernias (PEH). Nonetheless, it is estimated that about 30-50% of patients will have symptomatic recurrence requiring additional surgical intervention. Revision surgery is technically demanding and may be associated with a higher rate of morbidity and poor patient-reported outcomes. We present the largest study of perioperative and quality-of-life outcomes among patients who underwent laparoscopic revision PEHr. A retrospective review of all patients who underwent laparoscopic revision paraesophageal hernia repair between February 2003 and October 2019, at a single institution was conducted. All revisions of Type I hiatal hernias were excluded. The following validated surveys were used to evaluate quality-of-life outcomes: Reflux Symptom Index (RSI) and Gastroesophageal Reflux Disease Health-Related QOL (GERD-HRQL). Patient demographic, perioperative, and quality-of-life (QOL) data wereanalyzed using univariate analysis. One hundred ninety patients were included in the final analysis (63.2% female, 90.5% single revision, 9.5% multiple revisions) with a mean age, BMI, and age-adjusted Charlson score of 56.6 ± 14.7years, 29.7 ± 5.7kg/m2, and 2.04 ± 1.9, respectively. The study cohort consisted of type II (49.5%), III (46.3%), and IV hiatal hernia (4.2%), respectively. Most patients underwent either a complete (68.7%) or partial (27.7%) fundoplication. A Collis gastroplasty was performed in 14.7% of patients. The median follow-up was 17.6months. The overall morbidity and mortality rate were 15.8% and 1.1%, respectively. The 30-day readmission rate was 9.5%. Additionally, at latest follow-up 47.9% remained on antireflux medication. At latest follow-up, there was significant improvement in mean RSI score (46.4%, p < 0.001) from baseline within the study population. Furthermore, there was no significant difference in QOL between patients who had a history of an initial repair only or history of revision surgery at latest review. The overall recurrence rate was 16.3% with 6.3% requiring a surgical revision. Laparoscopic revision PEHr is associated with a low rate of morbidity and mortality. Revision surgery may provide improvement in QOL outcomes, despite the high rate of long-term antireflux medication use. The rate of recurrent paraesophageal hernia remains low with few patients requiring a second revision. However, longer follow-up is needed to better characterize the long-term recurrence rate and symptomatic improvements.

P141 USE OF POLYPROPYLENE STRIPS FOR REINFORCEMENT OF THE CRUROPLASTY IN LAPAROSCOPIC PARAESOPHAGEAL HERNIA REPAIR: A RETROSPECTIVE COHORT STUDY

Abstract Aim Laparoscopic paraesophageal hernia repair is an effective treatment for symptomatic paraesophageal hernias. To reduce recurrence rates, the use of prosthetics for the crural repair has been suggested. Mesh-related complications are rare, but known to be disastrous. To address another form of crural repair, polypropylene strips are suggested. This study aimed to assess peri- and postoperative complications of reinforcement of the cruroplasty with polypropylene strips. Material and Methods From 2013 to 2020, patients with a type II, III or IV primary or recurrent paraesophageal hernia that underwent cruroplasty with polypropylene strips were retrospectively reviewed. Intra- and postoperative complications were graded according to the Clavien-Dindo classification. The incidence of symptomatic recurrent hiatal hernia (CT or endoscopy proven) and hospital stay were assessed. Results One-hundred-and-fifty-eight patients were included. Mean age was 65 years (standard deviation 10.4), 119 patients were female (75.3%). Almost 50% of surgeries took place between 2018 and 2020. Median follow-up was 7 months (interquartile range 17.5). Mean operation time in the primary hernia group was 159 minutes (standard deviation 39.0), and length of stay was 4.4 days. In 3/158 patients (2.0%) intra-operative complications occurred. Two patients developed a grade IV and seven patients a grade III postoperative complication. No mortality was recorded. Twelve recurrences (8.2%) were detected in the primary hernia group, and one (9.1%) in the recurrent hernia group. Conclusions There were no mesh-related complications seen and symptomatic recurrence rate was low, but longer follow up is needed.

Autologous Posterior Rectus Sheath as a Vascularized Onlay Flap: a Novel Approach to Hiatal Hernia Repair

IntroductionComplex and recurrent paraesophageal hernia repairs are a challenge for surgeons due to their high recurrence rates despite the use of various prosthetic and suturing techniques. MethodsHere we describe the use of vascularized fascia harvested from the posterior rectus sheath with peritoneum during robotic hiatal hernia repair in two patients with large complex diaphragmatic defects. ResultsSuccessful harvesting and onlay of the right posterior rectus sheath based on a falciform vascular pedicle was achieved robotically by rotating and securing the flap to the diaphragmatic hiatus as an onlay flap following cruroplasty of the hiatal defect. ConclusionsIn patients with difficult to repair large paraesophageal hernias, we demonstrate a promising new technique to restore the dynamic hiatal complex with the tensile strength of autologous vascularized fascia and peritoneum.

Efficacy and Safety of Recurrent Paraesophageal Hernia Repair with Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass (RYGB) has been explored as a revisional option to failed paraesophageal hernia (PEH) repair with fundoplication, particularly in patients suffering from obesity. However, few studies have assessed long-term outcomes of RYGB with revisional PEH repair in regard to acid-suppressing medication use. We retrospectively identified 19 patients who underwent revisional PEH repair with RYGB between 2011 and 2018. The median operative time was 232 minutes with a median hospital length of stay of two days. The median length of follow-up was 24 months. Two patients (10.5%) had complications in the first 30 days, and five patients (26.3%) had complications within one year. Of the 12 patients on preoperative acid suppression, 6 (50%) were either off medication or on reduced dose at 12 months. The median BMI decrease was 14.4 kg/m² at 12 months and did not change significantly afterward. Although rates of acid-suppression medication use did not change overall after revisional PEH repair with RYGB, patients experienced successful long-term management of morbid obesity and sustained weight loss. Revisional PEH repair with RYGB is a safe and effective option, with a complication rate comparable with the reported rates after revisional foregut procedures such as revisional Nissen fundoplication.

Safety of robotic assisted laparoscopic recurrent paraesophageal hernia repair: insights from a large single institution experience.

Laparoscopic repair of recurrent as opposed to primary paraesophageal hernias (PEHs) are historically associated with increased peri-operative complication rates, worsened outcomes, and increased conversion rates. The robotic platform may aid surgeons in these complex revision procedures. The aim of this study was to compare the outcomes of patients undergoing robotic assisted laparoscopic (RAL) repair of recurrent as opposed to primary PEHs. Patients undergoing RAL primary and recurrent PEH repairs from 2009 to 2017 at a single institution were reviewed. Demographics, use of mesh, estimated blood loss, intra-operative complications, conversion rates, operative time, rates of esophageal/gastric injury, hospital length of stay, re-admission/re-operation rates, recurrence, dysphagia, gas bloat, and pre- and post-operative proton pump inhibitor (PPI) use were analyzed. Analysis was accomplished using Chi-square test/Fischer's exact test for categorical variables and the Mann-Whitney U test for continuous variables. There were 298 patients who underwent RAL PEH repairs (247 primary, 51 recurrent). They were followed for a median (interquartile range) of 120 (44, 470) days. There were no significant differences in baseline demographics between groups. Patients in the recurrent PEH group had longer operative times, increased use of mesh, and increased length of hospital stay. They were also less likely to undergo fundoplication. There were no significant differences in estimated blood loss, incidence of intra-operative complications, re-admission rates, incidence of post-operative dysphagia and gas bloat, and incidence of post-operative PPI use. There were no conversions to open operative intervention or gastric/esophageal injury/leaks. Although repair of recurrent PEHs are historically associated with worse outcomes, in this series, RAL recurrent PEH repairs have similar peri-operative and post-operative outcomes as compared to primary PEH repairs. Whether this is secondary to the potential advantages afforded by the robotic platform deserves further study.

Redo surgery after laparoscopic fundoplication

To analyze the results of redo surgeries after previous laparoscopic fundoplication. A retrospective analysis included 37 repeated anti-reflux surgeries. Control group consisted of 38 patients after the first anti-reflux surgery performed on the same clinical base. The causes of unsatisfactory results of the first operations were studied. Intraoperative data, immediate and long-term results of surgical treatment were compared in both groups. Quality of life in both groups was studied before surgery and in long-term period using GIQLI questionnaire. The most common cause of recurrent reflux was a hernia recurrence combined with slipping or destruction of the fundoplication cuff. Dysphagia was usually a result of compression of the esophagus by tightly sutured diaphragmatic crura and recurrent paraesophageal hernia. The main group was characterized by significantly greater surgery time, hospital-stay, incidence of intraoperative and postoperative complications. However, a more significant improvement of quality of life (∆GIQLI) was observed in the main group due to the low QOL index before redo surgery. Redo surgeries are effective and safe procedures. These operations significantly improve QOL in long-term period despite certain technical difficulties. Repeated surgeries for dysphagia accounted for 2%, for recurrent reflux - 6%. Persistent postoperative dysphagia is usually associated with diaphragm repair rather fundoplication cuff. Reflux recurrence is often caused by cuff slippage and recurrent hernia.

Gastrointestinal Quality of Life Is Compromised after Repair of a Recurrent Paraesophageal Hernia Compared to a Primary Repair: A Retrospective Matched Case Comparison

Brown, Andrew M. MD; Nagle, Ramzy T.; Tatarian, Talar MD; Pucci, Michael J. MD, FACS; Chojnacki, Karen A. MD, FACS; Rosato, Ernest L. MD, FACS; Palazzo, Francesco MD Author Information

Revisional paraesophageal hernia repair outcomes compare favorably to initial operations.

Recurrent paraesophageal hernia (PEH) repair is performed for symptomatic recurrent hiatal hernia and/or reflux with little understanding as to outcomes related to perioperative and subjective patient variables. The aim of this study was to understand what differences exist between patients undergoing initial paraesophageal hernia (IPEH) repair and those undergoing redo paraesophageal hernia (RPEH) repair. A review of PEH repairs between 2009 and 2013 was performed from a single institution. RPEH patients were identified and analyzed for demographic information, perioperative/intraoperative details, and postoperative outcomes. A similar comparison group of IPEH patients was randomly selected from the same sample as a control. A phone questionnaire was administered to the RPEH group. Among 336 total PEH repairs from 2009 to 2013, 34 RPEH patients were identified. A matched cohort of 76 patients was identified. RPEH and IPEH groups had similar DeMeester score, incidence of Barrett's esophagus, incidence of gastritis, and LOS. Readmission rates (15 vs. 24%, p=0.283) and recurrence rate (4 vs. 12%, p=0.201) were not statistically different between IPEH and RPEH repairs, respectively. Operative times (163 vs. 209min, p<0.001), incidence of Collis gastroplasty (1 vs. 24%, p<0.001), and EBL>10cc (25 vs. 51%, p<0.023) differed between IPEH and RPEH repairs, respectively. Recurrent symptoms included chest pain (37%), solid dysphagia (42%), nausea (58%), vomiting (32%), bloating (63%), and hoarseness (21%). 21% of patients required ongoing antacid therapy. Patient satisfaction via phone questionnaires demonstrated 88% of patients were completely satisfied. Recurrent PEH repair is performed with similar outcomes to IPEH repair with the exception of increased operative time and blood loss. Collis gastroplasty is required more frequently in RPEH patients. Persistent symptoms exist following RPEH repair. Despite recurrent symptomatology, patient satisfaction is high. RPEH repair may be safely performed in patients with recurrent paraesophageal hernias with outcomes similar to IPEH repairs.

Long-term quality of life and risk factors for recurrence after laparoscopic repair of paraesophageal hernia.

Laparoscopic repair of paraesophageal hernia (PEH) has been shown to result in excellent relief of symptoms and improved quality of life (QOL) despite a relatively high radiographically identified recurrence rate. To assess potential risk factors for recurrence and long-term change in QOL after laparoscopic repair of PEH. This was a prospective study of 111 patients who underwent elective laparoscopic repair of type III PEH with biological mesh buttressed over a primary cruroplasty from April 3, 2009, through July 31, 2014, at the Department of Surgery, Johns Hopkins University of Medicine. We administered a modified version of a validated gastroesophageal reflux disease-specific QOL tool to patients before and at 2, 12, and 36 months after the procedure. Higher QOL scores represent greater severity of symptoms. An upper gastrointestinal tract barium-contrast radiographic examination was performed at 1 year to assess for recurrence. Demographic factors, comorbidities, and preoperative radiographic findings were analyzed as possible indicators for recurrence using logistic regression. Quality of life, measured by the gastroesophageal reflux disease-specific QOL tool, and recurrence, defined as a PEH of greater than 2 cm. Median patient age was 61 years, 63.1% of patients were women, and 81.1% of patients were white. Four patients required reoperation, of which only 1 was for symptomatic recurrent PEH. The mean follow-up time for the 36-month QOL assessment was 43.5 months. The overall preoperative and 2-, 12-, and 36-month QOL scores were 28.50, 10.18, 9.74, and 10.58, respectively (P < .001). Recurrences were found in 19 of the 70 patients (27%) who completed the 1-year radiographic examination. Compared with baseline, all individual symptoms improved significantly except for early satiety (mean [SD] score, 3.18 [1.88] at baseline vs 2.07 [1.70] at the 36-month follow-up; P = .07), nausea (1.69 [1.63] vs 0.77 [1.25]; P = .08), pain with swallowing (1.06 [1.50] vs 0.53 [0.90]; P = .73), and bloating/gas (3.28 [1.71] vs 2.23 [1.72]; P = .05) at the 36-month QOL assessment. Although not statistically significant, preoperative hernias containing most of the stomach were more likely to recur after repair when compared with those involving gastric cardia and fundus (odds ratio, 3.74 [95% CI, 0.93-15.14]; P = .06). Overall, laparoscopic repair of PEH with biological mesh results in excellent long-term QOL. The cause of recurrence is likely multifactorial and individualized to each patient. Further evaluation of novel techniques and unidentified patient factors is needed.

Laparoscopic Repair of Paraesophageal Hernias with a Falciform Ligament Buttress

BackgroundButtressing the crura in paraesophageal hernia (PEH) repairs with synthetic mesh may be associated with erosions and dysphagia, while biologic buttresses are expensive and do not decrease long-term recurrence rates. This study documents outcomes following laparoscopic PEH repairs using the falciform ligament as a buttress. MethodsThis is a prospective study of laparoscopic PEH repairs with a falciform ligament buttress. Preoperatively and at 6 months follow-up, medications, radiologic studies and symptom scores were recorded. Patients included had a hiatal defect greater than 5 cm, while recurrent PEH or prior gastric surgery patients were excluded. ResultsThirty-four patients were included with a mean age of 61 years, and 33 patients completed postoperative evaluation with a mean follow-up of 7.1 months. The mean symptom severity decreased from 11.24±1.71 to 3.24 ± 0.84, mean symptom frequency decreased from 11.62±1.70 to 3.45 ± 0.85, and mean total symptom score decreased from 22.85±3.40 to 6.69±1.69 (p < 0.0001). Three patients had recurrences on the upper gastrointestinal (UGI) series. Only one required reoperation. ConclusionsLaparoscopic PEH repair with a falciform ligament buttress is a viable option. Ongoing follow-up will demonstrate the utility of this approach to decrease morbidity and recurrence rates for paraesophageal hernia repairs.

Paraesophageal Hernia Repair With Partial Longitudinal Gastrectomy in Obese Patients.

Background and Objectives:Treatment of gastroesophageal reflux disease (GERD) with hiatal hernia in obese patients has proven difficult, as studies demonstrate poor symptom control and high failure rates in this patient population. Recent data have shown that incorporating weight loss procedures into the treatment of reflux may improve overall outcomes.Methods:We retrospectively reviewed 28 obese and morbidly obese patients who presented from December 2007 through July 2013 with large or recurrent type 3 or 4 paraesophageal hernia. All of the patients underwent combined paraesophageal hernia repair and partial longitudinal gastrectomy. Charts were retrospectively reviewed, and the patients were contacted to determine symptomatic relief.Results:Mean preoperative body mass index was 38.1 ± 4.9 kg/m2. Anatomic failure of prior fundoplication occurred in 7 patients (25%). The remaining 21 had primary paraesophageal hernia, 3 of which were type 4. Postoperative complications included pulmonary embolism (n = 1), pulmonary decompensation (n = 2), and wound infection (n = 1). Mean hospital stay was 5 ± 3 days. Upper gastrointestinal esophagogram was performed in 21 patients with no immediate recurrence or staple line dehiscence. Mean excess weight loss was 44 ± 25%. All of the patients surveyed experienced near to total resolution of their preoperative symptoms within the first month. At 1 year, symptom scores decreased significantly. At 27 months, however, there was a mild increase in the scores. Return of severe symptoms occurred in 2 patients, both of whom underwent conversion to gastric bypass.Conclusions:Combined laparoscopic paraesophageal hernia repair with longitudinal partial gastrectomy offers a safe, feasible approach to the management of large or recurrent paraesophageal hernia in well-selected obese and morbidly obese patients. Short-term results were promising; however, intermediate results showed increasing rates of reflux symptoms that required medical therapy or conversion to gastric bypass.

Defining recurrence after paraesophageal hernia repair: Correlating symptoms and radiographic findings

Laparoscopic repair of paraesophageal hernia (PEH) has been shown to result in excellent relief of symptoms and improved quality of life (QOL) despite a high radiographically identified recurrence rate. Because there is no uniform definition of PEH recurrence, it is difficult to compare studies reporting on this. This study attempts to introduce consistency to the definition of PEH recurrence based on correlation of symptoms and radiographic findings. This is an analysis of data derived from an ongoing prospective study. From April 2009 to December 2012, we enrolled 101 patients who underwent elective laparoscopic PEH repair with bioprosthesis buttressed over a primary cruroplasty. A validated gastroesophageal reflux disease-specific QOL tool was administered to patients before, and at 2 and 12 months postoperatively. Upper gastrointestinal barium contrast examination (UGI) was performed at 1 year. Of 101 patients, 13 were not available for follow-up, 58 reached the 1-year milestone for interval UGI, and 1 patient required reoperation for symptomatic recurrent PEH. There was no relationship between total QOL score and radiographic recurrent hernia (RRH); however, significant deterioration in many symptoms was seen in RRH > 2 cm. Based on these findings, we defined recurrence as RRH > 2 cm and calculated our recurrence rate as 28% (n = 16). Our analysis of symptom scores after laparoscopic PEH repair suggests that significant worsening occurs with RRH > 2 cm. Given that there is no consistent description of recurrent PEH, we suggest this as a possible standardized definition. Overall, patients with recurrent PEHs continue to experience excellent QOL and rarely require reoperation.

Combined paraesophageal hernia repair and partial longitudinal gastrectomy in obese patients with symptomatic paraesophageal hernias

Obesity is a risk factor for gastroesophageal reflux disease and hiatal hernia. Studies have demonstrated poor symptom control in obese patients undergoing fundoplication. The ideal operation remains elusive. However, addressing both obesity and the anatomic abnormality should be the goal. This study retrospectively identified 19 obese (body mass index [BMI], >30kg/m(2)) and morbidly obese (BMI, >40kg/m(2)) patients who presented between December 2007 and November 2011 for management of large or recurrent paraesophageal hernia. All the patients underwent a combined primary paraesophageal hernia repair and longitudinal gastrectomy. Charts were retrospectively reviewed to collect preoperative, operative, and short-term postoperative results. Quantitative data were analyzed using Student's t test and qualitative data with χ(2) testing. Laparoscopy was successful for all 19 patients. The mean preoperative BMI was 37.8±4.1kg/m(2), and the mean operative time was 236±80min. Preoperative endoscopy showed that 5 patients who had undergone prior fundoplication experienced anatomic failures, whereas the remaining 14 patients had type 3 and one type 4 paraesophageal Hernia. Mesh was used to reinforce the hiatus in 15 of the 19 cases. The postoperative complications included pulmonary embolism (n=1) and pulmonary decompensation (n=2) due to underlying chronic obstructive pulmonary disease. The mean hospital stay was 5.3±3days. Upper gastrointestinal esophagography was performed for all the patients, with no short-term recurrence of paraesophageal hernia. Weight loss was seen for all the patients during the first month, with a mean BMI drop of 2.7±1kg/m(2). All the patients experienced near to total resolution of their preoperative symptoms within the first month. Combined laparoscopic paraesophageal hernia repair and longitudinal gastrectomy offer a safe and feasible approach for the management of large or recurrent paraesophageal hernias in well-selected obese and morbidly obese patients. In a short-term follow-up period, this approach demonstrated effective symptom control and weight loss.

High-Resolution Manometry Patterns of Lower Esophageal Sphincter Complex in Symptomatic Post-Fundoplication Patients

IntroductionThere has been an increase in the number of patients seeking treatment after an anti-reflux surgical procedure. The objective of this study is to describe high-resolution manometry (HRM) topography as it relates to the post-fundoplication anatomy. MethodsRetrospective review of a prospectively maintained database was conducted to identify patients who underwent esophagogastroduodenoscopy and HRM at Creighton University Medical Center (CUMC) between November 2008 and October 2010, for symptoms after a previous fundoplication. Patients were categorized as having intact, intrathoracic, disruptured, twisted, or slipped fundoplication based on endoscopic findings. ResultsSixty-one patients {intact, 17(28%), disrupted, 2(3%), twisted, 3(5%), intra-thoracic, 18(30%), slipped, 21(34%)} are included in this study. A double high-pressure zone (HPZ) configuration was identified in both intra-thoracic and slipped fundoplication. This was not noted in appropriately positioned fundoplications. In intra-thoracic fundoplications, the HPZ below the fundoplication was lower pressure and showed respiratory variations. In slipped fundoplication, the higher HPZ had lower pressure and no respiratory variations. In appropriately positioned fundoplication, the lower esophageal sphincter (LES) pressure and extent of relaxation in the single HPZ correlated with intact (normal pressure and good relaxation), disrupted (low pressure and good relaxation), and twisted (high pressure with incomplete relaxation) fundoplication. Patients with only a recurrent para-esophageal hernia had characteristics of an appropriately positioned fundoplication. ConclusionLES complex HRM findings correlate well with anatomical status of the fundoplication.

Simple suture or prosthesis hiatal closure in laparoscopic repair of paraesophageal hernia: a retrospective cohort study

Laparoscopic repair of paraesophageal hernia (PEH) involves removal of the hernia sac, cruroplasty, and fundoplication. Mesh application to cruroplasty seems to reduce hernia recurrence rate, but may be associated with dysphagia. The aim of the study was to review the clinical and laboratory outcomes of a series of patients with PEH after laparoscopic repair. Patients with PEH, who had laparoscopic repair and 1-year postoperative follow-up, were included in the study. Pre- and postoperative testing included symptom questionnaires, barium esophagogram, pH-monitoring, barium swallow testing. In the first half cases, suturing of large hernia gaps was reinforced with prosthesis (PR), whereas in the second half only suture cruroplasty (SC) was performed. Sixty-eight patients (36 male) with PEH were included in the study. There were no conversions to open. Postoperatively, dysphagia grading was significantly correlated to esophageal transit time (P < 0.001). There were seven recurrences; one paraesophageal and six wrap migrations. Also, four cases with stenosis were identified all in the PR group. Dysphagia was more common (P= 0.05) and esophageal transit more delayed (P= 0.034) after PR than after SC. Two revisions, one for esophageal stenosis and one for recurrent PEH, derived from the SC group. Reflux was more common after Toupet fundoplication than after Nissen fundoplication (NF) (P= 0.031) in patients with impaired esophageal motility. Laparoscopic repair of PEH with SC is associated with satisfactory clinical outcomes and low rate of wrap migration, at least similar to PR hiatal repair. NF is effective as an antireflux procedure in all cases.