Impact of pre-existing mesh at the hiatus at revisional hiatal hernia surgery.

Recurrence after laparoscopic hiatus hernia repair (LHR) is high, with few symptomatic patients undergoing redo LHR. Morbidity is higher in redo surgery compared with the primary operation. Tens of studies have explored the safety of redoing LHR. However, the impact of existing mesh on operative risk is rarely examined. We aim to assess the impact of mesh at the hiatus on the safety of redo LHR. This was a cohort study examining redo LHR patients from a prospectively maintained database from January 2002 to December 2023. The primary outcome was intra-/postoperative complications. Follow-up was extracted from clinical records. Predictors of complications were assessed using univariable and multivariable logistic regression analyses. Redo LHR was performed in 100 patients; 22 had previous mesh. One encountered mortality with 23 complications. Five patients had absorbable mesh, with the remainder nonabsorbable. Overall complications were significantly higher with mesh at nine (40.9%) compared to no mesh redo at 14 (17.9%), P = 0.023. There was no difference in rates of visceral injury with mesh at four (18.2%) and no mesh at six (7.7%), P = 0.22. The median follow-up was 7 months; there was no difference in reflux rates (P = 0.70) but higher rates of dysphagia (P = 0.010). Higher overall complications were noted in patients with previous hiatal mesh repair at the time of LHR. However, major visceral complications were similar regardless of mesh use. Mesh at the hiatus should not be a deterrent for reoperative hiatus surgery.

The Impact of Age on the Post-operative Outcomes in Patients Undergoing Resection for Oesophageal and Gastric Cancer.

BACKGROUND: Within our ageing population, there is an increasing number of elderly patients presenting with oesophagogastric cancer. Resection remains the mainstay of curative treatment however it has substantial morbidity. The aim of this study was to assess whether age was an independent predictor of resection related complications in our unit. METHODS: A retrospective cohort study of prospectively collated data from 2002 to 2020 of patients undergoing resection for oesophageal and gastric cancers was analysed. Patients aged over 75 and 75 and under were compared for peri-operative morbidity (via the Clavien-Dindo classification), length of stay (LOS), unplanned readmission, 30- and 90-day mortality, and use of neoadjuvant therapy. RESULTS: Data for 466 consecutive patients undergoing oesophagogastric resection (277 oesophagectomy and 189 gastrectomy) were available for analysis. 22% of patients were aged over 75 (14% (39/277) of the oesophagectomy cohort, 34% (65/189) of the gastrectomy cohort). Oesophagectomy patients over 75 were more likely to develop post-operative complications, particularly cardiac or thromboembolic, (69.2%) than those in the younger cohort (50.4%, p = 0.029). There was no difference in complication rates between the younger and older patients undergoing gastrectomy (29.0% vs. 33.9% p = 0.495). The 30- and 90-day mortality rates were 1.4% (n = 4) and 2.5% (n = 7), respectively, for the oesophagectomy cohort and 1.1% (n = 2) and 1.6% (n = 3) for the gastrectomy cohort, with no difference between age groups. CONCLUSION: In this series, we found that patients over the age of 75 were able to undergo oesophageal and gastric resection with curative intent with acceptable post-operative morbidity and mortality.

The effect of surgical weight loss on upper airway fat in obstructive sleep apnoea.

PURPOSE: Obesity is a reversible risk factor for obstructive sleep apnoea (OSA). Weight loss can potentially improve OSA by reducing fat around and within tissues surrounding the upper airway, but imaging studies are limited. Our aim was to study the effects of large amounts of weight loss on the upper airway and volume and fat content of multiple surrounding soft tissues. METHODS: Participants undergoing bariatric surgery were recruited. Magnetic resonance imaging (MRI) was performed at baseline and six-months after surgery. Volumetric analysis of the airway space, tongue, pharyngeal lateral walls, and soft palate were performed as well as calculation of intra-tissue fat content from Dixon imaging sequences. RESULTS: Among 18 participants (89% women), the group experienced 27.4 ± 4.7% reduction in body weight. Velopharyngeal airway volume increased (large effect; Cohen's d [95% CI], 0.8 [0.1, 1.4]) and tongue (large effect; Cohen's d [95% CI], - 1.4 [- 2.1, - 0.7]) and pharyngeal lateral wall (Cohen's d [95% CI], - 0.7 [- 1.2, - 0.1]) volumes decreased. Intra-tissue fat decreased following weight loss in the tongue, tongue base, lateral walls, and soft palate. There was a greater effect of weight loss on intra-tissue fat than parapharyngeal fat pad volume (medium effect; Cohen's d [95% CI], - 0.5 [- 1.2, 0.1], p = 0.083). CONCLUSION: The study showed an increase in velopharyngeal volume, reduction in tongue volume, and reduced intra-tissue fat in multiple upper airway soft tissues following weight loss in OSA. Further studies are needed to assess the effect of these anatomical changes on upper airway function and its relationship to OSA improvement.

Intragastric laparoscopy for oesophageal eroded mesh removal: An approach to avoid resection.

The augmentation of hiatal repair for large hiatus hernia with mesh is controversial. There is some evidence that recurrence rates are less with mesh repair; however, there is a risk of mesh erosion. Complicated erosion may require complex revisional surgery and oesophagogastric resection. We present a novel approach to the treatment of oesophageal mesh erosion, by utilising a combined approach of endoscopy and intragastric laparoscopy. The symptomatic relief from this procedure may obviate the need for foregut resection in some patients.

Perioperative outcomes in patients who undergo neoadjuvant chemoradiotherapy versus chemotherapy versus up-front surgery in patients with oesophageal cancer.

BACKGROUND: Oesophagectomy is the mainstay of curative treatment for oesophageal cancer. The role of neoadjuvant therapy has evolved over time as evidence for its survival benefit comes to hand. Clinician reluctance to offer patients neoadjuvant therapy may be based on the perception that patients receiving treatment before surgery may be exposed to a greater risk of perioperative complications. The aim of this study was to examine short-term outcomes in patients who undergo neoadjuvant therapy versus up-front surgery in patients with oesophageal cancer. METHODS: This was a retrospective cohort study of prospectively collated data from 2001 to 2020 of patients undergoing resection for oesophageal cancer. Patients who had neoadjuvant chemoradiotherapy, chemotherapy and up-front surgery were compared for perioperative morbidity (via the Clavien-Dindo classification), length of stay, unplanned readmission, and 30- and 90-day mortality. Logistic regression was performed to predict perioperative morbidity following surgery. RESULTS: In total, 284 patients underwent an oesophagectomy. Most patients received neoadjuvant treatment (41% received chemoradiotherapy (117/284), 33% received chemotherapy (93/284)), and 26% of patients received up-front surgery (74/284). Patients who received neoadjuvant chemoradiotherapy or up-front surgery were more likely to have a complication (57%, 67/117 and 57%, 43/74) than patients who received neoadjuvant chemotherapy only (38%, 35/93, P = 0.009). The 30- and 90-day mortality rates were 1.4% (n = 4) and 2.8% (n = 8), respectively, with no difference between the use of neoadjuvant therapy. CONCLUSION: In this series, we found that patients who received neoadjuvant treatment could undergo oesophagectomy with curative intent with acceptable postoperative morbidity and mortality.

The influence of socioeconomic disadvantage on short- and long-term outcomes after oesophagectomy for cancer: an Australian multicentre study.

BACKGROUND: Socioeconomic status (SES) affects outcomes following surgery for various cancers. There are currently no Australian studies that examine the role of socioeconomic disadvantage on outcomes following oesophagectomy for cancer. This study assessed whether SES was associated with short-term perioperative morbidity, long-term survival, and oncological outcomes following oesophagectomy across three tertiary oesophageal cancer centres in Australia. METHODS: A retrospective cohort study was performed comprising all patients who underwent oesophagectomy for cancer across three Australian centres. Patients were stratified into SES groups using the Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD). Outcomes measured included perioperative complication rates, overall survival, and disease-free survival. RESULTS: The study cohort was 462 patients, 205 in the lower SES and 257 in the higher SES groups. The lower SES group presented with more advanced oesophageal cancer stage, a higher rate of T3 (52.6% versus 42.7%, P = 0.038) and N2 disease (19.6% versus 10.5%, P = 0.006), and had a higher rate of readmission within 30 days (11.2% versus 5.4%, P = 0.023). There was no difference in overall survival or disease-free survival between groups. CONCLUSION: Lower socioeconomic status was associated with more advanced stage and increased risk of early, unplanned readmission following oesophagectomy, but was not associated with a difference in overall or disease-free survival.

Sarcopenia impacts perioperative and survival outcomes after esophagectomy for cancer: a multicenter study.

BACKGROUND: The impact of sarcopenia on outcomes after esophagectomy is controversial. Most data are currently derived from Asian populations. This study aimed to correlate sarcopenia to short-term perioperative complication rates and long-term survival and recurrence outcomes. METHODS: A retrospective analysis was performed of patients undergoing esophagectomy for cancer from 3 tertiary referral centers in Australia. Sarcopenia was defined using cutoffs for skeletal muscle index (SMI), assessed on preoperative computed tomography images. Outcomes measured included complications, overall survival (OS), and disease-free survival (DFS). RESULTS: Of 462 patients (78.4% male; median age, 67 years), sarcopenia was evident in 276 (59.7%). Patients with sarcopenia had a higher rate of major (Clavien-Dindo ≥ 3b) complications (27.9% vs 14.5%; P < .001), including higher rates of postoperative cardiac arrythmia (16.3% vs 9.7%; P = .042), pneumonia requiring antibiotics (14.5% vs 9.1%; P = .008), and 30-day mortality (5.1% vs 0%; P = .002). In the sarcopenic group, the median OS was lower (37 months [95% CI, 27.1-46.9] vs 114 months [95% CI, 75.8-152.2]; P < .001), as was the median DFS (27 months [95% CI, 18.9-35.1] vs 77 months [95% CI, 36.4-117.6]; P < .001). Sarcopenia was an independent risk factor for lower survival on multivariate analysis (hazard ratio, 1.688; 95% CI, 1.223-2.329; P = .001). CONCLUSION: Patients with preoperative sarcopenia based on analysis of SMI are at a higher risk of major complications and have inferior survival and oncologic outcomes after esophagectomy for esophageal cancer.

Radiologic myosteatosis predicts major complication risk following esophagectomy for cancer: a multicenter experience.

BACKGROUND: Myosteatosis is a measure of skeletal muscle quality that is readily identifiable on computed tomography (CT). The effect of preoperative myosteatosis on outcomes after radical esophagectomy remains unclear. This study aimed to correlate the presence of myosteatosis on CT scan with perioperative morbidity, mortality, and survival outcomes after esophagectomy in an Australian population across 3 esophageal cancer centers. METHODS: A retrospective analysis was performed for all patients undergoing radical esophagectomy for cancer across 3 centers. Radiologic assessment of preoperative CT images was performed to determine the presence of myosteatosis. The outcomes measured included perioperative complication rate, overall survival (OS), and disease-free survival (DFS). RESULTS: A total of 462 patients were included in the analysis (male patients, 78.4%; median age, 67 years). Moreover, 353 patients (76.4%) had myosteatosis on CT. Compared to patients with normal skeletal muscle attenuation, patients with myosteatosis had a higher rate of major (Clavien-Dindo grade ≥ IIIb) complication (14.7% vs 24.9%, respectively; P = .026) and a higher rate of 30-day mortality (0.0% vs 4.0%, respectively; P = .048). Myosteatosis was associated with a major complication on multivariate analysis (hazard ratio, 1.906; 95% CI, 1.057-3.437; P = .032). There was no difference in OS and DFS between patients with and without myosteatosis (OS: 59 vs 56 months, respectively [P = .465]; DFS: 39 vs 42 months, respectively; P = .172). CONCLUSION: The presence of myosteatosis on radiologic imaging was associated with an increased risk of major complications and 30-day mortality. Identifying myosteatosis can be an adjunct to preoperative nutritional assessment and prognostication, facilitating early recognition of patients at risk of complications.

Initial experience with laparoscopic gastric bypass in an Australian general foregut surgery unit.

BACKGROUND: Laparoscopic gastric bypass (LGB) is an increasingly utilized approach to bariatric surgery in Australia. A high proportion of those procedures are revisional due to Australia's legacy of laparoscopic adjustable gastric banding (LAGB), which is not the case internationally. The aim of this study was to compare post-operative outcomes in an Australian general foregut surgery unit against benchmarks published in the literature. METHODS: This is retrospective cohort study of morbidly obese patients undergoing primary or revisional laparoscopic Roux-en-Y gastric bypass (RYGB) or laparoscopic one anastomosis gastric bypass (OAGB) with the two senior authors between 5 May 2015 and 27 June 2019. Perioperative data for the unit's first 100 cases were collected prospectively, stored on a unit database and analysed. Post-operative complications at 30 days, 90 days, mortality, length of hospital stay, and Defined Adverse Events were chosen as indicators of the perioperative outcome (as defined in the Monash Bariatric Surgery Registry). RESULTS: In this cohort, 35% of procedures were RYGB and 65% were OAGB. The majority (58%) were revisional procedures. Most patients (74%) were female. The median age was 50. The comorbidity profile of the population was similar to those published internationally. The median hospital stay was 4 days. There was no mortality. Early complications occurred in 9% of patients, with 3% occurring late. CONCLUSION: Outcomes of our first 100 cases are comparable with those recorded in the literature, notwithstanding a much higher proportion of revisional cases. LGB can be safely introduced in Australian general foregut surgery units by experienced laparoscopic surgeons.

Factors associated with postoperative pulmonary morbidity after esophagectomy for cancer.

BACKGROUND: Most studies analyzing risk factors for pulmonary morbidity date from the early 1990s. Changes in technology and treatment such as minimally invasive esophagectomy (MIE) and neoadjuvant treatment mandate analysis of more contemporary cohorts. METHODS: Predictive factors for overall and specific pulmonary morbidity in 858 patients undergoing esophagectomy between 1998 and 2008 in five Australian university hospitals were analyzed by logistic regression models. RESULTS: A total of 394 patients underwent open esophagectomy, and 464 patients underwent MIE. A total of 259 patients received neoadjuvant chemoradiotherapy, 139 preoperative chemotherapy alone, and 2 preoperative radiotherapy alone. In-hospital mortality was 3.5%. Smoking and the number of comorbidities were risk factors for overall pulmonary morbidity (odds ratio [OR] 1.47, P = 0.016; OR 1.35, P = 0.001) and pneumonia (OR 2.29, P = 0.002; 1.56, P = 0.005). The risk of respiratory failure was higher in patients with more comorbidities (OR 1.4, P = 0.035). Respiratory comorbidities (OR 3.81, P = 0.017) were strongly predictive of postoperative acute respiratory distress syndrome (ARDS). ARDS (4.51, P = 0.032) or respiratory failure (OR 8.7, P < 0.001), but not anastomotic leak (OR 2.22, P = 0.074), were independent risk factors for death. MIE (OR 0.11, P < 0.001) and thoracic epidural analgesia (OR 0.12, P = 0.003) decreased the risk of respiratory failure. Neoadjuvant treatment was not associated with an increased risk of pulmonary complications. CONCLUSIONS: Preoperative comorbidity and smoking were risk factors for respiratory complications, whereas neoadjuvant treatment was not. MIE and the use of thoracic epidural analgesia decreased the risk of respiratory failure. Respiratory failure and ARDS were the only independent factors associated with an increased risk of in-hospital death, whereas anastomotic leakage was not.

Acute cholecystitis or simple biliary colic after an emergency presentation: why it matters.

BACKGROUND: Laparoscopic cholecystectomy (LC) is often performed during the index admission after emergency presentation for acute biliary pain. Many patients have acute cholecystitis (AC) that may increase operative difficulty and complications. Our primary aim was to assess the validity of Tokyo Guidelines (TG18) for diagnosing AC by comparison with the admitting team diagnosis, operative findings and histopathology. The secondary aim was to assess outcomes after same-admission or delayed LC. METHODS: Retrospective analysis of patients who underwent LC after presenting to a tertiary hospital emergency department over a 12-month period was conducted. RESULTS: A total of 139 patients underwent LC with no mortality or bile duct injury. A diagnosis of AC made by the admitting surgical team had sensitivity of 84% and specificity of 57%. The TG18 diagnosis had sensitivity of 84% and specificity of 53%. A diagnosis of AC by the admitting surgical team correlated well with TG18 criteria diagnosis. There was poor correlation between clinical and histopathological diagnoses. Nine percent of patients had complications and 4% required conversion to open procedure. Patients with a clinical diagnosis of AC had longer post-operative length of stay and more complications compared with those who had non-AC diagnosis. There was no difference in outcomes between same-admission LC or delayed LC. CONCLUSION: TG18 diagnosis of AC does not improve accuracy of diagnosis or predictability of a poor outcome over the admitting surgical team diagnosis. Same-admission LC for patients with AC is associated with similar outcomes compared to those who undergo delayed LC.

Cartilage defects are associated with physical disability in obese adults.

OBJECTIVE: To describe the associations between physical disability measures and knee cartilage defects in obese adults. METHODS: One hundred and eleven obese subjects were recruited from laparoscopic adjustable gastric banding or exercise/diet weight loss programmes. All subjects completed disease-specific (WOMAC) and general health status (SF-36) questionnaires, and were assessed for range of knee motion, tibiofemoral alignment and quadriceps strength. Knee cartilage defects were graded on MRI according to established protocol. Regression analysis was adjusted for age, gender, BMI and presence of clinical knee OA. RESULTS: The association between higher whole compartment cartilage defect scores and increasing BMI, age and clinical knee OA was confirmed in this obese cohort (r = 0.27, P = 0.01; r = 0.26, P = 0.007; P < 0.0001, respectively), whereas new associations were found with reduced knee range of motion (r = 0.5, P < 0.0001). No associations were found between defect scores and quadriceps strength. Varus malalignment was associated with higher medial cartilage defect scores (r = 0.33, P = 0.013). Higher levels of pain, stiffness and physical disability (WOMAC, SF-36) were associated with higher medial compartment and patella cartilage defect scores. CONCLUSIONS: Knee cartilage defects increase with increasing obesity and are associated with both objective and self-reported measures of physical disability. Longitudinal studies are required to assess the potential for change or improvement in cartilage defects with weight loss.

Omission of the calibration bougie in laparoscopic repair of paraesophageal hernia.

BACKGROUND: The use of an intraesophageal bougie has traditionally been an integral step in the repair of large hiatal hernia and fundoplication. Typically, the bougie is passed by the anesthesiologist or a member of the surgical team into the stomach to enable calibration of the hiatal repair and fundoplication. An inherent risk of esophagogastric perforation is associated with this maneuver. The authors report their experience comparing symptomatic outcomes for patients who have had a large hiatus hernia repaired with and without the use of a calibration bougie. METHODS: Data were collected prospectively for 28 consecutive patients undergoing elective laparoscopic repair of a paraesophageal hernia. A bougie was used in the first 14 patients. In the next 14 patients, the use of a bougie was omitted. Symptom and quality-of-life data were collected preoperatively and 6 months postoperatively for all the patients. RESULTS: All the patients were satisfied with their symptomatic outcome, as reflected in their postoperative quality-of-life scores. No patients required dilation for postoperative dysphagia. There was no difference in postoperative dysphagia scores between the two groups. CONCLUSION: The current series of consecutively performed laparoscopic paraesophageal hernia repairs showed no benefit in terms of symptomatic outcome associated with the use of an intraesophageal bougie. Currently, the authors' standard practice is to perform laparoscopic repair of the paraesophageal hernia and fundoplication without the aid of a calibration bougie.

Evaluation of lightweight titanium-coated polypropylene mesh (TiMesh) for laparoscopic repair of large hiatal hernias.

BACKGROUND: The use of mesh for laparoscopic repair of large hiatal hernias may reduce recurrence rates in comparison with primary suture repair. However, there is a potential risk of mesh-related oesophageal complications due to prosthesis erosion. The aim of this study was to evaluate a lightweight polypropylene mesh (TiMesh) repair of hiatal hernias with particular reference to intraluminal erosion. METHODS: Data were collected prospectively on 18 consecutive patients undergoing elective laparoscopic repair of a large hiatal hernia with the use of TiMesh between November 2004 and December 2005. Quality of life and symptom analysis was performed using QOLRAD questionnaires preoperatively and postoperatively after 6 weeks, 6 months, 1 year and 2 years. Barium studies were performed preoperatively and 2 years postoperatively to assess hernia recurrence. After 2 years, oesophagogastric endoscopy was performed to assess signs of mesh-related complications. RESULTS: All operations were completed laparoscopically. There was no 30-day mortality and median hospital stay was 2.8 days (range 2-13 days). Complications occurred in two patients (11%), both of whom were treated without residual disability. Two years after hiatal hernia repair, there was significant improvement in quality-of-life scores (QOLRAD 5.79, p < 0.001). There was no difference between pre- and postoperative dysphagia scores. No signs of stricture formation or prosthetic erosion were identified during endoscopic follow-up. One patient had a small (2 cm) sliding hiatal hernia demonstrated by barium studies, which was asymptomatic. CONCLUSIONS: Laparoscopic reinforcement of primary hiatal closure with TiMesh leads to a durable repair in patients with large hiatal hernias. Endoscopic follow-up did not show any signs of mesh-related complications after prosthetic reinforcement of the crural repair. Our preliminary results suggest that it is safe to proceed with this lightweight polypropylene mesh for reinforcement of the hiatal repair.

Acute paraesophageal hernia repair: short-term outcome comparisons with elective repair.

BACKGROUND: In the literature, there is a wide range of reported morbidity and mortality rates after acute paraesophageal hernia (PH) repair. MATERIALS AND METHODS: Data were collected from all patients undergoing PH repair between December 2001 and October 2011. Outcome data were compared between the acute and elective groups. RESULTS: Over the study period, 268 patients underwent PH repair, of which 42 patients underwent acute repair compared with 226 elective repairs. Morbidity and mortality rates were both higher, albeit nonsignificantly, in the acute group (16.6% vs. 6.6%, P=0.058 and 4.8% vs. 0.4%, P=0.065, respectively). CONCLUSIONS: Because of the poorer preoperative medical status, lower success rates of minimal access surgery, and longer inpatient stay, combined with the trends toward increased morbidity and mortality rates, of patients undergoing acute repair of PH, we would recommend routine elective laparoscopic surgery as the standard of care for individuals with symptomatic PH and minimal comorbidities.

Transfusion-Dependent Anaemia: An Overlooked Complication of Paraoesophageal Hernias.

Introduction. A paraoesophageal hernia (PH) may be one reason for iron-deficiency anaemia (IDA) but is often overlooked as a cause. We aimed to assess the incidence and resolution of transfusion-dependent IDA in patients presenting for hiatal hernia surgery. Methods. We analysed a prospective database of patients undergoing laparoscopic hiatal repair in order to identify patients with severe IDA requiring red cell/iron transfusion. Results. Of 138 patients with PH managed over a 4-year period, 7 patients (5.1%; M : F 2 : 5; median age 62 yrs (range 57-82)) with IDA requiring red cell/iron transfusion were identified. Preoperatively, 3/7 patients underwent repetitive and unnecessary diagnostic endoscopic investigations prior to surgery. Only 2/7 ever demonstrated gastric mucosal erosions (Cameron ulcers). All patients were cured from anaemia postoperatively. Discussion. PH is an important differential diagnosis in patients with IDA, even those with marked anaemia and no endoscopically identifiable mucosal lesions. Early recognition can avoid unnecessary additional diagnostic endoscopies. Laparoscopic repair is associated with low morbidity and results in resolution of anaemia.

Postoperative Dysphagia in laparoscopic paraesophageal hernia repair: the effect of distal esophageal angulation.

BACKGROUND: Dysphagia following laparoscopic paraesophageal hernia repair is an uncommon but difficult problem that may be due to technical factors. We looked for an association between esophageal angulation after posterior crural repair and postoperative dysphagia. MATERIALS AND METHODS: Patients undergoing paraesophageal hiatus hernia repair were identified from a prospectively maintained dedicated database. All patients underwent a standardized laparoscopic repair. Essentially the hernia sac was dissected from the mediastinum, a posterior hiatal repair was carried out with interrupted polyester sutures, and augmented with mesh on lay. A partial posterior fundoplication was then carried out. We used the number of posterior sutures as a proxy for anterior esophageal angulation. Quality-of-life data and dysphagia scores were recorded preoperatively, at 6 weeks postoperatively and 12 months postoperatively using validated instruments. RESULTS: Between November 2004 and September 2010, 114 consecutive patients underwent paraesophageal hiatus hernia repair. There was 1 postoperative death in the series. Median age was 67 years (interquartile range, 59 to 77 y) and 90 (79%) were female. Median hospital stay was 3 days (interquartile range, 2 to 5 y). Follow-up data were available in 87 (76%) of patients at 6 weeks and 94 (82%) of patients at 12 months postoperation. Overall, there was a significant improvement in quality of life that was sustained out to 12 months (P<0.001). Dakkak dysphagia scores were significantly improved postoperatively. Improvement was sustained out to 12 months (P<0.001). Three patients underwent endoscopic esophageal dilation for dysphagia following surgery. There was no significant correlation between the number of posterior sutures used and dysphagia outcome. Specifically there was no association with overall Dakkak scores or change in Dakkak score. CONCLUSIONS: Anterior angulation due to posterior hiatal repair does not result in worsening dysphagia, even in patients with large hiatal defects. A posterior repair should therefore remain the standard approach for hiatal closure.