Does Mesh Augmentation of the Hiatal Repair with Gore Bio-A® Improve Symptomatic Outcomes in Laparoscopic Fundoplication?

Introduction: Laparoscopic fundoplication is performed for the management of symptomatic hiatus hernias and gastro-oesophageal reflux disease (GORD) refractory to medical therapy. We adopted the use of Gore Bio-A® for selected laparoscopic hiatus hernia repairs in 2011 and with this case series aimed to establish whether mesh augmentation affects symptomatic outcomes. Methods: A retrospective review of prospectively collected data from all laparoscopic fundoplications performed by a single surgeon between October 2011 and January 2013 was performed. Patient specific data were entered into a proforma and analysed using Microsoft ExcelTM. Patient reported outcomes were assessed with a system specific quality of life questionnaire (GORD-HRQL) both pre and post-operatively. Results: Twenty-three patients underwent laparoscopic fundoplication during the study period. Gore Bio-A® re-enforcement of the hiatal repair was used in 14 patients and was the preferred option for those with pre-operative evidence of a large hiatus hernia. Whilst overall there was a statistically significant difference between pre and post-operative scores (21 vs 0, p=<0.0001, Mann-Whitney U test), there was no clear difference observed in pre-operative scores (22 vs 20, p=0.21, Mann-Whitney U test), postoperative scores (0 vs 0, p=0.92, Mann-Whitney U test) or symptom improvement (21 vs 20, p=0.24, MannWhitney U test) between the mesh and non-mesh groups. Conclusions: Augmentation of the hiatal repair with biosynthetic mesh is safe, feasible and may contribute to improved symptomatic outcomes in selected cases with a large hiatus hernia. We suggest a further assessment with a larger randomised sample and long term follow-up for definitive evaluation.

O168 VERY LONG-TERM (5-19 YEARS) FOLLOW-UP OF PARAESOPHAGEAL HERNIA REPAIR: PERMANENT MESH vs STANDARD CRUROPLASTY

Aim Aim of this comparative study was to analyze very long-term safety, symptomatic outcomes and rate of recurrence in a cohort of patients who underwent large hiatus hernia repair with or without synthetic mesh. Background & Methods The use of a permanent mesh to reinforce the hiatus could reduce the rate of radiological and symptomatic recurrences after laparoscopic paraesophageal hernia repair. However, strictures and even erosions into the esophageal lumen have been reported. Aim of this comparative study was to analyze very long-term safety, symptomatic outcomes and rate of recurrence in a cohort of patients who underwent large hiatus hernia repair with or without synthetic mesh. Observational cohort study using a prospectively maintained database. From November 2001 to September 2005, 39 consecutive patients underwent laparoscopic repair and fundoplication for large hiatus hernia (> 5 cm). Thirteen patients (Group M) received crural reinforcement with non-absorbable mesh, while 26 patients (Group S) underwent standard cruroplasty. Mesh-related complications, postoperative symptoms and hernia recurrence at very long-term follow-up through upper gastrointestinal endoscopy, GERD-HRQL and FOREGUT questionnaires. Results There were 23 women and 16 men, with a median age of 60 years (range 28-81). The hernia size was similar in both groups. Postoperative complications occurred in 2 patients (5.1%) and there was no mortality. The median long-term follow-up was 168 months (range 139-197 months, IQR: 23.5). At last follow-up visit, occasional (once a month) dysphagia occurred in 23% of Group M patients, but none required endoscopic dilatation. The hernia recurrence rate was 0. No short or long-term complications related to the use of the mesh were recorded. In group S, non of patients, complained of dysphagia, whereas 2 (7.7%) patients complained of occasional reflux symptoms and other 2 (7.7%) of dyspepsia. In 4 patients (15.4%), a small hiatus hernia recurrence or a partially slipped fundoplication was noted, but all patients were asymptomatic. GERD-HRQL scores significantly decrease in both groups (p<0.05). Conclusion Laparoscopic antireflux surgery with permanent prosthetic mesh is an effective and safe procedure in carefully selected patients with large hiatal hernia.

P169 COMPARISON OF LAPAROSCOPIC TOUPET FUNDOPLICATION AND MAGNETIC SPHINCTER AUGMENTATION IN PATIENTS WITH 3-5 CM HIATUS HERNIA

Aim To compare quality of life in patients with large hiatus hernia undergoing laparoscopic Toupet fundoplication and magnetic sphincter augmentation. Background and Methods Laparoscopic Toupet fundoplication (LTF) and laparoscopic magnetic sphincter augmentation (MSA) have been compared in a previous retrospective study (Asti E et al, Medicine, 2016) in patients with small hiatal hernia (<3 cm). There is no universal consensus in the use of MSA in patients with large hiatus hernia. This is an observational, retrospective, comparative cohort study. Patients with <3 cm or >5 cm hiatus hernia measured by endoscopy and barium swallow study and those with previous esophago-gastric surgery were excluded. The primary outcome was quality of life based on the Gastro-Esophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) questionnaire. Secondary outcomes were proton pump inhibitors (PPI) use, incidence of dysphagia and gas-related symptoms, and hiatus hernia recurrence rate. Results Between March 2007 and June 2018, 150 patients with GERD met the inclusion criteria; 88 underwent a LTF and 62 a MSA procedure. Both groups had similar preoperative features. The mean follow-up was 64 months and all patients were followed for at least one year after surgery. There was no statistically significant difference between LTF and MSA in GERD-HRQL scores (p=0.178), PPI use (p=0.327), gas-related symptoms (p=0.162), dysphagia (p=0.254), and reoperation rate (p=0.167). Conclusion Both LTF and MSA have similar safety profile and disease-specific quality of life in patients with large hiatal hernia.

Gastric perforation through a hiatus hernia into the left lung in an 84-year-old woman

An 84-year-old woman presented to the emergency department with a sudden onset of chest pain, shortness of breath and vomiting. She had a medical history of hiatus hernia, gastro-oesophgeal reflux disease and asthma only, but had several recent courses of oral steroids to treat her asthma. Initially she was hypoxic, tachycardic and normotensive. ECG was normal, chest X-ray showed a hiatus hernia and right middle zone consolidation. Inflammatory markers were normal. CT angiogram was performed to exclude aortic pathology, for which it was negative. It did however show a large hiatus hernia which had perforated and was communicating with the left lung. The patient deteriorated clinically and became hypotensive and more hypoxic. She was transferred to the intensive care unit but died 36 hours later as she was too unwell to undergo any exploratory surgery.

Rectal varices due to chronic inferior mesenteric vein thrombosis caused by external compression in a large hiatus hernia containing the pancreas

A 79-year-old woman presented with a large fresh rectal bleed. Computed tomography revealed that she had a large type IV hiatus hernia, which contained the stomach and pancreas. Compression of the inferior mesenteric vein and splenic vein had led to thrombosis within these vessels and retrograde flow within the inferior mesenteric vein. This had led to the formation of portosystemic rectal varices. Ectopic varices occasionally form in the rectum, often in the context of liver cirrhosis. At the time of writing, ours is the first reported case of portosystemic rectal varices formulated in response to obstruction of vessels within a hiatus hernia.

PS01.068: LAPAROSCOPIC MANAGEMENT OF LARGE HIATAL HERNIA WITH SIMPLY SUTURE CLOSURE

Background Laparoscopic approach has been demonstrated as safe and effective surgical access in approaching gastroesophageal reflux disease (GERD) and hiatal hernia repair. Several studies have proposed for repairing that hiatal hernia, especially large hiatus with mesh reinforcement. The objective of our study was to evaluate the effect of simple suture closure in management of large hiatus hernia (> 5 cm). Methods Between September 2012 to February 2018, 32 patients who underwent laparoscopic large hiatal hernia (> 5 cms hernia defect) repair by simply suture closure were included in our study. Different anti-reflux surgery was performed according to esophageal function examination. Peri-operative data and complications were retrospectively reviewed. 30-months complications and symptom control at 1 year were assessed by GERD-HRQL score and PPI use. Results 29 cases were performed completely with laparoscopy, with 3 cases with da Vinci Surgical System and 1 case through left thoracotomy. Hiatal hernia of all patients was repaired by simply suture closure, 24 cases were successfully operated with Nissen, 5 cases with, 2 cases with Dor and 1 case with Belsey Mark IV Fundoplication. At 3 months postoperatively follow-up, 94% of patients were off anti-reflux medications, abdominal pain occurred in 8.8(3 cases) of patients, mild dysphagia occurred in 1 patient, and 2 patients with severe dysphagia required dilator therapy. Two patients (5.9%) developed recurrence on routine follow up. Conclusion Our study showed simply suture closure was a feasible technique for repair large hiatus hernia. The advantages between laparoscopic mesh cruroplasty and simply suture closure for large hiatal hernia repair, randomised controlled trials are needed. Disclosure All authors have declared no conflicts of interest.