Hill Repair—Why It Is Still Relevant and Should Be Taught?

The Hill repair for gastroesophageal reflux disease, though effective, durable, and in some regards a superior repair, has unfortunately seen less widespread adoption in the laparoscopic era relative to Nissen and Toupet fundoplications. Some purported objections to the Hill repair include conceptual and technical barriers, need for intraoperative manometry, and lack of clear-cut advantages. However, it has proven to be remarkably durable at 20 years and beyond relative to other repairs, with a low side-effect profile; there are also unique applications of the Hill repair and Hill sutures which broaden one’s armamentarium for managing the spectrum of patients with reflux disease. Lastly, understanding its anatomic components strengthens the surgeon’s knowledge of the anatomy and function of the gastroesophageal junction and antireflux repairs.

P68 DEFINITIVE RESULTS OF THE HELLER MYOTOMY ASSOCIATED WITH THE DOR FUNDOPLICATION PERFORMED WITH INTRAOPERATIVE MANOMETRY FOR THE PRIMARY SURGICAL TREATMENT OF ESOPHAGEAL ACHALASIA: ONE CENTER EXPERIENCE

Objective In 1978 the Heller-Dor operation was proposed to accomplish new concepts of surgical pathophysiology: to abolish the lower esophageal sphincter with the division of the U-and sling fibers of the lesser gastric curvature, to prevent GER with an effective but not too effective partial fundoplication which protects the myotomy surface. Proponents performed this operation under intraoperative manometric control. We report on results we achieved in the period 1978-2016. Methods The Heller-Dor was performed in 367 patients (laparotomy 1978-1993, 209, 96 men; median age, 45 years; IQR 31.8–59.4 years, laparoscopy 1994-2016,158, 78 men; median age, 48 years; IQR 35.5–63.7 years; age p=0.166; gender p=0.346). Intraoperative manometry was performed and interpreted according to standard criteria. Follow-up consisted of periodical interview, endoscopy, barium swallow, which reports were graded in semiquantitative scales of evaluation. Results Mortality occurred in 1/209 (heart failure), 1/158 (coagulation disorder). Median follow-up was 193 months (IQR 137.1–273.4 months) in the laparotomy group, 95 months (IQR 71.1–140 months) in the laparoscopy group. Myotomy achieved the complete abolition of the high pressure zone in 100% of the patients in both groups. In the laparotomy group poor results were assessed in 22 (10.5%), for esophagitis in 15 and recurrent dysphagia in 7 with sigmoid achalasia. In the laparoscopy group poor results occurred in 7 (4.3%), 5 for esophagitis and 2 for recurrent dysphagia in sigmoid achalasia. In the second period the fundoplication was always sutured to the diaphragm to avoid slipping, the number of sigmoid esophagus cases decreased significantly. In the laparotomy group, gastroesophageal reflux and esophagitis appeared after a median period of 74.8 months since myotomy, recurrent dysphagia was evident shortly after surgery. Conclusions In light of the timing of appearance of causes of poor results assed in the laparotomy group, we consider the 95.7% of satisfactory results achieved with the laparoscopic Heller-Dor after 95 months median follow up, the indicator of potential of cure of this operation.