RISK OF DE NOVO BARRETT'S ESOPHAGUS POST SLEEVE GASTRECTOMY: A SYSTEMATIC REVIEW AND META-ANALYSIS OF STUDIES WITH LONG TERM FOLLOW UP.

BACKGROUND: Sleeve gastrectomy (SG) is one of the most commonly performed bariatric procedures worldwide. Gastroesophageal reflux disease (GERD) is a major concern in patients undergoing SG and is a risk factor for Barrett's esophagus (BE). We conducted a systematic review and meta-analysis to assess the incidence of and analyze predictive factors for post-SG BE. METHODS: A comprehensive literature search was conducted in April 2024, for studies reporting on incidence of BE, erosive esophagitis (EE) and hiatal hernia (HH) post SG. Primary outcomes were post SG pooled rates of de novo BE, EE, GERD symptoms, proton pump inhibitor (PPI) use and HH. Meta-regression analysis was performed to assess if patient and post SG factors influenced the rates of post SG BE. RESULTS: Nineteen studies with 2046 patients (79% females) were included. Mean age was 42.2 years (SD 11.1) and follow up ranged from 2 to 11.4 years. The pooled rate of de novo BE post SG was 5.6% (CI 3.5-8.8). Significantly higher pooled rates of EE [Risk Ratio (RR) 3.37], HH [RR 2.09], GER/GERD symptoms [RR 3.32] and PPI use [RR 3.65], were found among patients post SG. GER/GERD symptoms post SG positively influenced the pooled BE rates, while age, sex, BMI, post SG EE and HH did not. CONCLUSION: Our analysis shows that SG results in a significantly increased risk of de novo BE and higher rates of EE, PPI use and HH. Our findings suggest that clinicians should routinely screen patients with SG for BE and future surveillance intervals should be followed as per societal guidelines.

Forgoing Preoperative Manometry for Minimally Invasive Hiatal Hernia Repair.

INTRODUCTION: Hiatal hernia commonly occurs in adults. Although most patients are asymptomatic, some experience reflux symptoms or dysphagia. These patients are frequently managed with acid suppression and lifestyle changes. However, medical management does not provide durable relief for some patients; therefore, surgical repair is considered. Routine preoperative investigations include esophagoscopy, esophagography, and manometry. We investigated the role of preoperative motility studies for the management of these patients when partial fundoplication is planned. METHODS: We performed a retrospective review of 185 patients who underwent elective minimally invasive hiatal hernia repair with partial fundoplication between 2014 and 2018. Patients were divided into two groups based on whether a preoperative motility study was performed. The primary outcomes were postoperative dysphagia, complications, postoperative interventions, and use of proton pump inhibitors. RESULTS: Ninety-nine patients underwent preoperative manometry and 86 did not. The lack of preoperative manometry was not associated with increased postoperative morbidity, including leak rate, readmission, and 30-d mortality. The postoperative dysphagia rates of the manometry and nonmanometry groups were 5% (5/99 patients) and 7% (6/86 patients) (P = 0.80), respectively. Furthermore, seven of 99 (7%) patients in the manometry group and 10 of 86 (12%) (P = 0.42) patients in the nonmanometry group underwent interventions, mainly endoscopic dilation, postoperatively owing to symptom recurrence. CONCLUSIONS: Forgoing preoperative manometry was not associated with significant adverse outcomes after minimally invasive hiatal hernia repair. Although manometry is reasonable to perform, it should not be considered a mandatory part of the preoperative assessment when partial fundoplication is planned.

High-resolution 3-dimensional tomography may be a useful tool for understanding the anatomy of hiatal hernias and surgical planning of patients eligible for laparoscopic or robotic antireflux surgery.

BACKGROUND: 3D computed tomography (CT) has been seldom used for the evaluation of hiatal hernias (HH) in surgical patients. This study aims to describe the 3D CT findings in candidates for laparoscopic or robotic antireflux surgery or HH repair and compare them with other tests. METHODS: Thirty patients with HH and/or gastroesophageal reflux disease (GERD) who were candidates for surgical treatment and underwent high-resolution CT were recruited. The variables studied were distance from the esophagogastric junction (EGJ) to the hiatus; total gastric volume and herniated gastric volume, percentage of herniated volume in relation to the total gastric volume; diameters and area of the esophageal hiatus. RESULTS: HH was diagnosed with CT in 21 (70%) patients. There was no correlation between the distance EGJ-hiatus and the herniated gastric volume. There was a statistically significant correlation between the distance from the EGJ to the hiatus and the area of the esophageal hiatus of the diaphragm. There was correlation between tomographic and endoscopic findings for the presence and size of HH. HH was diagnosed with manometry in 9 (50%) patients. There was no correlation between tomographic and manometric findings for the diagnosis of HH and between hiatal area and lower esophageal sphincter basal pressure. There was no correlation between any parameter and DeMeester score. CONCLUSIONS: The anatomy of HH and the hiatus can be well defined by 3D CT. The EGJ-hiatus distance may be equally measured by 3D CT or upper digestive endoscopy. DeMeester score did not correlate with any anatomical parameter.

Hiatal hernia reporting: time to remove subjectivity?

INTRODUCTION: The size of a hiatal hernia (HH) is a key determinant of the approach for surgical repair. However, endoscopists will often utilize subjective terms, such as "small," "medium," and "large," without any standardized objective correlations. The aim of this study was to identify HHs described using objective axial length measurements versus subjective size allocations and compare them to their corresponding manometry and barium swallow studies. METHODS AND PROCEDURES: Retrospective chart reviews were conducted on 93 patients diagnosed endoscopically with HHs between 2017 and 2021 at Newton-Wellesley Hospital. Information was collected regarding their HH subjective size assessment, axial length measurement (cm), manometry results, and barium swallow readings. Linear regression models were used to analyze the correlation between the objective endoscopic axial length measurements and manometry measurements. Ordered logistic regression models were used to correlate the ordinal endoscopic and barium swallow subjective size allocations with the continuous axial length measurements and manometry measurements. RESULTS: Of the 93 endoscopy reports, 42 included a subjective size estimate, 38 had axial length measurement, and 12 gave both. Of the 34 barium swallow reads, only one gave an objective HH size measurement. Axial length measurements were significantly correlated with the manometry measurements (R2 = 0.0957, p = 0.049). The endoscopic subjective size estimates were also closely related to the manometry measurements (R2 = 0.0543, p = 0.0164). Conversely, the subjective size estimates from barium swallow reads were not significantly correlated with the endoscopic axial length measurements (R2 = 0.0143, p = 0.366), endoscopic subjective size estimates (R2 = 0.0481, p = 0.0986), or the manometry measurements (R2 = 0.0418, p = 0.0738). Mesh placement was significantly correlated to pre-operative endoscopic axial length measurement (p = 0.0001), endoscopic subjective size estimate (p = 0.0301), and barium swallow read (p = 0.0211). However, mesh placement was not significantly correlated with pre-operative manometry measurements (0.2227). CONCLUSIONS: Endoscopic subjective size allocations and objective axial length measurements are associated with pre-operative objective measurements and intra-operative decisions, suggesting both can be used to guide clinical decision making. However, including axial length measurements in endoscopy reports can improve outcomes reporting.

SAGES guidelines for the surgical treatment of hiatal hernias.

BACKGROUND: Hiatal hernia (HH) is a common condition. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of HH. METHODS: Systematic reviews were conducted for four key questions regarding the treatment of HH in adults: surgical treatment of asymptomatic HH versus surveillance; use of mesh versus no mesh; performing a fundoplication versus no fundoplication; and Roux-en-Y gastric bypass (RYGB) versus redo fundoplication for recurrent HH. Evidence-based recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluations methodology by subject experts. When the evidence was insufficient to base recommendations on, expert opinion was utilized instead. Recommendations for future research were also proposed. RESULTS: The panel provided one conditional recommendation and two expert opinions for adults with HH. The panel suggested routinely performing a fundoplication in the repair of HH, though this was based on low certainty evidence. There was insufficient evidence to make evidence-based recommendations regarding surgical repair of asymptomatic HH or conversion to RYGB in recurrent HH, and therefore, only expert opinions were offered. The panel suggested that select asymptomatic patients may be offered surgical repair, with criteria outlined. Similarly, it suggested that conversion to RYGB for management of recurrent HH may be appropriate in certain patients and again described criteria. The evidence for the routine use of mesh in HH repair was equivocal and the panel deferred making a recommendation. CONCLUSIONS: These recommendations should provide guidance regarding surgical decision-making in the treatment of HH and highlight the importance of shared decision-making and consideration of patient values to optimize outcomes. Pursuing the identified research needs will improve the evidence base and may allow for stronger recommendations in future evidence-based guidelines for the treatment of HH.

Coated poly-4-hydroxybutyrate (Phasix ST™) mesh is safe and effective for hiatal hernia repair: our institutional experience and review of the literature.

BACKGROUND: Poly-4-hydroxybutyrate (P4HB) is a bioabsorbable mesh with a non-adhesive coating on one side that is being used to reinforce the hiatus during hiatal hernia repair; however, there is limited data regarding its use. The aim of this study was to investigate outcomes after hiatal hernia repair using this mesh at our institution and through a review of the literature. METHODS: An institutional review board-approved prospective database was retrospectively reviewed for all patients undergoing hiatal hernia repair from April 2018 to December 2022. A systematic review with meta-analysis was conducted to evaluate outcomes using P4HB coated mesh. RESULTS: In our institutional cohort, there were 230 patients (59 males; 171 females) with a mean follow-up of 20 ± 14.6 months. No mesh-related complications occurred. Hernia recurrence was diagnosed in 11 patients (4.8%) with a median time to recurrence of 16 months. In the systematic review, 4 studies with 221 patients (76 males; 145 females) were included. Median follow-up ranged from 12 to 27 months. Recurrence rate in these studies was reported from 0 to 8.8%, with a total of 12 recurrences identified. Like our institutional cohort, no mesh-related complications were reported. After our recurrences were combined with those from the systematic review, a total of 23 recurrences were included in the meta-analysis. Our meta-analysis revealed a low recurrence rate following hiatal hernia repair with P4HB coated mesh (incidence rate per 100 person-years, 2.82; 95% confidence interval, 1.60, 4.04). CONCLUSION: P4HB coated mesh is safe and effective for hiatal hernia repairs.

Paraesophageal hernia recurrence following repair: making the case for reoperative surgery in a propensity-matched cohort.

BACKGROUND: Paraesophageal hernia repairs (PEHRs) have high rates of radiographic recurrence, with some patients requiring repeat operation. This study characterizes patients who underwent PEHR to identify the factors associated with postoperative symptom improvement and radiographic recurrence. We furthermore use propensity score matching to compare patients undergoing initial and reoperative PEHR to identify the factors predictive of recurrence or need for reoperation. METHODS: After IRB approval, patients who underwent PEHR at a tertiary care center between January 2018 and December 2022 were identified. Patient characteristics, preoperative imaging, operative findings, and postoperative outcomes were recorded. A computational generalization of inverse propensity score weight was then used to construct populations of initial and redo PEHR patients with similar covariate distributions. RESULTS: A total of 244 patients underwent PEHR (78.7% female, mean age 65.4 ± 12.3 years). Most repairs were performed with crural closure (81.4%) and fundoplication (71.7%) with 14.2% utilizing mesh. Postoperatively, 76.5% of patients had subjective symptom improvement and of 157 patients with postoperative imaging, 52.9% had evidence of radiographic recurrence at a mean follow-up of 10.4 ± 13.6 months. Only 4.9% of patients required a redo operation. Hernia type, crural closure, fundoplication, and mesh usage were not predictors of radiographic recurrence or symptom improvement (P > 0.05). Propensity weight score analysis of 50 redo PEHRs compared to a matched cohort of 194 initial operations revealed lower rates of postoperative symptom improvement (P < 0.05) but no differences in need for revision, complication rates, ED visits, or readmissions. CONCLUSIONS: Most PEHR patients have symptomatic improvement with minimal complications and reoperations despite frequent radiographic recurrence. Hernia type, crural closure, fundoplication, and mesh usage were not significantly associated with recurrence or symptom improvement. Compared to initial PEHR, reoperative PEHRs had lower rates of symptom improvement but similar rates of recurrence, complications, and need for reoperation.

Surgeon variability in repair of hiatal hernia at the time of bariatric surgery.

BACKGROUND: Hiatal hernia (HH) is estimated to affect between 20 and 50% of patients undergoing bariatric surgery. However, there is no consensus regarding the preoperative assessment and intraoperative repair of HH. The aim of this study was to evaluate the variation in surgeon assessment and repair of HH during bariatric surgery across a multi-hospital healthcare system. METHODS: A retrospective cohort analysis was conducted using data obtained from the metabolic and bariatric accreditation quality improvement program (MBSAQIP) and institutional medical records. All adult patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were included. Preoperative assessment of HH was defined as either EGD or upper GI/Esophagram (UGI) within one year of surgery. Surgeons were evaluated individually and by hospital. Chi-square analysis and ANOVA were performed. RESULTS: From January 2018 to February 2023, 3,487 bariatric surgeries were performed across 4 hospitals and 11 surgeons (2481 SG and 1006 RYGB). HH were concurrently repaired during 24% of operations. The rate of HH repair in SG was 25 and 22% in RYGB (p = 0.06). Preoperatively, 41% of patients underwent EGD and 23% had an UGI. HH was diagnosed in 22% of EGDs. Patients who underwent preoperative EGD had higher rates of HH repair than those without a preop EGD (33% vs. 17%; p < 0.001). The rate of preoperative EGD utilization by surgeon varied significantly from 3 to 92% (p < 0.001) as did HH repair rates between surgeons (range 8-57%; p < 0.001). Even among patients with a preoperatively diagnosed HH, the repair rate ranged 20-91% between individual surgeons (p < 0.001). CONCLUSION: Within a healthcare system there was significant heterogeneity in approach to assessment and repair of HH during bariatric surgery. This appears to be mediated by multiple factors, including utilization of preoperative studies, individual surgeon differences, and differences between hospitals.

Cruroplasty with or without mesh? A systematic literature review with a novel time-organized proportion meta-analysis.

BACKGROUND: Improved outcomes with the use of non-absorbable mesh (NAM) for inguinal hernia repairs led to its rapid adoption for hiatal hernia (HH) repairs; however, feared complications occurred, and the trend shifted toward using absorbable mesh (AM). We aimed to analyze the literature assessing objective HH recurrence rates after primary laparoscopic cruroplasty with or without the use of different mesh types. METHODS: A systematic literature review with both pairwise and time-organized proportion meta-analyses of articles published between January 1993 and September 2022 was performed using the MEDLINE, EMBASE, and Taylor & Francis databases to identify relevant studies comparing groups undergoing cruroplasty with suture repair (SR) alone, AM, NAM, or partially absorbable mesh (PAM). Studies documenting an objective follow-up ≥ 6 months were included. The primary outcome was the HH recurrence rate confirmed by barium esophagram or upper GI endoscopy. RESULTS: A total of 34 studies met the inclusion criteria, including 6 randomized clinical trials, 25 retrospectives studies, and 3 prospective cohort studies. A total of 2170 subjects underwent laparoscopic HH repair and completed an objective follow-up ≥ 6 months after surgery; the objective recurrence rate was 20.8% (99/477) at a mean follow-up of 25.8 ± 16.4 months for the SR group, 20.6% (244/1187) at 28.1 ± 13.8 months for the AM group, 13.7% (65/475) at 30.8 ± 15.3 months for the NAM group, and 0% (0/31) at 32.5 ± 13.5 months for the PAM group. However, the pairwise meta-analysis revealed that overall mesh use was not superior to SR in preventing long-term HH recurrence. CONCLUSION: The use of AM does not appear to reduce HH recurrence compared to SR alone. Although the data favors NAM to decrease objective HH recurrence in the mid-term, the long-term (≥ 48 months) recurrence rate was similar with or without any type of mesh.

Lessons learned from revision procedures: a case series pleading for reinforcement of the anterior hiatus in recurrent hiatal hernia.

BACKGROUND: Hiatal Hernia (HH) is a common structural defect of the diaphragm. Laparoscopic repair with suturing of the hiatal pillars followed by fundoplication has become standard practice. In an attempt to lower HH recurrence rates, mesh reinforcement, commonly located at the posterior site of the esophageal hiatus, has been used. However, effectiveness of posterior mesh augmentation is still up to debate. There is a lack of understanding of the mechanism of recurrence requiring further investigation. We investigated the anatomic location of HH recurrences in an attempt to assess why HH recurrence rates remain high despite various attempts with mesh reinforcement. METHODS: A retrospective case series of prospectively collected data from patients with hiatal hernia repair between 2012 and 2020 was performed. In total, 54 patients with a recurrent hiatal hernia operation were included in the study. Video clips from the revision procedure were analyzed by a surgical registrar and senior surgeon to assess the anatomic location of recurrent HH. For the assessment, the esophageal hiatus was divided into four equal quadrants. Additionally, patient demographics, hiatal hernia characteristics, and operation details were collected and analyzed. RESULTS: 54 patients were included. The median time between primary repair and revision procedure was 25 months (IQR 13-95, range 0-250). The left-anterior quadrant was involved in 43 patients (80%), the right-anterior quadrant in 21 patients (39%), the left-posterior quadrant in 21 patients (39%), and the right-posterior quadrant in 10 patients (19%). CONCLUSION: In this study, hiatal hernia recurrences occured most commonly at the left-anterior quadrant of the hiatus, however, posterior recurrences were not uncommon. Based on our results, we hypothesize that both posterior and anterior hiatal reinforcement might be a suitable solution to lower the recurrence rate of hiatal hernia. A randomized controlled trial using a circular, bio-absorbable mesh has been initiated to test our hypothesis.

Peroral endoscopic myotomy is an effective treatment for achalasia combined with hiatal hernia.

PURPOSE: To explore the feasibility of peroral endoscopic myotomy (POEM) in patients with achalasia and hiatal hernia. MATERIALS AND METHODS: We performed a retrospective review of 2136 patients with achalasia between January 2016 and December 2022. Patients with achalasia and hiatal hernia were assigned into study group, and matched patients with achalasia but no hiatal hernia were assigned into control group. The preoperative baseline information, procedure-related adverse events (AEs) and follow-up data were compared between the two groups. RESULTS: Hiatal hernia was identified in 56/1564 (3.6%) patients with achalasia. All of these patients underwent POEM with success. The preoperative baseline characteristics were similar between the study and control group. The study group presented with a similar rate of mucosal injury (12.5% vs 16.1, P = 0.589), pneumothorax (3.6% vs 1.8%, P = 1.000), pleural effusion (8.9% vs 12.5%, P = 0.541) and major AEs (1.8% vs 1.8%, P = 1.000) compared with the control group. As for the follow-up data, no significant differences were observed in clinical success (96.4% vs 92.9%, P = 0.679; 93.6% vs 94.0%, P = 1.000; 86.5% vs 91.4%, P = 0.711) clinical reflux (25.0% vs 19.6%, P = 0.496; 31.9% vs 26.0%, P = 0.521; 35.1% vs 31.4%, P = 0.739) and proton pump inhibitor usage (17.9% vs 16.1%, P = 0.801; 29.8% vs 24.0%, P = 0.520; 32.4% vs 25.7%, P = 0.531) between the study group and control group at 1-year, 2-year and 3-year follow-ups. CONCLUSIONS: POEM is a safe and effective treatment for achalasia combined with hiatal hernia.

Patients report significant improvement in quality of life following hiatal hernia repair-despite recurrence.

BACKGROUND: Hiatal hernia (HH) repairs have been associated with high recurrence rates. This study aimed to investigate if changes in patient's self-reported GERD health-related quality of life (HRQL) scores over time are associated with long-term surgical outcomes. METHODS: Retrospective chart reviews were conducted on all patients who had laparoscopic or robotic HH repairs between 2018 and 2022 at a tertiary care center. Information was collected regarding initial BMI, endoscopic HH measurement, surgery, and pre- and post-operative HRQL scores. Repeat imaging at least a year following surgical repair was then evaluated for any evidence of recurrence. Paired t tests were used to compare pre- and post-operative HRQL scores. Wilcoxon ranked-sum tests were used to compare the HRQL scores between the recurrence cohort and non-recurrence cohorts at different time points. RESULTS: A total of 126 patients underwent HH repairs and had pre- and post-operative HRQL scores. Mesh was used in 23 repairs (18.25%). 42 patients had recorded HH recurrences (33.3%), 35 had no evidence of recurrence (27.7%), and 49 patients (38.9%) had no follow-up imaging. The average pre-operative QOL score was 24.99 (SD ± 14.95) and significantly improved to 5.63 (SD ± 8.51) at 2-week post-op (p < 0.0001). That improvement was sustained at 1-year post-op (mean 7.86, SD ± 8.26, p < 0.0001). The average time between the initial operation and recurrence was 2.1 years (SD ± 1.10). Recurrence was significantly less likely with mesh repairs (p = 0.005). There was no significant difference in QOL scores at 2 weeks, 3 months, 6 months, or 1 year postoperatively between the cohorts (p = NS). CONCLUSION: Patients had significant long-term improvement in their HRQL scores after surgical HH repair despite recurrences. The need to re-intervene in patients with HH recurrence should be based on their QOL scores and not necessarily based on established recurrence.

Tailoring the wrap: intraoperative functional lumen imaging probe (FLIP) during hiatal hernia repair.

INTRODUCTION: The introduction of the functional lumen imaging probe (FLIP) has provided objective, real-time feedback on the geometric variations with each component of a hiatal hernia repair (HHR). The utility of this technology in altering intraoperative decision-making has been scarcely reported. Herein, we report a single-center series of intraoperative FLIP during HHR. METHODS: A retrospective review of electronic medical records between 2020 and 2022 was conducted and all patients undergoing non-recurrent HHR with FLIP were queried. Patient and hernia characteristics, intraoperative FLIP values and changes in decision-making, as well as early post-operative outcomes were reported. Both diameter and distensibility index (DI) were measured at 40 ml and 50 ml balloon inflation after hiatal dissection, after hiatal closure, and after fundoplication when indicated. RESULTS: Thirty-three patients met inclusion criteria. Mean age was 62 ± 14 years and mean BMI was 28 ± 6 kg/m2. The majority (53%) were type I hiatal hernias. The largest drop in DI occurred after hiatal closure, with minimal change seen after fundoplication (mean DI of 4.3 ± 2. after completion of HH dissection, vs 2.7 ± 1.2 after hiatal closure and 2.3 ± 1 after fundoplication when performed). In 13 (39%) of cases, FLIP values directly impacted intraoperative decision-making. Fundoplication was deferred in 4/13 (31%) patients, the wrap was loosened in 2/13 (15%); the type of fundoplication was altered to achieve adequate anti-reflux values in 2/13 (15%) patients, and in 1/13 (3%) the wrap was tightened. CONCLUSION: FLIP measurements can be used intraoperatively to guide decision-making and alter management plan based on objective values. Long-term outcomes and further prospective studies are required to better delineate the value of this technology.

Robotic surgery versus Laparoscopic surgery for anti-reflux and hiatal hernia surgery: a short-term outcomes and cost systematic literature review and meta-analysis.

PURPOSE: The objective of this study is to compare the operative time, intraoperative complications, length of stay, readmission rates, overall complications, mortality, and cost associated with Robotic Surgery (RS) and Laparascopic Surgery (LS) in anti-reflux and hiatal hernia surgery. METHODS: A comprehensive literature search was conducted using MEDLINE (via PubMed), Web of Science and Scopus databases. Studies comparing short-term outcomes and cost between RS and LS in patients with anti-reflux and hiatal hernia were included. Data on operative time, complications, length of stay, readmission rates, overall complications, mortality, and cost were extracted. Quality assessment of the included studies was performed using the MINORS scale. RESULTS: Fourteen retrospective observational studies involving a total of 555,368 participants were included in the meta-analysis. The results showed no statistically significant difference in operative time, intraoperative complications, length of stay, readmission rates, overall complications, and mortality between RS and LS. However, LS was associated with lower costs compared to RS. CONCLUSION: This systematic review and meta-analysis demonstrates that RS has non-inferior short-term outcomes in anti-reflux and hiatal hernia surgery, compared to LS. LS is more cost-effective, but RS offers potential benefits such as improved visualization and enhanced surgical techniques. Further research, including randomized controlled trials and long-term outcome studies, is needed to validate and refine these findings.

Functional results after hiatal repair and gastropexy without fundoplication in patients with paraoesophageal hernia.

PURPOSE: Paraoesophageal hernias (PEH) are associated with a high complication rate and often occur in elderly and fragile patients. Surgical gastropexy without fundoplication is an accepted alternative procedure; however, outcomes and functional results are rarely described. Our study aims to evaluate short-term outcomes and the long-term quality of life after gastropexy as treatment for PEH. METHODS: Single center cohort analysis of all consecutive patients who underwent gastropexy for PEH without fundoplication. Postoperative outcomes and functional results were retrospectively collected. Reflux symptoms developed postoperatively were reported using the validated quality of life questionnaire: GERD-Health Related Quality of Life Qestionnaire (GERD-HRQL). RESULTS: Thirty patients (median age: 72 years (65-80)) were included, 40% classified as ASA III. Main PEH symptoms were reflux (63%), abdominal/thoracic pain (47%), pyrosis (33%), anorexia (30%), and food blockage (26%). Twenty-six laparoscopies were performed (86%). Major complications (III-IVb) occurred in 9 patients (30%). Seven patients (23%) had PEH recurrence, all re-operated, performing a new gastropexy. Median follow-up was 38 (17-50) months. Twenty-two patients (75%) reported symptoms resolution with median GERD-HRQL scale of 4 (1-6). 72% (n = 21) reported operation satisfaction. GERD-HRQL was comparable between patients who were re-operated for recurrence and others: 5 (2-19) versus 3 (0-6), p = 0.100. CONCLUSION: Gastropexy without fundoplication was performed by laparoscopy in most cases with acceptable complications rates. Two-thirds of patients reported symptoms resolution, and long-term quality-of-live associated to reflux symptoms is good. Although the rate of PEH recurrence requiring a new re-intervention remained increased (23%), it does not seem to affect long-term functional results.

Short-term results of laparoscopic anti-reflux surgery with the RefluxStop device in patients with gastro-esophageal reflux disease and ineffective esophageal motility.

PURPOSE: In gastro-esophageal reflux disease (GERD) requiring surgical treatment, concomitant ineffective esophageal motility (IEM) is a decisive factor in surgical planning, due to concern regarding dysphagia. Anti-reflux surgery with the RefluxStop device is a promising technique. We assessed initial feasibility and clinical outcomes of RefluxStop surgery in patients with GERD and IEM. METHODS: Retrospective analysis of patients with GERD, hiatal hernia (HH), and IEM, who underwent surgery with RefluxStop at our institution and achieved 12-month follow-up. Technique feasibility was assessed, in addition to symptom resolution (GERD-HRQL questionnaire), adverse events, HH recurrence, dysphagia, and patient satisfaction. Placement of the device was confirmed by video fluoroscopy on postoperative day 1, and at 3 and 12 months. RESULTS: Between June 2020 and November 2022, 20 patients with IEM underwent surgery with RefluxStop and completed 12-month follow-up. All patients reported typical symptoms of GERD, and 12 had preoperative dysphagia. The median HH length was 4.5 cm (IQR, 3.75-5). The median operating time was 59.5 min (IQR, 50.25-64) with no implant-related intra- or postoperative complications. No HH recurrence was observed. One patient reported persistent left-sided thoracic pain at 11 months post-surgery, which required diagnostic laparoscopy and adhesiolysis. Three patients reported severe postoperative dysphagia: balloon dilatation was performed towards resolution. The mean GERD-HRQL scores improved (from 40.7 at baseline to 4.8 at 3 months and 5.7 at 12 months (p <0.001)). CONCLUSION: RefluxStop surgery was feasible and offered effective treatment for this group of patients with GERD and IEM. All patients had complete resolution or significant improvement of GERD symptoms, and 90% of them were satisfied with their quality of life 1 year after surgery.

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.

Esophagogastroduodenoscopy findings that do no not explain dysphagia are associated with underutilization of high-resolution manometry.

In patients with dysphagia that is not explained by upper endoscopy, high-resolution esophageal manometry (HRM) is the next logical step in diagnostic testing. This study investigated predictors of failure to refer for HRM after an upper endoscopy that was performed for but did not explain dysphagia. This was a retrospective cohort study of patients >18 years of age who underwent esophagogastroduodenoscopy (EGD) for dysphagia from 2015 to 2021. Patients with EGD findings that explained dysphagia (e.g. esophageal mass, eosinophilic esophagitis, Schatzki ring, etc.) were excluded from the main analyses. The primary outcome was failure to refer for HRM within 1 year of the index non-diagnostic EGD. We also investigated delayed referral for HRM, defined as HRM performed after the median. Multivariable logistic regression modeling was used to identify risk factors that independently predicted failure to refer for HRM, conditioned on the providing endoscopist. Among 2132 patients who underwent EGD for dysphagia, 1240 (58.2%) did not have findings to explain dysphagia on the index EGD. Of these 1240 patients, 148 (11.9%) underwent HRM within 1 year of index EGD. Endoscopic findings (e.g. hiatal hernia, tortuous esophagus, Barrett's esophagus, surgically altered anatomy not involving the gastroesophageal junction, and esophageal varices) perceived to explain dysphagia were independently associated with failure to refer for HRM (adjusted odds ratio 0.45, 95% confidence interval 0.25-0.80). Of the 148 patients who underwent HRM within 1 year of index EGD, 29.7% were diagnosed with a disorder of esophagogastric junction outflow, 17.6% with a disorder of peristalsis, and 2.0% with both disorders of esophagogastric outflow and peristalsis. The diagnosis made by HRM was similar among those who had incidental EGD findings that were non-diagnostic for dysphagia compared with those who had completely normal EGD findings. Demographic factors including race/ethnicity, insurance type, and income were not associated with failure to refer for HRM or delayed HRM. Patients with dysphagia and endoscopic findings unrelated to dysphagia have a similar prevalence of esophageal motility disorders to those with normal endoscopic examinations, yet these patients are less likely to undergo HRM. Provider education is indicated to increase HRM referral in these patients.

Exploring Roemheld syndrome: a comprehensive review with proposed diagnostic criteria.

Roemheld syndrome (RS) is a condition that triggers cardiac symptoms due to gastrointestinal compression of the heart. It is often misdiagnosed as other types of cardiac or digestive disorders, leading to unnecessary treatments and reduced quality of life. Here, we provide a thorough review of RS, covering its pathogenesis, etiology, diagnosis, treatment, and outcome. We found that a number of conditions, including gallstones, hiatal hernia, excessive gas, and gastroesophageal reflux syndrome, can cause RS. The symptoms of RS can include chest pain, palpitations, shortness of breath, nausea, vomiting, bloating, and abdominal pain. Clinical history, physical examination, electrocardiograms, and improvement in symptoms following gastrointestinal therapy can all be used to identify RS. We also propose a set of criteria, the IKMAIR criteria, to improve the diagnostic approach for this condition. Dietary changes, lifestyle adjustments, pharmaceutical therapies, and surgical procedures can all be used to control RS. Depending on the underlying etiology and the outcome of treatment, RS has a varying prognosis. We conclude that RS is a complicated and understudied disorder that needs more attention from researchers and patients as well as from medical professionals. We recommend the inclusion of RS in the differential diagnosis for individuals with gastrointestinal problems and unexplained cardiac symptoms. Additionally, we advise treating RS holistically by attending to its cardiac and gastrointestinal components.

The role of anterior gastropexy in elderly Japanese hiatal hernia patients.

PURPOSE: As Japanese society ages, the number of surgeries performed in elderly patients with hiatal hernia (HH) is increasing. In this study, we examined the feasibility, safety, and potential effectiveness of the addition of anterior gastropexy to hiatoplasty with or without mesh repair and/or fundoplication in elderly Japanese HH patients. METHODS: We retrospectively evaluated 39 patients who underwent laparoscopic HH repair between 2010 and 2021. We divided them into 2 groups according to age: the "younger" group (< 75 years old, n = 21), and the "older" group (≥ 75 years old, n = 18). The patient characteristics, intraoperative data, and postoperative results were collected. RESULTS: The median ages were 68 and 82 years old in the younger and older groups, respectively, and the female ratio was similar between the groups (younger vs. older: 67% vs. 78%, p = 0.44). The older group had more type III/IV HH cases than the younger group (19% vs. 83%, p < 0.001). The operation time was longer in the older group than in the younger group, but there was no significant difference in blood loss, perioperative complications, or postoperative length of stay between the groups. The older group had significantly more cases of anterior gastropexy (0% vs. 78%, p < 0.001) and less fundoplication (100% vs. 67%, p = 0.004) than the younger group. There was no significant difference in HH recurrence between the groups (5% vs. 11%, p = 0.46). CONCLUSIONS: The addition of anterior gastropexy to other procedures is feasible, safe, and potentially effective in elderly Japanese patients with HH.