Magnetic Sphincter Augmentation In Patients With Paraesophageal Hernia Vs. Large Sliding Hiatal Hernia: Comparison of Clinical Outcome And Complexity Of The Surgery

Introduction: Recent studies encourage the use of magnetic sphincter augmentation (MSA) in patients with large sliding hiatal hernia (LHH). However, the utility of MSA in patients with paraesophageal hernia (PEH) is poorly studied. The aim of this study is to compare the outcome and complexity of surgery in patients with PEH to those with LHH. Methods: A total of 37 (65% female) patients underwent PEH repair with MSA in our institution between 2013 and 2019. A group of 37, age/sex matched patients with LHH (≥ 4 cm) who underwent MSA formed the control group. The clinical outcome and the complexity of the surgery were then compared between groups. Results: At a median follow-up of 25.3 (17–35) months, there was significant improvement in the GERD-HRQL total-scores for PEH (18 vs. 3, p < 0.001) and LHH (26 vs. 4, p < 0.0001) patients when compared to preoperative values. The PEH group was similar to LHH group in regard to pH-normalization (71% vs. 64%, p = 0.76) and freedom from PPI (94.4% vs. 91.9%, p = 1.00). Small asymptomatic hernia recurrence was seen in 19% and 18% of LHH and PEH patients, respectively (p = 0.546). One patient (3%) required surgical intervention for symptomatic recurrence in each group. The rate of dysphagia and need for dilation were similar between the groups. No significant differences in operative time, blood loss, and hospital stay were detected between patients with PEH and those with LHH. However, there was a trend toward higher necessity for additional operative maneuvers (40.5% vs 13.5%, p = 00.17) and longer hospital stay in PEH. Conclusion: Despite the inherent differences between LHH and PEH, repair of hernia and MSA results in high rate of favorable outcome and low rate of recurrence in both groups. GERD symptom control, freedom from PPI and improvement in quality of life are comparable. However, the greater need for additional surgical maneuvers and longer hospital stay reflect the greater complexity of procedures for repair of PEH with MSA.

Small hiatal hernia and postprandial reflux after vertical sleeve gastrectomy: A multiethnic Asian cohort

Background Laparoscopic vertical sleeve gastrectomy (LSG) is a popular bariatric procedure performed in Asia, as obesity continues to be on the rise in our population. A major problem faced is the development of de novo gastroesophageal reflux disease (GERD) after LSG, which can be chronic and debilitating. In this study, we aim to assess the relationship between the presence of small hiatal hernia (HH) and the development of postoperative GERD, as well as to explore the correlation between GERD symptoms after LSG and timing of meals. In doing so, we hope to gain a better understanding about the type of reflux that occurs after LSG and take a step closer towards effectively managing this difficult to treat condition. Methods We retrospectively reviewed data collected from patients who underwent LSG in our hospital from Dec 2008 to Dec 2016. All patients underwent preoperative upper GI endoscopy, during which the identification of hiatal hernia takes place. Patients' information and reflux symptoms are recorded using standardized questionnaires, which are administered preoperatively, and again during postoperative follow up visits. Results Of the 255 patients, 125 patients (74%) developed de novo GERD within 6 months post-sleeve gastrectomy. The rate of de novo GERD was 57.1% in the group with HH, and 76.4% in the group without HH. Adjusted analysis showed no significant association between HH and GERD (RR = 0.682; 95% CI 0.419 to 1.111; P = 0.125). 88% of the patients who developed postoperative GERD reported postprandial symptoms occurring only after meals, and the remaining 12% of patients reported no correlation between the timing of GERD symptoms and meals. Conclusion There is no direct correlation between the presence of small hiatal hernia and GERD symptoms after LSG. Hence, the presence of a small sliding hiatal hernia should not be exclusion for sleeve gastrectomy. Electing not to perform concomitant hiatal hernia repair also does not appear to result in higher rates of postoperative or de novo GERD.

The Benefits of Nonablative Radiofrequency Treatment of the Lower Esophageal Sphincter After Transoral Incisionless Fundoplication

Non-ablative radiofrequency treatment to the lower esophageal sphincter (Stretta) has been shown to be beneficial after failed Nissen fundoplication. To our knowledge, this is the first report of Stretta after transoral incisionless fundoplication (TIF). This patient is a 17-year-old female who had gastroesophageal reflux disease (GERD) symptoms for 9 years. She presented with heartburn, regurgitation, and epigastric discomfort. She used omeprazole for 9 years. Esophagogastroduodenoscopy (EGD) showed a 2 cm sliding hiatal hernia and DeMeester score of 25. The GERD Health-Related Quality of Life (GERD-HRQL) score on omeprazole was 14. Patient underwent a TIF procedure, which was uneventful. Her symptoms resolved, and she discontinued omeprazole. Six months later, she had episodes of repeated violent vomiting followed by recurrence of regurgitation, nausea, bloating, and dysphagia. She resumed omeprazole. Diagnostic workup included gastric emptying scan, which was normal. EGD showed no hiatal hernia and partial disruption of the TIF valve. DeMeester score was 36.3. Esophageal manometry with impedance showed intact peristalsis and normal relaxation of the lower esophageal sphincter. The patient underwent Stretta, which was uneventful. The previous TIF did not increase the complexity of the procedure. There were no immediate or postoperative complications. The patient reported gradual improvement of her symptoms with complete resolution 2 months postoperatively. She discontinued omeprazole. The GERD-HRQL score 17 months post-Stretta was 0. This case highlights the feasibility, safety, and efficacy of performing Stretta following TIF. It provides an endoluminal alternative to complex revisional antireflux surgery. Prospective studies with longer follow-up are required to validate this concept.

Strangulated Morgagni hernia and sliding hiatal hernia: A rare association.

Morgagni hernias are congenital diaphragmatic hernias accounting for 3 to 5% of all diaphragmatic hernias. The association with hiatal hernia is rarely reported in the literature. We report another case of a right Morgagni hernia revealed by an acute intestinal obstruction associated with a sliding hernia hiatal. The aim is to discusses the clinical presentation and to highlight the management characteristics.