P-BN11 Patient Reported Outcomes of Phasix™ ST Mesh for Laparoscopic Hiatal Hernia Repair

Background Laparoscopic hiatal hernia repair continues to suffer from high recurrence rates, which has prompted the use of mesh reinforcement by some surgeons. Use of mesh however remains controversial due to its association with complications such as erosion, fibrosis and oesophageal stenosis. Biosynthetic Poly-4-Hydroxybutyrate Phasix™ ST mesh is an emerging technology which combines the durability of synthetic mesh with the remodelling characteristics of biologic mesh and includes an anti-adhesion hydrogel barrier. There is a paucity of patient reported outcome data for Phasix™ ST mesh. This study evaluates early patient reported outcomes following laparoscopic hiatal hernia repair with Phasix™ ST mesh. Methods Adult patients undergoing laparoscopic hiatal hernia repair with Phasix™ ST mesh between July 2020 to June 2021 at our institution were identified. Prospective data, including demographic data and complication rates, was collected from electronic and paper medical records. The 12-Item Short Form Survey (SF-12) was administered to assess quality of life pre-operatively and post-operatively with a minimum 30-day follow-up. Results Fourteen patients (12 female, one male) were included with a median age of 66 years (range 52-79). There were no intraoperative complications, mesh-related complications, re-operation, re-admission, or recurrence at a median follow-up of 4 months (IQR 4.0). Median physical health component (PHC) score was 32.7 (IQR 6.2) at baseline and increased to 41.6 (IQR 13.7) post-operatively. Median difference in PHC score was +11.4 (IQR 10.7). Median mental health component (MHC) score was 39.8 (IQR 12.5) at baseline and increased to 57.4 (IQR 8.2) post-operatively. Mean difference in MHC score was +17.7 (IQR 15.9). Conclusions To our knowledge, this is the first report of outcomes on the use of Phasix™ ST mesh for laparoscopic hiatal hernia repair in the United Kingdom. Our study found that it is associated with improvements in both physical and mental quality of life in the short-term post-operative follow-up, although there is some variation in the degree of improvement reported.

The Outcomes of Performing Partial Fundoplication Based on Endoflip Versus Manometric Findings

Background The surgical management of gastroesophageal reflux disease (GERD) involves extensive diagnostic studies and sophisticated surgical techniques. The workup should be comprehensive and purposeful. High resolution impedance manometry (HRIM) provides valuable information regarding peristalsis and lower esophageal sphincter relaxation. The disadvantages of HRIM such as intolerance or inability to pass the catheter led to its selective use or even omission especially in laparoscopic hiatal hernia repair with partial fundoplication. This pragmatic approach risks missing motility disorders in patients with secondary reflux symptoms related to achalasia or scleroderma. Endolumenal functional lumen imaging probe (endoFLIP) can fill this void as it evaluates the dynamics of the esophagogastric junction under sedation. This study aims to compare the outcomes of preoperative use of HRIM vs endoFLIP for laparoscopic repair of hiatal hernia with partial fundoplication. Methods This is a retrospective cohort study for consecutive patients who underwent antireflux surgery with partial fundoplication between July 2018 and February 2021. Preoperative and postoperative outcomes were compared between two cohorts of patients: those with preoperative HRIM and those with preoperative endoFLIP. Results A total of 72 patients were evaluated, 41 had preoperative HRIM and 31 had endoFLIP. There was no statistically significant difference in their age, sex, BMI, duration of GERD symptoms, or proton pump inhibitors use. The endoscopic findings of esophagitis, hiatal hernia, and Hill’s grade were comparable. There was no difference in the American Society of Anesthesiology classification or the choice of antireflux surgery. The improvement of postoperative GERD scores and dysphagia subscore was similar between the two groups. Conclusion Performing partial fundoplication based on endoFLIP evaluation of the dynamics of the esophagogastric junction is safe and does not increase postoperative dysphagia compared to preoperative manometric use. Randomized prospective studies are needed to confirm the findings of this study.

532 OUTCOME OF QUILICI’S HEPATIC SHOULDER PROCEDURE TO AUGMENT LAPAROSCOPIC HIATOPLASTY IN LARGE OR RECURRENT HIATAL HERNIA

Laparoscopic hiatoplasty and fundoplication is the gold standard of surgical treatment of GERD and hiatal hernia. However, the main drawback of laparoscopic hiatal hernia repair is a substantial recurrence rate. Hence, prosthetic meshs have been used to reduce the risk for recurrence. But meshs may cause major complications. As a consequence we adopted the hepatic shoulder plasty described by Quilici to augment the hiatal hernia repair in patients with a high risk for hernia recurrence. Methods Patients with large (>4 cm) axial hiatal hernia, giant paraesophageal or with recurrent hernia consecutively underwent laparoscopic hernia repair with crural sutures and hepatic shoulder plasty. A Toupet or a floppy Nissen fundoplication was added. In patients with giant paraesophageal hernia the hernia sack was resected. Perioperative complications were recorded. Follow-up comprised endoscopy and/or radiography and QoL-evaluation with the Eypasch score (GIQLI). Results Between 2012 and 2018 51 patients (mean age 71 years, 65% female) underwent Quilici’s procedure. Among them 33,3% had one or more previous hiatal hernia repair. There were no conversions. Postoperative complication rate was 7.8%. At follow-up after 2 years 6 recurrences (12%) were encountered, 4 of them were symptomatic (8%). One patient underwent reoperation due to hernia recurrence. In 84% QoL was significantly improved at follow-up. Conclusion In patients with high risk of recurrence, biological augmentation of the hiatal closure with the left lobe of the liver may be a valuable alternative to prosthetic reinforcement. We observed no complication attributable to liver lobe transposition.

704 OBSERVATIONAL MEDICAL TREATMENT OR SURGERY FOR GIANT PARAOESOPHAGEAL HIATAL HERNIA IN ELDERLY PATIENTS.

Giant paraoesophageal hernias (GPHH) occur frequently in the elderly, account for about 5–10% of all hiatal hernias. Up to now persists the controversy between expectant medical treatment versus surgical treatment, regarding which is the most appropriate option depending on the presence or absence of symptoms. The aim of this study is to assess whether an indication for surgical repair of PHH is possible in older patients adequately evaluated before surgerymptoms. Methods Patients and method: Prospective study including patients hospitalized from January 2015 to December 2019 with GPHH more than 70 years old, comparing 2 group of patients which were separated in: Group A including a cohort of 23 patient in whom observational and conservative was indicated by gastroenterologist and Group B includes 66 patients in whom elective laparoscopic hiatal hernia repair was indicated at the moment of its diagnosis. Results Charlson’s score and ASA II or III were more frequent in group A. Emergency hospitalization was exclusively seen in group A and elective surgery in Group B. Symptomatic patients were seen in both groups (86.9 and 86.4% respectively). Symptoms period before the hospitalization was more prolonged in group A (21.8 + 7.8 vs 6.2 + 3.5 years) (p = 0.001). Symptoms of acute complications were seen frequently in Group A UCI and hospital stay were significantly more prolonged in Group A due to sepsis, emergency surgery and complications. In hospital mortality occurred in 5/23 patients (21.7%) in group A vs 1/66 patients (1.5%), Group B. Conclusion

Preoperative measurement of the hiatal surface with MDCT: impact on surgical planning

Objective To evaluate the accuracy and reproducibility of hiatal surface area (HSA) measurement on dedicated multidetector computed tomography (MDCT) acquisition, in patients, previously subjected to laparoscopic sleeve gastrectomy (LSG), and affected by gastroesophageal reflux disease (GERD). Intraoperative HSA measurement was considered the reference standard. Methods Fifty-two candidates for laparoscopic hiatal hernia repair were prospectively included in the study. MDCT images were acquired during swallowing of oral iodinated contrast media and during strain. Measurements were performed by nine readers divided into three groups according to their experience. Results were compared with intraoperative measurements by means of Spearman correlation coefficient. Reproducibility was evaluated with intra- and interreader agreement by means of weighted Cohen’s kappa and intraclass correlation coefficient (ICC). Results Significant differences between MDCT and intraoperative HSA measurements were observed for swallowing imaging for less experienced readers (p = 0.037, 0.025, 0.028 and 0.019). No other statistically significant differences were observed (p > 0.05). The correlation between HSA measured intraoperatively and on MDCT was higher for strain imaging compared to swallowing (r = 0.94—0.92 vs 0.94—0.89). The overall reproducibility of MDCT HSA measurement was excellent (ICC of 0.95; 95% CI 0,8993 to 0,9840) independently of reader’s experience Conclusion HSA can be accurately measured on MDCT images. This method is reproducible and minimally influenced by reader experience. The preoperative measurement of HSA has potential advantages for surgeons in terms of correct approach to hiatal defects in obese patient.

Tapasztalataink a rekeszsérvek laparoszkópos sebészetével

Összefoglaló. Bevezetés: A hiatus hernia egy anatómiai betegség; gyakoribb előfordulása idősebbeknél jelezheti, hogy a betegség idővel előrehalad, súlyosbodik. Elhanyagolt esetben szövődmények alakulhatnak ki, melyek növelhetik a perioperatív mortalitást. Célkitűzés: A laparoszkópos hiatusrekonstrukciók sebészetében szerzett műtéti tapasztalataink ismertetése mellett igyekeztünk statisztikailag alátámasztható korrelációt találni a rekeszizom-defektus anatómiai paraméterei, valamint a betegek életkora között. Módszer: Retrospektív tanulmányunk keretében elemeztük azon betegeinket, akik laparoszkópos hiatus hernia műtéten estek át egy 58 hónapos (2016. január–2020. október) vizsgálati periódus során. A rekeszi defektus méreteit endoszkópos vonalzóval a műtét közben megmértük, a hiatus oesophagei felszínét standard matematikai formula segítségével számoltuk ki. A sürgősséggel műtétre kerülő betegeink adatait külön elemeztük. Statisztikai analízis: A defektus mérete és a betegek életkora és magassága közötti korrelációt a Spearman-féle ró (ρ)-korreláció segítségével állapítottuk meg. A szignifikanciaszint p≤0,05 volt. Eredmények: Az elektív csoportban 142 operált páciensből 47 beteg mérési adatai feleltek meg a kritériumoknak. Az átlagéletkor 64,7 ± 12,7 év volt, 33 páciens volt nő (70,2%), az átlagos testtömegindex 28,8 ± 5,5 kg/m2 volt. A defektus haránt átmérője és felszíne szignifikáns pozitív korrelációt mutatott a betegek életkorával (p≤0,05). Akut indikációval 5 beteg került műtétre; a defektus méretét illetően hasonló eredményeket tapasztaltunk, mint az elektív csoportnál, 2 esetben azonban súlyos szövődmények alakultak ki. Következtetés: A betegség mögött húzódó anatómiai okok jobb megértése és a megfigyeléseink alapján módosított sebésztechnika reményeink szerint csökkentheti a hosszú távú kiújulások számát a jövőben. Az időben elvégzett elektív beavatkozás alacsonyabb mortalitással, kevesebb szövődménnyel és rövidebb hospitalizációval jár együtt. Orv Hetil. 2021; 162(19): 754–759. Summary. Introduction: Hiatal hernia is an anatomical disease, and the higher incidence for elderly patients suggests that it is progressing over time. Neglected cases can cause serious complications, raising perioperative mortality. Objective: We are presenting our experience in laparoscopic hiatal reconstructions. Our main goal is to find a statistical correlation between the anatomical parameters of the hiatal defect and the patients age. Method: Surgical data were reviewed retrospectively for patients who underwent laparoscopic hiatal hernia repair between January 2016 and October 2020. Dimensions of the hiatal defect were measured intraoperatively with an endoscopic ruler. The defect size was calculated using a standard formula. The acute surgeries were analyzed as a separate arm of the study. Statistical analysis: The correlation between the patients age and the size of the defect were calculated using Spearman’s rho (ρ) correlation. The level of significance was p≤0.05. Result: In the elective group, out of 142 patients 47 met the inclusion criteria. The mean age was 64.7 ± 12.7 years, 33 patients were women, and the mean BMI was 28.8 ± 5.5 kg/m2. Patient age showed significant positive correlation with the transverse dimension and the size of the hiatal defect. 5 patients underwent surgery due to acute indications. We found similarities in the size of the defects; at 2 patients we documented severe complications. Conclusions: A better understanding of the underlying anatomical disorders and the consecutively modified surgical technique will hopefully reduce the long-term recurrencies in the future. The elective surgery performed in the right time results in lower mortality, less complications and shorter hospitalization time. Orv Hetil. 2021; 162(19): 754–759.

Systematic Review of Laparoscopic versus Robotic Hiatal Hernia Repair

To investigate, the results which contrasted robotic assisted hiatal hernia repair (RA-HHR) against laparoscopic hiatal hernia repair (LPHHR) we conducted a review. The results indicated feasibility and safety associated with the robotic method. The comparison of studies did not reveal variations in mortality and morbidity rate, conversion rate, ICU stay, 1-month mortality, and post-operative complications, quality of life between the RA-HHR cohort and LPHHR cohort.