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Concept: Hiatus hernia

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BACKGROUND: Revision antireflux surgery and large hiatal hernia repair require extensive dissection at the gastroesophageal junction. This may lead to troublesome symptoms due to delayed gastric emptying, eventually requiring gastrectomy. The aim of this study was to evaluate the outcome of gastrectomy for severely delayed gastric emptying after large hiatal hernia repair or redo antireflux surgery. METHODS: Eleven patients were treated between 1995 and 2010 and entered in the study. Preoperative and operative data were retrospectively collected. Standardized questionnaires were sent to all of the patients to evaluate symptomatic outcome. RESULTS: The primary intervention was Nissen fundoplication in nine patients, Toupet fundoplication in one, and cruroplasty in another. The repairs were for refractory gastroesophageal reflux disease in five patients and a symptomatic large hiatal hernia in six. Subsequent gastrectomy was partial in four patients, subtotal in six, and total in one. There was one minor postoperative complication. After a mean (±SD) duration of 102 ± 59 months, nine patients were available for symptomatic follow-up. Eight patients experienced daily symptoms related to dumping. Daily symptoms indicative of delayed gastric emptying were present in seven patients at follow-up. Mean general quality of life was increased from 3.8 ± 2.2 before gastrectomy to 5.4 ± 1.8 at follow-up. Eight patients reported gastrectomy as worthwhile. CONCLUSION: Gastrectomy after previous antireflux surgery or large hiatal hernia repair is safe with the potential to improve quality of life. Although upper gastrointestinal symptoms tend to persist, gastrectomy can be considered a reasonable, last-resort surgical option for alleviating upper gastrointestinal symptoms after this kind of surgery.

Concepts: Abdomen, Hiatus hernia, Cardia, Surgery, Achalasia, Gastroenterology, Nissen fundoplication, Gastroesophageal reflux disease

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PURPOSE: Closure of the esophageal hiatus is an important step during laparoscopic antireflux surgery and hiatal hernia surgery. The aim of this study was to investigate the correlation between the preoperatively determined hiatal hernia size and the intraoperative size of the esophageal hiatus. METHODS: One hundred patients with documented chronic gastroesophageal reflux disease underwent laparoscopic fundoplication. All patients had been subjected to barium studies before surgery, specifically to measure the presence and size of hiatal hernia. The size of the esophageal hiatus was measured during surgery by calculating the hiatal surface area (HSA). HSA size >5 cm(2) was defined as large hiatal defect. Patients were grouped according to radiologic criteria: no visible hernia (n = 42), hernia size between 2 and 5 cm (n = 52), and >5 cm (n = 6). A retrospective correlation analysis between hiatal hernia size and intraoperative HSA size was undertaken. RESULTS: The mean radiologically predicted size of hiatal hernias was 1.81 cm (range 0-6.20 cm), while the interoperative measurement was 3.86 cm(2) (range 1.51-12.38 cm(2)). No correlation (p < 0.05) was found between HSA and hiatal hernia size for all patients, and in the single radiologic groups, 11.9 % (5/42) of the patients who had no hernia on preoperative X-ray study had a large hiatal defect, and 66.6 % (4/6) patients with giant hiatal hernia had a HSA size <5 cm(2). CONCLUSIONS: The study clearly demonstrates that a surgeon cannot rely on preoperative findings from the barium swallow examination, because the sensitivity of a preoperative swallow is very poor.

Concepts: Hiatus hernia, Measurement, Obesity, Nissen fundoplication, Esophageal cancer, Surgery, Achalasia, Gastroesophageal reflux disease

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The last 2 decades have witnessed a revolution in the treatment of patients with paraesophageal hernia (PEH). Nowadays, the laparoscopic repair with fundoplication is considered as the primary treatment modality in most academic centers for symptomatic patients. Three findings have clearly emerged: (1) this procedure is technically demanding; (2) it is associated with relief of symptoms in most patients; and (3) most recurrences are small and asymptomatic. This article describes our approach step-by-step to the repair of a paraesophageal hiatal hernia, focusing on several technical controversies.

Concepts: Hernias, Surgery, Hiatus hernia

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Magnetic sphincter augmentation (MSA) has emerged as an alternative surgical treatment of gastroesophageal reflux disease (GERD). The safety and efficacy of MSA has been previously demonstrated, although adequate comparison to Nissen fundoplication (NF) is lacking, and required to validate the role of MSA in GERD management.

Concepts: Hiatus hernia, Cough, Achalasia, Medicine, Asthma, Gastroenterology, Nissen fundoplication, Gastroesophageal reflux disease

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In 2012 the United States Food and Drug Administration approved implantation of a magnetic sphincter to augment the native reflux barrier based on single-series data. We sought to compare our initial experience with magnetic sphincter augmentation (MSA) with laparoscopic Nissen fundoplication (LNF).

Concepts: Native Americans in the United States, Hiatus hernia, Achalasia, United States, Nissen fundoplication, Gastroesophageal reflux disease

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Esophageal hiatal hernia involves abnormal abdominal entry into thoracic cavity. It is classified based on orientation between esophageal junction and diaphragm. Sliding hiatal hernia (Type-I) comprises the most frequent category, emanating from right crus of diaphragm. Type-II esophageal hernia engages both left and right muscular crura. Type-III and IV additionally include the left crus. Age and increased body mass index are key risk factors, and congenital skeletal aberrations trigger pathogenesis through intestinal malrotations. Familiar manifestations include gastric reflux, nausea, bloating, chest and epigastric discomfort, pharyngeal and esophageal expulsion and dysphagia. Weight loss and colorectal bleeding are severe symptoms. Areas covered: This review summarizes updated evidence of pathophysiology, risk factors, diagnosis and management of hiatal hernias. Laparoscopy and oesophagectomy procedures have been discussed as surgical procedures. Expert commentary: Endoscopy identifies untreatable gastric reflux; radiology is better for pre-operative assessments; manometry measures esophageal peristalsis, and CT scanning detects gastric volvulus and associated organ ruptures. Gastric reflux disease is mitigated using antacids and proton pump and histamine-2-receptor blockers. Severe abdominal penetration into chest cavity demands surgical approaches. Hence, esophagectomy has chances of post-operative morbidity, while minimally invasive laparoscopy entails fewer postoperative difficulties and better visualization of hernia and related vascular damages.

Concepts: Crura of superficial inguinal ring, Hiatus hernia, Crus, Gastroenterology, Obesity, Thorax, Surgery, Gastroesophageal reflux disease

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Delayed gastric emptying (DGE) following hiatus hernia surgery may affect a substantial number of patients with adverse clinical consequences. Here, we aim to evaluate the impact of DGE following laparoscopic repair of very large hiatus hernias on patients' quality of life, gastrointestinal symptomatology, and daily function.

Concepts: Life, Pediatric surgery, Abdomen, Gastroenterology, Hernia, Hernias, Hiatus hernia, Surgery

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In patients with severe type IV hiatal hernias, clinicians should consider congenital shortened esophagus. This article reviews the causes of shortened esophagus and its clinical manifestations.

Concepts: Hiatus hernia, Hernia, Hernias

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A Collis gastroplasty combined with a Nissen fundoplication is commonly used when a shortened esophagus is encountered. An alternative combines intra-abdominal fixation of the gastroesophageal junction via a Hill gastropexy with a Nissen fundoplication to maintain length and avoid juxtaposing acid-secreting tissue against the diseased esophagus.

Concepts: Hiatus hernia, Nissen fundoplication, Achalasia, Gastroesophageal reflux disease

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Laparoscopic cruroplasty and fundoplication have become the gold standard in the treatment of hiatal hernia and gastro-oesophageal reflux disease (GERD). The use of a mesh-reinforcement of the cruroplasty has been proven effective; although, there is a lack of evidence considering which type of mesh is superior. The aim of this study was to compare recurrence rates after mesh reinforced cruroplasty using biological versus synthetic meshes.

Concepts: Obesity, Hiatus hernia, Achalasia, Gastroenterology, Nissen fundoplication, Gastroesophageal reflux disease