Laparoscopic repair of giant paraesophageal hernia: are there factors associated with anatomic recurrence?

BACKGROUND: Repair of giant paraesophageal hernia (PEH) is associated with a favorably high rate of symptom improvement; however, rates of recurrence by objective measures remain high. Herein we analyze our experience with laparoscopic giant PEH repair to determine what factors if any can predict anatomic recurrence. METHODS: We prospectively collected data on PEH characteristics, variations in operative techniques, and surgeon factors for 595 patients undergoing laparoscopic PEH repair from 2008 to 2015. Upper GI study was performed at 6 months postoperatively and selectively thereafter-any supra-diaphragmatic stomach was considered hiatal hernia recurrence. Exclusion criteria included revisional operation (22.4%), size <5 cm (17.6%), inadequate follow-up (17.8%), and confounding concurrent operations (6.9%). Inclusion criteria were met by 202 patients (31% male, median age 71 years, and median BMI 28.7). RESULTS: At a median follow-up of 6 months (IQR 6-12), overall anatomic recurrence rate was 34.2%. Symptom recurrence rate was 9.9% and revisional operation was required in ten patients (4.9%). Neither patient demographics nor PEH characteristics (size, presence of Cameron erosions, esophagitis, or Barrett's) correlated with anatomic recurrence. Technical factors at operation (mobilized intra-abdominal length of esophagus, Collis gastroplasty, number of anterior/posterior stitches, use of crural buttress, use of pledgeted or mattress sutures, or gastrostomy) were also not correlated with recurrence. Regarding surgeon factors, annual volume of fewer than ten cases per year was associated with increased risk of anatomic failure (54 vs 33%, P = 0.02). Multivariate analysis identified surgeon experience (<10 cases per year) as an independent factor associated with early hiatal hernia recurrence (OR 3.7, 95% CI 1.34-10.9). CONCLUSIONS: Laparoscopic repair of giant PEH is associated with high anatomic recurrence rate but excellent symptom control. PEH characteristics and technical operative variables do not appear to significantly affect rates of recurrence. In contrast, surgeon volume does appear to contribute significantly to durability of repair.

Use of mesh for hiatal hernia repair: a survey of SAGES members.

BACKGROUND: Mesh use during hiatal hernia repair (HHR) has been suggested to be safe and effective. Concern has been raised about the risk of mesh-related complications, and the higher risk of complications if revisional hiatal surgery is undertaken after mesh has been used. Available data have not established a clear role for mesh in HHR. To assess surgeons' adoption of the use of mesh for HHR, SAGES members were surveyed regarding their practice related to mesh use for HHR. METHODS: Between April and September 2010, an internet-based survey tool was used to survey SAGES members. Potential participants were contacted via e-mail and invited to complete the survey. Of the 5,323 attempted contacts, 5,024 reached active e-mail accounts. From these, 2,518 members responded (50% response rate). RESULTS: The majority of respondents currently perform HHR (69%), but only 18% perform more than 20 per year. Of those who perform HHR, 94% use a laparoscopic approach for the majority of repairs. Whereas 25% of surgeons use mesh for the majority of repairs, 23% of surgeons never use mesh. When mesh is used, an absorbable mesh is most commonly used (67%). An onlay technique is used by 93% of respondents. Only 7% of surgeons who have been in practice more than 20 years use mesh compared with 59% of surgeons in practice less than 10 years. Fifty-seven percent of surgeons have never performed revisional foregut surgery on a patient with prior mesh. CONCLUSIONS: Although the majority of surgeons have used mesh for HHR, it is the minority who use it routinely, with younger surgeons more likely to use mesh than older surgeons. Absorbable mesh is most commonly used. When mesh is used, an onlay technique is most commonly used. There is no clear accepted use of mesh in hiatal hernia repair.

Transcervical videoscopic esophageal dissection during two-field minimally invasive esophagectomy: early patient experience.

BACKGROUND: Transhiatal (two-field) esophagectomy reduces cardiopulmonary complications by avoiding thoracic access, but requires blind mediastinal dissection. The authors developed a minimally invasive esophagectomy (MIE) technique applying single-incision laparoscopy technology to better visualize the thoracic esophageal dissection. This is performed using laparoscopy and simultaneous transcervical videoscopic esophageal dissection (TVED). Our aim is to demonstrate feasibility of two-field MIE with TVED and improve recovery in high-risk patients. METHODS: We performed a retrospective cohort study of eight patients who underwent two-field MIE with TVED over 10 months. The majority were male (N = 6) with mean age of 63 ± 12 years. Mean body mass index (BMI) was 30.2 ± 5.1 kg/m(2). Indications for operation were: high-grade dysplasia (N = 2), adenocarcinoma (N = 6) with one receiving neoadjuvant chemoradiation. Using the Charlson comorbidity index, three patients were low risk and five were high risk. TVED was performed with a modified single-incision access device across the left neck. The mediastinal esophagus was dissected distally and circumferentially with simultaneous transabdominal laparoscopy for gastric conduit creation and distal esophageal dissection. RESULTS: Mean operative time was 292 min (range 194-375 min). Three obese patients required temporary abdominal desufflation to avoid extrinsic mediastinal compression. Mean estimated blood loss was 119 mL (range 25-400 mL). A median of 23 lymph nodes (range 13-29) was harvested. Median intensive care unit (ICU) stay was 1 day (range 1-5 days), and median overall stay was 7 days (range 5-16 days). The three low-risk patients had no major complications. Three of five high-risk patients had major complications, including two cervical anastomotic leaks. Major complications were seen in three of four obese patients (BMI >30 kg/m(2)). There were no mortalities. CONCLUSIONS: The TVED approach may avoid the morbidity of transthoracic esophageal dissection by improving esophageal visualization. Complications with TVED appear to correlate with obesity and comorbidities. Although TVED appears feasible, a larger experience is required.

Pilot study on objective measurement of abdominal wall strength in patients with ventral incisional hernia.

BACKGROUND: Outcomes after ventral incisional hernia (VIH) repair are measured by recurrence rate and subjective measures. No objective metrics evaluate functional outcomes after abdominal wall reconstruction. This study aimed to develop testing of abdominal wall strength (AWS) that could be validated as a useful metric. METHODS: Data were prospectively collected during 9 months from 35 patients. A total of 10 patients were evaluated before and after VIH repair, for a total of 45 encounters. The patients were tested simultaneously or in succession by two of three examiners. Data were collected for three tests: double leg lowering (DLL), trunk raising (TR), and supine reaching (SR). Raw data were compared and tested for validity, and continuous data were transformed to categorical data. Agreement was measured using the intraclass correlation coefficient (ICC) for DLL and using kappa for the ordinal measures. RESULTS: Simultaneous testing yielded the following interobserver reliability: DLL (0.96 and 0.87), TR (1.00 and 0.95), and SR (0.76). Reproducibility was assessed by consecutive tests, with correlation as follows: DLL (0.81), TR (0.81), and RCH (0.21). Due to poor interobserver reliability for the SR test compared with the DLL and TR tests, the SR test was excluded from calculation of an overall score. Based on raw data distribution from the DLL and TR tests, the DLL data were categorized into 10º increments, allowing construction of a 10-point score. The median AWS score was 5 (interquartile range [IQR], 4-7), and there was agreement within 1 point for 42 of the 45 encounters (93%). CONCLUSIONS: The findings from this study demonstrate that the 10-point AWS score may measure AWS in an accurate and reproducible fashion, with potential for objective description of abdominal wall function of VIH patients. This score may help to identify patients suited for abdominal wall reconstruction while measuring progress after VIH repair. Further longitudinal outcomes studies are needed.

Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series.

BACKGROUND: Primary laparoscopic hiatal hernia repair is associated with up to a 42% recurrence rate. This has lead to the use of mesh for crural repair, which has resulted in an improved recurrence rate (0-24%). However, mesh complications have been observed. METHODS: We compiled two cases, and our senior author contacted other experienced esophageal surgeons who provided 26 additional cases with mesh-related complications. Care was taken to retrieve technical operative details concerning mesh size and shape and implantation technique used. RESULTS: Twenty-six patients underwent laparoscopic and two patients open surgery for large hiatal hernia (n = 28). Twenty-five patients had a concomitant Nissen fundoplication, two a Toupet fundoplication, and one a Watson fundoplication. Mesh types placed were polypropylene (n = 8), polytetrafluoroethylene (PTFE) (n = 12), biological mesh (n = 7), and dual mesh (n = 1). Presenting symptoms associated with mesh complications were dysphagia (n = 22), heartburn (n = 10), chest pain (n = 14), fever (n = 1), epigastric pain (n = 2), and weight loss (n = 4). Main reoperative findings were intraluminal mesh erosion (n = 17), esophageal stenosis (n = 6), and dense fibrosis (n = 5). Six patients required esophagectomy, two patients had partial gastrectomy, and 1 patient had total gastrectomy. Five patients did not require surgery. In this group one patient had mesh removal by endoscopy. There was no immediate postoperative mortality, however one patient has severe gastroparesis and five patients are dependent on tube feeding. Two patients died 3 months postoperatively of unknown cause. There is no apparent relationship between mesh type and configuration with the complications encountered. CONCLUSION: Complications related to synthetic mesh placement at the esophageal hiatus are more common than previously reported. Multicenter prospective studies are needed to determine the best method and type of mesh for implantation.

Worldwide Experience with Erosion of the Magnetic Sphincter Augmentation Device.

BACKGROUND: The magnetic sphincter augmentation device continues to become a more common antireflux surgical option with low complication rates. Erosion into the esophagus is an important complication to recognize and is reported to occur at very low incidences (0.1-0.15%). Characterization of this complication remains limited. We aim to describe the worldwide experience with erosion of the magnetic sphincter augmentation device including presentation, techniques for removal, and possible risk factors. MATERIALS AND METHODS: We reviewed data obtained from the device manufacturer Torax Medical, Inc., as well as the Manufacturer and User Facility Device Experience (MAUDE) database. The study period was from February 2007 through July 2017 and included all devices placed worldwide. RESULTS: In total, 9453 devices were placed and there were 29 reported cases of erosions. The median time to presentation of an erosion was 26 months with most occurring between 1 and 4 years after placement. The risk of erosion was 0.3% at 4 years after device implantation. Most patients experienced new-onset dysphagia prompting evaluation. Devices were successfully removed in all patients most commonly via an endoscopic removal of the eroded portion followed by a delayed laparoscopic removal of the remaining beads. At a median follow-up of 58 days post-removal, there were no complications and 24 patients have returned to baseline. Four patients reported ongoing mild dysphagia. CONCLUSIONS: Erosion of the LINX device is an important but rare complication to recognize that has been safely managed via minimally invasive approaches without long-term consequences.