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.

521 PREOPERATIVE BOTULINUM TOXIN TYPE A: PROPOSAL OF A NEW STRATEGY FOR GIANT HERNIA MANAGEMENT

Botulinum toxin is already in use to treat abdominal wall giant hernia. The concept is to reduce pressure e create new space in the abdominal compartiment after the surgey. We show a case that a similar aproach was used to treat giant hiatal hernia. Methods We used botulinum toxin 4 weeks prior the surgery to increase de abdominal compartment. it was checked in a ct scan. Results The surgey was performed with a hiatoplasty, fundoplication and a gastropexy. Conclusion The use of botulinum seens to be a new stragy for selected cases. Video https://www.dropbox.com/s/td7fr3a6buejqnd/Bianchi%20ET%20botox.wmv?dl=0.

Comparison of the Effectiveness of "Оnlay" Plastics of Large and Giant Hernias of The Esophageal Aperture of the Diaphragm with a Polypropylene Mesh Implant and a Biocarbon Double-Layer Mesh Implant

This article is a continuation of a series of studies on the optimization of techniques and methods of surgical operations for hernias of the esophageal aperture of the diaphragm and is based on the use of the author’s development of a model of a two-layer biocarbon mesh implant. The purpose of this study is to highlight the immediate and long-term results of using a double-layer biocarbon mesh implant in comparison with the standard method of using a polypropylene implant when operating patients with large and giant hiatal hernia. All patients were split into 2 research groups that underwent alloplasty with various implants: Group I of 221 patients who underwent alloplasty with a polypropylene mesh implant (171 patients with large hernias of 10-20 cm2) and 50 patients with giant hernias of the esophageal orifice with the area of the hernial defect exceeding 20 cm2); Group II of 79 patients who underwent an original alloplasty with a bi-layer biocarbon mesh implant (50 patients with large hernias and 29 patients with giant hernia of the esophageal orifice). Postoperative complications were classified according to the Clavien-Dindo scale. De Meester index was used as a comparison criterion. The article discusses the results of operations of 300 patients for large and giant hernias of the esophageal aperture of the diaphragm, of which 79 were operated on using a prototype biocarbon double-layer mesh implant according to the author's patent. The paper presents immediate and long-term results. The results of surgical treatment are pilot and representative, which determine the further tactics and direction of improving operations to remove large and giant hernias of the esophageal opening of the diaphragm. For the first time, data on the use of the author's development of a bi-layer biocarbon mesh implant are presented and compared with a polypropylene mesh implant during an "on-line" plastic repair of large and giant hiatal hernia. Significant differences were obtained in relapses of all types in favor of a biocarbon mesh implant (5,6 versus 22,8%; p < 0,0001; Fisher's exact test).