Observational medical treatment or surgery for giant paraesophageal hiatal hernia in elderly patients.

Giant paraesophageal hernias (GPHH) occur frequently in the elderly and account for about 5-10% of all hiatal hernias. Up to now controversy persists between expected medical treatment and surgical treatment. To assess if an indication for surgical repair of GPHH is possible in elderly patients. A prospective study that includes patients over 70 years of age hospitalized from January 2015 to December 2019 with GPHH. Patients were separated into Group A and Group B. Group A consisted of a cohort of 23 patients in whom observation and medical treatment were performed. Group B consisted of 44 patients submitted to elective laparoscopic hiatal hernia repair. Symptomatic patients were observed in both groups (20/23 in Group A and 38/44 in Group B). Charlson's score >6 and ASA II or III were more frequent in Group A. Patients in Group A presented symptoms many years before their hospitalization in comparison to Group B (21.8+7.8 vs. 6.2+3.5 years, respectively) (P=0.0001). Emergency hospitalization was observed exclusively in Group A. Acute complications were frequently observed and hospital stays were significantly longer in Group A, 14 patients were subjected to medical management and 6 to emergency surgery. In-hospital mortality occurred in 13/20 patients (65%) versus 1/38 patients (2.6%) in Group B (P=0.0001). Laparoscopic paraesophageal hiatal hernia repair can be done safely, effectively, and in a timely manner in elderly patients at specialized surgical teams. Advanced age alone should not be a limiting factor for the repair of paraesophageal hernias.

Late esophagogastric anatomic and functional changes after sleeve gastrectomy and its clinical consequences with regards to gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) is described as a complication after sleeve gastrectomy. Most studies have used only clinical symptoms or upper gastrointestinal endoscopy for evaluation of reflux after surgery. Manometry, acid reflux tests, and esophageal barium swallow have not been commonly used. The objective of this study is to evaluate the short- and long-term incidence of clinical gastroesophageal reflux, the lower esophageal sphincter (LES) pressure, acid reflux, and endoscopic and radiological changes after sleeve gastrectomy (SG). A total of 315 patients were studied after SG; 248 (78.3%) completed more than 5 years of follow-up and 67 (21.4%) have more than 8 years (range 8-10 years) of follow-up. The preoperative weight was 106 + 14.1 kg with a mean body mass index 38.4 + 3.4 kg/m2. Patients with prior GERD were excluded for SG. During the follow-up patients were subjected to clinical, endoscopic, radiological, manometric, and 24-hour pH monitoring and duodenogastric reflux evaluations. Reflux symptoms were observed in 65.1% of patients at late follow-up. Patients without reflux symptoms presented an LES resting pressure of 13.3 ± 4.2 mmHg while patients with reflux symptoms presented an LES resting pressure of 9.8 + 2.1 mmHg. In patients with reflux symptoms, a positive acid reflux test was observed in 77.5% of patients with a mean DeMeester score of 41.7 ± 2.9 (range 14.1-131.7). During endoscopy, esophagitis was found in 29.4%, hiatal hernia in 5.7%, and Barrett's esophagus was diagnosed in 4.8%. Positive duodenogastric reflux was found in 31.8% of patients and 57.7% of our patients received proton pump inhibitor treatment after SG. Sleeve gastrectomy presents anatomic and functional changes that are associated with increased GERD.

Laparoscopic subtotal gastrectomy in morbid obese patients: a valid option to laparoscopic gastric bypass in particular circumstances (prospective study).

BACKGROUND: Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) without resection of the distal stomach is largely performed over the world for morbid obesity. Potential risk of gastric remnant carcinoma development has been suggested. PURPOSE: To present the results obtained after LRYGB with resection of distal stomach. METHOD: This prospective study includes 400 consecutive patients. The mean body weight was 105.9 ± 16.8 Kg (range 83-145 kg), and body mass index (BMI) was 38.5 ± 4.4 kg/m2 (32.9-50.3). Postoperative morbid-mortality and follow-up were analyzed. RESULTS: Operative time was 128.5 ± 18.7 min, hospital discharge occurred at 3rd postoperative day, postoperative complications occurred in 9.25%, early surgical complications were observed in 3% and medical complications 4%, late surgical complications occurred 2.25%, no mortality was observed. At 1 year follow-up, BMI was 25.3 ± 2.7 kg/m2 with % of weight loss (%WL) of 84.6 + 19.1%. At five years follow-up very similar values were observed. CONCLUSION: The results obtained after LRYGB with resection of distal stomach are similar to results published after non resection LRYGB regarding early and late results and can be indicated in high risk areas of gastric carcinoma.

[Plasma ghrelin levels in the late postoperative period of vertical sleeve gastrectomy]. / Efecto de la gastrectomía tubular vertical en los niveles de ghrelina plasmática en pacientes obesos.

BACKGROUND: Plasma ghrelin levels may decrease after vertical sleeve gastrectomy, probably due to the excision of a large portion of the gastric fundus. It is worth exploring the long term effects of this surgical procedure on ghrelin levels and their associations with changes in body weight. AIM: To assess ghrelin levels and changes in body weight, one and five years after a vertical sleeve gastrectomy. MATERIAL AND METHODS: Plasma ghrelin was measured prior to gastric sleeve gastrectomy, immediately after surgery and BMI was controlled at one and five years of the postoperative period in 16 and 10 obese patients, respectively. Mean baseline body mass index was 40.4 ± 6 kg/m2. RESULTS: Ghrelin decreased in 10 patients and increased in six during the long term postoperative period. At one year, mean body mass index decreased to 25.1 ± 1.6 kg/m2. Changes in weight and ghrelin levels had no relationship whatsoever. At five years of follow up, body mass index had increased to 29.9 ± 2.5 kg/m2, again without any association with ghrelin levels. CONCLUSIONS: Ghrelin levels may decrease or increase after vertical sleeve gastrectomy and have no association with changes in body weight.

[Esophageal sarcomatoid squamous carcinoma: report of one case]. / Carcinoma escamoso sarcomatoide de la unión gastroesofágica: caso clínico.

Sarcomatoid squamous carcinoma (ESC) is a rare esophageal neoplasm, with a clinical, etiological and pathological behavior that differs from squamous cancer. From the histological point of view it has a dual configuration. The squamous epithelial component is usually limited to small areas, while the major part is constituted by mesenchymatous (sarcomatoid) polypoid tissue. Treatment is esophagectomy or total esophagogastrectomy depending on the tumor location. Early detection is critical in terms of survival. For large lesions, preoperative chemo-radiotherapy can be considered. We report a 78-year-old male presenting with dysphagia. An upper gastrointestinal endoscopy showed a tumor located below the cardia. The patient was subjected to a total esophageal and gastric resection. In a second operation, the digestive transit was reconstituted in 2 steps. The pathology report informed a sarcomatoid squamous carcinoma. After 18 months of follow up, the patient is ambulatory.

[Hiatal hernias: why and how should they be surgically treated]. / Hernias hiatales: ¿cuándo y por qué deben ser operadas?

INTRODUCTION: There is controversy in the literature about the choice of expectant medical treatment versus surgical treatment of hiatal hernias, depending on the presence or absence of symptoms. This study presents the results obtained by our group, considering disease duration and postoperative results. PATIENTS AND METHOD: A total of 121 patients were included and divided by age, disease duration, type of hiatal hernia and postoperative outcome. RESULTS: In 32% of the patients younger than 70 years, symptom duration was longer than 11 years and 68% of those aged more than 71 years had long-term symptoms (p<.05). Type iv hernias (complex) and those with diameters measuring more than 16 cm were observed in the group with longer symptom duration. Complications were more frequent in the older age group, in those with longer symptom duration and in those with type iv complex hernias. There was no postoperative mortality and only one patient (0.8%) with a type iii hernia and severe oesophagitis required reoperation. CONCLUSION: We recommend that patients with hiatal hernia undergo surgery at diagnosis to avoid complications and risks. Older patients should not be excluded from surgical indication but should undergo a complete multidisciplinary evaluation to avoid complications and postoperative mortality.

DEVELOPMENT OF ADENOCARCINOMA AFTER RADIOFREQUENCY ABLATION OF BARRETT'S ESOPHAGUS ASSOCIATED TO FUNDOPLICATION AND SUPPRESSION-DUODENAL DIVERSION PROCEDURE: A LESSON TO BE LEARNED.

Despite endoscopic eradication therapy being an effective and durable treatment for Barrett's esophagus-related neoplasia, even after achieving initial successful eradication, these patients remain at risk of recurrence and require ongoing routine examinations. Failure of radiofrequency ablation and argon plasma coagulation is reported in 10-20% of cases.

TOMOGRAPHIC SARCOPENIA PREDICTS ANASTOMOTIC LEAKS AND LONG-TERM SURVIVAL IN GASTRIC CANCER PATIENTS OPERATED WITH CURATIVE INTENT.

BACKGROUND: The preoperative nutritional state has prognostic postoperative value. Tomographic density and area of psoas muscle are validated tools for assessing nutritional status. There are few reports assessing the utility of staging tomography in gastric cancer patients in this field. AIMS: This study aimed to determine the influence of sarcopenia, measured by a preoperative staging computed tomography scan, on postoperative morbimortality and long-term survival in patients operated on for gastric cancer with curative intent. METHODS: This retrospective study was conducted from 2007 to 2013. The definition of radiological sarcopenia was by measurement of cross-sectional area and density of psoas muscle at the L3 (third lumbar vertebra) level in an axial cut of an abdominopelvic computed tomography scan (in the selection without intravascular contrast media). The software used was OsirixX version 10.0.2, with the tool "propagate segmentation", and all muscle seen in the image was manually adjusted. RESULTS: We included 70 patients, 77% men, with a mean cross-sectional in L3 of 16.6 cm2 (standard deviation+6.1) and mean density of psoas muscle in L3 of 36.1 mean muscle density (standard deviation+7.1). Advanced cancers were 86, 28.6% had signet-ring cells, 78.6% required a total gastrectomy, postoperative surgical morbidity and mortality were 22.8 and 2.8%, respectively, and overall 5-year long-term survival was 57.1%. In the multivariate analysis, cross-sectional area failed to predict surgical morbidity (p=0.4) and 5-year long-term survival (p=0.34), while density of psoas muscle was able to predict anastomotic fistulas (p=0.009; OR 0.86; 95%CI 0.76-0.96) and 5-year long-term survival (p=0.04; OR 2.9; 95%CI 1.04-8.15). CONCLUSIONS: Tomographic diagnosis of sarcopenia from density of psoas muscle can predict anastomotic fistulas and long-term survival in gastric cancer patients treated with curative intent.

GASTROESOPHAGEAL SYMPTOMS AFTER LAPAROSCOPIC GASTRIC BYPASS: MISTAKES IN PERFORMING THE PROCEDURE?

AIM: Laparoscopic Roux-en-Y gastric bypass (LGB) is the recommended procedure for morbidly obese patients with gastroesophageal reflux disease (GERD). However, there have been reported gastroesophageal reflux symptoms or esophagitis after LGB. Few functional esophageal studies have been reported to date. To evaluate the anatomic and physiologic factors contributing to the appearance of these problems in patients who underwent LGB. METHODS: This prospective study included 38 patients with postoperative gastroesophageal reflux symptoms submitted to LGB. They were subjected to clinical, endoscopic, radiologic, manometric, and 24-h pH-monitoring evaluations. RESULTS: Eighteen (47.4%) of 38 patients presented with heartburn or regurgitation, 7 presented with pain, and 4 presented with dysphagia. Erosive esophagitis was observed in 11 (28.9%) patients, and Barrett's esophagus (5.7%) and jejunitis (10.5%) were also observed. Hiatal hernia was the most frequent finding observed in 15 (39.5%) patients, and most (10.5%) of these patients appeared with concomitant anastomotic strictures. A long blind jejunal loop was detected in one (2.6%) patient. Nearly 75% of the patients had hypotensive lower esophageal sphincter (9.61±4.05 mmHg), 17.4% had hypomotility of the esophageal body, and 64.7% had pathologic acid reflux (% time pH <4=6.98±5.5; DeMeester's score=32.4±21.15). CONCLUSION: Although rare, it is possible to observe gastroesophageal reflux and other important postoperative symptoms after LGB, which are associated with anatomic and physiologic abnormalities at the esophagogastric junction and proximal gastric pouch.

RISK FACTORS FOR REOPERATION, MORBIDITY, AND MORTALITY IN PATIENTS WITH SMALL BOWEL OBSTRUCTION SUBMITTED TO SURGICAL TREATMENT.

AIM: Small bowel obstruction (SBO) is a frequent cause of emergency department admissions. This study aimed to determine risk factors of reoperations, postoperative adverse event, and operative mortality (OM) in patients surgically treated for SBO. METHODS: This is a retrospective study conducted between 2014 and 2017. Exclusion criteria include gastric outlet obstruction, large bowel obstruction, and incomplete clinical record. STATA version 14 was used for statistical analysis, with p-value <0.05 with 95% confidence interval considered statistically significant. RESULTS: A total of 218 patients were included, in which 61.9% were women. Notably, 88.5% of patients had previous abdominal surgery. Intestinal resection was needed in 28.4% of patients. Postoperative adverse event was present in 28.4%, reoperation was needed in 9.2% of cases, and a 90-day surgical mortality was 5.9%. Multivariate analysis determined that intestinal resection, >3 days in intensive care unit (ICU), >7 days with nasogastric tube (NGT), pain after postoperative day 3, POAE, and surgical POAE were the risk factors for reoperations, while age, C-reactive protein, intestinal resection, >3 days in ICU, and >7 days with NGT were the risk factors for POAE. OM was determined by >5 days with NGT and POAE. CONCLUSIONS: Postoperative course is determined mainly for patient's age, preoperative level of C-reactive protein, necessity of intestinal resection, clinical postoperative variables, and the presence of POAE.

LAPAROSCOPIC REDO FUNDOPLICATION ALONE, REDO NISSEN FUNDOPLICATION, OR TOUPET FUNDOPLICATION COMBINED WITH ROUX-EN-Y DISTAL GASTRECTOMY FOR TREATMENT OF FAILED NISSEN FUNDOPLICATION.

BACKGROUND: Laparoscopic Nissen fundoplication fails to control the gastroesophageal reflux in almost 15% of patients, and most of them must be reoperated due to postoperative symptoms. Different surgical options have been suggested. AIMS: This study aimed to present the postoperative outcomes of patients submitted to three different procedures: redo laparoscopic Nissen fundoplication alone (Group A), redo laparoscopic Nissen fundoplication combined with distal gastrectomy (Group B), or conversion to laparoscopic Toupet combined with distal gastrectomy with Roux-en-Y gastrojejunostomy (Group C). METHODS: This is a prospective study involving 77 patients who were submitted initially to laparoscopic Nissen fundoplication and presented recurrence of gastroesophageal reflux after the operation. They were evaluated before and after the reoperation with clinical questionnaire and objective functional studies. After reestablishing the anatomy of the esophagogastric junction, a surgery was performed. None of the patients were lost during follow-up. RESULTS: Persistent symptoms were observed more frequently in Group A or B patients, including wrap stricture, intrathoracic wrap, or twisted fundoplication. In Group C, recurrent symptoms associated with this anatomic alteration were infrequently observed. Incompetent lower esophageal sphincter was confirmed in 57.7% of patients included in Group A, compared to 17.2% after Nissen and distal gastrectomy and 26% after Toupet procedure plus distal gastrectomy. In Group C, despite the high percentage of patients with incompetent lower esophageal sphincter, 8.7% had abnormal acid reflux after surgery. CONCLUSIONS: Nissen and Toupet procedures combined with Roux-en-Y distal gastrectomy are safe and effective for the management of failed Nissen fundoplication. However, Toupet technique is preferable for patients suffering from mainly dysphagia and pain.

Laparoscopic surgical treatment for patients with short- and long-segment Barrett's esophagus: which technique in which patient?

Laparoscopic antireflux surgery is very successful in patients with short-segment Barrett's esophagus (BE), but in patients with long-segment BE, the results remain in discussion. In these patients, during the open era of surgery, we performed acid suppression + duodenal diversion procedures added to the antireflux procedure (fundoplication + vagotomy + antrectomy + Roux-en-Y gastrojejunostomy) to obtain better results at long-term follow-up. The aim of this prospective study is to present the results of 3 to 5 years' follow-up in patients with short-segment and long-segment or complicated BE (ulcer or stricture) who underwent fundoplication or the acid suppression-duodenal diversion technique, both performed by a laparoscopic approach. One hundred eight patients with histologically confirmed BE were included: 58 patients with short-segment BE, and 50 with long-segment BE, 28 of whom had complications associated with severe erosive esophagitis, ulcer, or stricture. After surgery, among patients treated with fundoplication with cardia calibration, endoscopic erosive esophagitis was observed in 6.9% of patients with short-segment BE, while 50% of patients with long-segment BE presented with positive acid reflux, persistence of endoscopic esophagitis with intestinal metaplasia, and progression to dysplasia (in 5% of cases; P = 0.000). On the contrary, after acid suppression-duodenal diversion surgery in patients with long-segment BE, more than 95.6% presented with successful results regarding recurrent symptoms and endoscopic regression of esophagitis. Regression of intestinal metaplasia to the cardiac mucosa was observed in 56.9% of patients with short-segment BE who underwent fundoplication and in 61% of those with long-segment BE treated with the acid suppression-duodenal diversion procedure. Patients with long-segment BE who experienced fundoplication alone presented no regression of intestinal metaplasia; on the contrary, progression to dysplasia was observed in 1 case (P = 0.049). Patients with short-segment BE can be successfully treated with fundoplication, but for patients with long-segment BE, we suggest performance of fundoplication plus an acid suppression-duodenal diversion procedure.

Lies, Damn Lies, and Bad Statistics?

A wide spectrum of research such as experimental, randomized trials, cohort or epidemiological studies, technical or control case reports, systematic reviews, and meta-analyses has resulted in a huge amount of publications. These studies and publications may be subject to errors due to poor application of statistical tests, which can lead to misinformation, misinterpretation, and erroneous conclusions, sometimes even considered as lies. In this article, some ideas about this issue are discussed in order to adopt new directions in the future and thus avoid lies and bad statistics.

WHEN SHOULD BE CONVERTED LAPAROSCOPIC SLEEVE GASTRECTOMY TO LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS DUE TO GASTROESOPHAGEAL REFLUX?

BACKGROUND: Gastroesophageal reflux (GER) is one of the most common indications for conversion of sleeve gastrectomy (LSG) to laparoscopic Roux-en-Y gastric bypass (LRYGBP). Objective evaluations are necessary in order to choose the best definitive treatment for these patients. AIM: To present and describe the findings of the objective studies for gastroesophageal reflux disease performed before LSG conversion to LRYGBP in order to support the indication for surgery. METHOD: Thirty-nine non-responder patients to proton pump inhibitors treatment after LSG were included in this prospective study. They did not present GER symptoms, esophagitis or hiatal hernia before LSG. Endoscopy, radiology, manometry, 24 h pH monitoring were performed. RESULTS: The mean time of appearance of reflux symptoms was 26.8+24.08 months (8-71). Erosive esophagitis was found in 33/39 symptomatic patients (84.6%) and Barrett´s esophagus in five. (12.8%). Manometry and acid reflux test were performed in 38/39 patients. Defective lower esophageal sphincter function was observed independent the grade of esophagitis or Barrett´s esophagus. Pathologic acid reflux with elevated DeMeester´s scores and % of time pH<4 was detected in all these patients. more significant in those with severe esophagitis and Barrett´s esophagus. Radiologic sleeve abnormalities were observed in 35 patients, mainly cardia dilatation (n=18) and hiatal hernia (n=11). Middle gastric stricture was observed in only six patients. CONCLUSION: Patients with reflux symptoms and esophagitis or Barrett´s esophagus after SG present defective lower esophageal sphincter function and increased acid reflux. These conditions support the indication of conversion to LRYGBP.

LYMPHOPARIETAL INDEX IN ESOPHAGEAL CANCER IS STRONGER THAN TNM STAGING IN LONG-TERM SURVIVAL PROGNOSIS IN A LATIN-AMERICAN COUNTRY.

BACKGROUND: The identification of prognostic factors of esophageal cancer has allowed to predict the evolution of patients. AIM: Assess different prognostic factors of long-term survival of esophageal cancer and evaluate a new prognostic factor of long-term survival called lymphoparietal index (N+/T). METHOD: Prospective study of the Universidad de Chile Clinical Hospital, between January 2004 and December 2013. Included all esophageal cancer surgeries with curative intent and cervical anastomosis. Exclusion criteria included: stage 4 cancers, R1 resections, palliative procedures and emergency surgeries. RESULTS: Fifty-eight patients were included, 62.1% were men, the average age was 63.3 years. A total of 48.3% were squamous, 88% were advanced cancers, the average lymph node harvest was 17.1. Post-operative surgical morbidity was 75%, with a 17.2% of reoperations and 3.4% of mortality. The average overall survival was 41.3 months, the 3-year survival was 31%. Multivariate analysis of the prognostic factors showed that significant variables were anterior mediastinal ascent (p=0.01, OR: 6.7 [1.43-31.6]), anastomotic fistula (p=0.03, OR: 0.21 [0.05-0.87]), N classification (p=0.02, OR: 3.8 [1.16-12.73]), TNM stage (p=0.04, OR: 2.8 [1.01-9.26]), and lymphoparietal index (p=0.04, RR: 3.9 [1.01-15.17]. The ROC curves of lymphoparietal index, N classification and TNM stage have areas under the curve of 0.71, 0.63 and 0.64 respectively, with significant statistical difference (p=0.01). CONCLUSION: The independent prognostic factors of long-term survival in esophageal cancer are anterior mediastinal ascent, anastomotic fistula, N classification, TNM stage and lymphoparietal index. In esophageal cancer the new lymphoparietal index is stronger than TNM stage in long-term survival prognosis.

Enhancement in liver SREBP-1c/PPAR-alpha ratio and steatosis in obese patients: correlations with insulin resistance and n-3 long-chain polyunsaturated fatty acid depletion.

Sterol receptor element-binding protein-1c (SREBP-1c) and peroxisome proliferator-activated receptor-alpha (PPAR-alpha) mRNA expression was assessed in liver as signaling mechanisms associated with steatosis in obese patients. Liver SREBP-1c and PPAR-alpha mRNA (RT-PCR), fatty acid synthase (FAS) and carnitine palmitoyltransferase-1a (CPT-1a) mRNA (real-time RT-PCR), and n-3 long-chain polyunsaturated fatty acid (LCPUFA)(GLC) contents, plasma adiponectin levels (RIA), and insulin resistance (IR) evolution (HOMA) were evaluated in 11 obese patients who underwent subtotal gastrectomy with gastro-jejunal anastomosis in Roux-en-Y and 8 non-obese subjects who underwent laparoscopic cholecystectomy (controls). Liver SREBP-1c and FAS mRNA levels were 33% and 70% higher than control values (P<0.05), respectively, whereas those of PPAR-alpha and CPT-1a were 16% and 65% lower (P<0.05), respectively, with a significant 62% enhancement in the SREBP-1c/PPAR-alpha ratio. Liver n-3 LCPUFA levels were 53% lower in obese patients who also showed IR and hipoadiponectinemia over controls (P<0.05). IR negatively correlated with both the hepatic content of n-3 LCPUFA (r=-0.55; P<0.01) and the plasma levels of adiponectin (r=-0.62; P<0.005). Liver SREBP-1c/PPAR-alpha ratio and n-3 LCPUFA showed a negative correlation (r=-0.48; P<0.02) and positive associations with either HOMA (r=0.75; P<0.0001) or serum insulin levels (r=0.69; P<0.001). In conclusion, liver up-regulation of SREBP-1c and down-regulation of PPAR-alpha occur in obese patients, with enhancement in the SREBP-1c/PPAR-alpha ratio associated with n-3 LCPUFA depletion and IR, a condition that may favor lipogenesis over FA oxidation thereby leading to steatosis.

Postoperative results after laparoscopic approach for treatment of large hiatal hernias: is mesh always needed? Is the addition of an antireflux procedure necessary?

Laparoscopic approach has been suggested as the definitive treatment for large hiatal hernias. Reinforcement of the hiatoplasty and the need to perform antireflux surgery is still undergoing discussion. The purpose of this study was to evaluate the postoperative results, with special emphasis on the recurrence rate and reflux after surgery comparing the use or not of mesh reinforcement. This prospective study included 81 patients with a complete evaluation through a clinical questionnaire, barium sulfate radiologic evaluation, endoscopy, manometry, and 24-hour intraesophageal pH monitoring before and after a hiatoplasty with an antireflux procedure. Mesh reinforcement was used in 23 patients. Postoperative complications occurred in 11 patients (13.6%), without mortality. Recurrent hernia was observed in 10 patients without mesh reinforcement (12.3%), whereas those with mesh reinforcement showed no hiatal hernia recurrence (P = 0.33). Normal resting lower esophageal sphincter pressure was obtained after fundoplication in 87.2% of patients, and abnormal acid reflux was observed in 12.8% of patients after surgery. In conclusion, mesh reinforcement in patients with large Type IV could prevent recurrent hiatal hernias, and an antireflux procedure must be performed in order to avoid postoperative acid reflux.

Hiatal hernia repair: prevention of mesh erosion and migration into the esophagogastric junction.

BACKGROUND: Erosion and migration into the esophagogastric lumen after laparoscopic hiatal hernia repair with mesh placement has been published. AIM: To present surgical maneuvers that seek to diminish the risk of this complication. METHOD: We suggest mobilizing the hernia sac from the mediastinum and taking it down to the abdominal position with its blood supply intact in order to rotate it behind and around the abdominal esophagus. The purpose is to cover the on-lay mesh placed in "U" fashion to reinforce the crus suture. RESULTS: We have performed laparoscopic hiatal hernia repair in 173 patients (total group). Early postoperative complications were observed in 35 patients (27.1%) and one patient died (0.7%) due to a massive lung thromboembolism. One hundred twenty-nine patients were followed-up for a mean of 41+28months. Mesh placement was performed in 79 of these patients. The remnant sac was rotated behind the esophagus in order to cover the mesh surface. In this group, late complications were observed in five patients (2.9%). We have not observed mesh erosion or migration to the esophagogastric lumen. CONCLUSION: The proposed technique should be useful for preventing erosion and migration into the esophagus.