O-EGS01 Emergency Giant Hiatal Hernia Repairs: Experiences in fundoplication versus gastropexy

Background An emergency presentation with a hiatal hernia tends to be life-threatening with a high associated mortality rate. Operative management aims to reduce the herniated stomach, dissect the hernial sac and reapproximate the crura. This will often be followed by a fundoplication or a gastropexy to reduce the risk of recurrence. This study compares the recurrence rates between patients who underwent fundoplication and gastropexy. Methods Over 8 years, from October 2012 to November 2020, 80 patients were admitted to a tertiary oesophagogastric centre requiring emergency surgery to repair a giant hiatal hernia. We conducted a retrospective review and analysis of their admission and follow-up. The primary outcome measure was acute and post-discharge symptomatic recurrence of hiatal hernia, and secondary outcomes were patient mortality and readmission rate. Results Of the 80 patients requiring emergency hiatal hernia surgery, 38% had fundoplication procedures, 53% had gastropexy, and 3% had both (n = 30, 42, 2 respectively). One patient had neither, and 6% (n = 5) patients had a complete or partial resection of the stomach due to necrosis, so they were not suitable for gastropexy or fundoplication. Eight patients (10%) had symptomatic recurrence of hiatal hernia requiring a repeat operation; three within the index admission, five post-discharge. 50% had undergone fundoplication, 38% underwent gastropexy and 13% underwent a resection (n = 4, 3, 1)(p-value=0.5). 19% (n = 15) patients were readmitted. Post-operative mortality was 6% (n = 5). Conclusions Emergency surgery for giant hiatal hernias is usually complex, and a significant cohort of these patients are elderly with significant co-morbidities. Nevertheless, there is no conclusive evidence in the literature favouring fundoplication versus gastropexy. Choice of technique is influenced by the surgeon’s experience and perioperative factors that influence the duration of the operation. This review, which includes the largest cohort of patients available in the literature, demonstrates that surgical technique does not influence the symptomatic recurrence rate in our patient group.