Morbidity and mortality in complex robot-assisted hiatal hernia surgery: 7-year experience in a high-volume center.

INTRODUCTION: Published data regarding robot-assisted hiatal hernia repair are mainly limited to small cohorts. This study aimed to provide information on the morbidity and mortality of robot-assisted complex hiatal hernia repair and redo anti-reflux surgery in a high-volume center. MATERIALS AND METHODS: All patients that underwent robot-assisted hiatal hernia repair, redo hiatal hernia repair, and anti-reflux surgery between 2011 and 2017 at the Meander Medical Centre, Amersfoort, the Netherlands were evaluated. Primary endpoints were 30-day morbidity and mortality. Major complications were defined as Clavien-Dindo ≥ IIIb. RESULTS: Primary surgery 211 primary surgeries were performed by two surgeons. The median age was 67 (IQR 58-73) years. 84.4% of patients had a type III or IV hernia (10.9% Type I; 1.4% Type II; 45.5% Type III; 38.9% Type IV, 1.4% no herniation). In 3.3% of procedures, conversion was required. 17.1% of patients experienced complications. The incidence of major complications was 5.2%. Ten patients (4.7%) were readmitted within 30 days. Symptomatic early recurrence occurred in two patients (0.9%). The 30-day mortality was 0.9%. Redo surgery 151 redo procedures were performed by two surgeons. The median age was 60 (IQR 51-68) years. In 2.0%, the procedure was converted. The overall incidence of complications was 10.6%, while the incidence of major complications was 2.6%. Three patients (2.0%) were readmitted within 30 days. One patient (0.7%) experienced symptomatic early recurrence. No patients died in the 30-day postoperative period. CONCLUSIONS: This study provides valuable information on robot-assisted laparoscopic repair of primary or recurrent hiatal hernia and anti-reflux surgery for both patient and surgeon. Serious morbidity of 5.2% in primary surgery and 2.6% in redo surgery, in this large series with a high surgeon caseload, has to be outweighed by the gain in quality of life or relief of serious medical implications of hiatal hernia when counseling for surgical intervention.

The Use of Standardized Measures to Predict and Assess Quality of Life after Laparoscopic Hiatal Hernia Repair.

The literature regarding laparoscopic hiatal hernia repair is difficult to interpret because of inconsistencies in describing hernia characteristics and outcome measures. This study was performed to evaluate risk factors for an unsatisfactory outcome after repair using objective definitions of hernia size and a clinically relevant outcome instrument. A retrospective review of a prospectively maintained database was conducted over a seven-year period. Data collected included patient demographics and hernia-related variables. Outcomes were defined using a validated quality of life (QOL) instrument. Postoperatively, the mean total QOL score decreased from 22.9 to 5.8 (P < 0.001). In all, 13.8 per cent of patients had unsatisfactory QOL scores postoperatively. Multivariate analysis showed that high gastroesophageal (GE) junction position (P = 0.03) and female gender (P = 0.02) were the only significant factors associated with an unsatisfactory postoperative QOL. Laparoscopic hiatal hernia repair significantly improves QOL. With respect to predicting clinically relevant outcomes, hernias are best characterized by the position of the GE junction. Females with high GE junction position are at the highest risk for an unsatisfactory outcome.

Laparoscopic repair of large hiatal hernias: clinical outcomes of 10 years.

BACKGROUND: Whilst laparoscopic repair is the most common surgical procedure for the treatment of large hiatal hernias, knowledge of long-term outcomes (>10 years) is scarce. The aim of this study was to evaluate the long-term results following this approach, in particular the hernia recurrence rate and the impact of repair on quality of life (QoL). METHODS: Patients were identified from a prospective database. A standardized questionnaire was used to assess symptoms and a barium swallow radiograph was performed to determine anatomy. A validated QoL measure, Gastrointestinal Quality of Life Index (GIQLI) was also applied to all patients. RESULTS: Of the 69 eligible patients, clinical follow-up was available for 54 patients (78.3%). Follow-up ranged from 72 to 185 (median: 114) months. Post-operative heartburn and dysphagia were significantly improved, with 45 patients (83%) reporting a good or excellent result. Contrast radiology in 35 patients (65%) revealed recurrence in 12 patients (34%). Fifty-four patients answered the GIQLI questionnaire. The mean GIQLI score was 117 (61-136). Patients with objectively documented anatomic recurrence had a QoL index of 92 (61-121) compared to an index of 122 (77-136, P < 0.01) in the non-recurrent hernia group. CONCLUSIONS: At mean 114 months follow-up, laparoscopic repair of large hiatal hernias achieves effective and durable relief of symptoms, and most patients are satisfied with the outcome.

Delayed Gastric Emptying Following Laparoscopic Repair of Very Large Hiatus Hernias Impairs Quality of Life.

BACKGROUND: 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. METHODS: Analysis of data collected from a multicenter prospective randomised trial of patients who underwent laparoscopic mesh versus sutured repair of very large hiatus hernias (>50% of stomach in chest). DGE was defined as gastric food retention visualised at endoscopy after 6 h of fasting at 6 months post-surgery. Quality of life (QOL), gastrointestinal symptomatology, and daily function were assessed with the SF-36 questionnaire, Visick scoring and structured surveys administered prior to surgery and at 1, 3, 6 and 12 months after surgery. RESULTS: Nineteen of 102 (18.6%) patients had DGE 6 months after surgery. QOL questionnaires were completed in at least 80% of patients across all time points. Compared with controls, the DGE group demonstrated significantly lower SF-36 physical component scores, delayed improvement in health transition, more adverse gastrointestinal symptoms, higher Visick scores and a slower rate of return to normal daily activities. These differences were still present 12 months after surgery. CONCLUSIONS: DGE following large hiatus hernia repair is associated with a negative impact on quality of life at follow-up to 12 months after surgery.

[Quality of life of patients with complicated reflux-esophagitis followed antireflux surgery]. / Kachestvo zhizni bol'nykh, operirovannykh po povodu refliuks-ézofagita i ego oslozhnenii.

AIM: To analyze quality of life of patients with complicated reflux-esophagitis followed antireflux surgery. MATERIAL AND METHODS: The trial enrolled 200 patients who underwent surgical treatment at the Burdenko Faculty Surgery Clinic of Sechenov First Moscow State Medical University for complicated reflux esophagitis from 2008 to 2015. Inclusion criteria were long-standing reflux esophagitis irresistible to conservative treatment, hiatal hernia with shortening of the esophagus and/or peptic stricture and/or Barrett's esophagus. Patients were divided into 2 groups according to the degree of esophagus shortening: group I - 98 patients with esophagus shortening degree I; group II - 102 patients with shortening grade II. Men/women ratio was 87(43.5%)/113(56.5%). Mean age was 56.0±13.9 years (16-83 years). We performed fundoplication in A.F. Chernousov modification in the first group and modified valvular gastroplication in the second group. All patients underwent survey within 6 months - 10 years after surgery to assess long-term outcomes. X-ray examination, upper GI endoscopy, standard laboratory tests were performed with pH-impedance and computed tomography if it was necessary. Quality of life was estimated by RAND SF-36 and GSRS (Gastrointestinal Symptom Rating Scale) questionnaires. RESULTS: SF-36 questionnaire revealed postoperative changes of physical, psychological and social values and was able to compare them with those in general population. Postoperative overall health was significantly higher in both groups compared with preoperative level and comparable with general population. GSRS questionnaire have also revealed positive changes. Overall postoperative GSRS score was 1.6±0.5 and 1.6±0.6 points in groups I and II respectively that corresponds to minor concern after surgery.

Repair of symptomatic paraesophageal hernias in elderly (>70 years) patients results in sustained quality of life at 5 years and beyond.

BACKGROUND: Paraesophageal hernias (PEHs) involve herniation of stomach and/or other viscera into the mediastinum. These commonly occur in the elderly and can severely limit quality of life. Short term outcomes of repaired PEH demonstrated low morbidity and significant improvement in quality of life, but long-term data for all patients, especially the elderly, are lacking. METHODS: Retrospective chart review of a prospectively collected database of patients aged 70 or greater with a symptomatic PEH repaired 5+ years ago. Quality of life data were assessed preoperatively, at 12-24 months, and at 5+ years using QOLRAD, GERD-HRQL, and DSS. RESULTS: We identified 137 patients who met the age criteria, with 69 patients undergoing surgery 5+ years ago. With ten patients were lost to follow-up, 59 patients were analyzed, including 24 males and 35 females. Median age at repair was 77 years. There were two 90-day mortalities, with one occurring within 30 days of surgery. Patients alive at evaluation had a median age of 74 years and were followed a median 7.4 years. From baseline, QOLRAD improved from 4 to 6.5, GERD-HRQL improved from 11 to 5, and swallowing improved from 11 to 38. During follow-up, 21 patients died. Deceased patients lived a median of 4 years after repair, with a median age at repair of 80 years. At a median time follow-up of 2 years, this group's QOLRAD improved from 5.1 to 7, GERD-HRQL improved from 16 to 4, and swallowing improved from 14.5 to 35. CONCLUSIONS: In elderly patients with symptomatic PEH undergoing surgical repair more than 5 years ago, there was sustained improvement in quality of life. This justifies surgical repair of symptomatic PEH in elderly patients.

Long-term quality of life and risk factors for recurrence after laparoscopic repair of paraesophageal hernia.

IMPORTANCE: Laparoscopic repair of paraesophageal hernia (PEH) has been shown to result in excellent relief of symptoms and improved quality of life (QOL) despite a relatively high radiographically identified recurrence rate. OBJECTIVE: To assess potential risk factors for recurrence and long-term change in QOL after laparoscopic repair of PEH. DESIGN, SETTING, AND PARTICIPANTS: This was a prospective study of 111 patients who underwent elective laparoscopic repair of type III PEH with biological mesh buttressed over a primary cruroplasty from April 3, 2009, through July 31, 2014, at the Department of Surgery, Johns Hopkins University of Medicine. We administered a modified version of a validated gastroesophageal reflux disease-specific QOL tool to patients before and at 2, 12, and 36 months after the procedure. Higher QOL scores represent greater severity of symptoms. An upper gastrointestinal tract barium-contrast radiographic examination was performed at 1 year to assess for recurrence. Demographic factors, comorbidities, and preoperative radiographic findings were analyzed as possible indicators for recurrence using logistic regression. MAIN OUTCOMES AND MEASURES: Quality of life, measured by the gastroesophageal reflux disease-specific QOL tool, and recurrence, defined as a PEH of greater than 2 cm. RESULTS: Median patient age was 61 years, 63.1% of patients were women, and 81.1% of patients were white. Four patients required reoperation, of which only 1 was for symptomatic recurrent PEH. The mean follow-up time for the 36-month QOL assessment was 43.5 months. The overall preoperative and 2-, 12-, and 36-month QOL scores were 28.50, 10.18, 9.74, and 10.58, respectively (P < .001). Recurrences were found in 19 of the 70 patients (27%) who completed the 1-year radiographic examination. Compared with baseline, all individual symptoms improved significantly except for early satiety (mean [SD] score, 3.18 [1.88] at baseline vs 2.07 [1.70] at the 36-month follow-up; P = .07), nausea (1.69 [1.63] vs 0.77 [1.25]; P = .08), pain with swallowing (1.06 [1.50] vs 0.53 [0.90]; P = .73), and bloating/gas (3.28 [1.71] vs 2.23 [1.72]; P = .05) at the 36-month QOL assessment. Although not statistically significant, preoperative hernias containing most of the stomach were more likely to recur after repair when compared with those involving gastric cardia and fundus (odds ratio, 3.74 [95% CI, 0.93-15.14]; P = .06). CONCLUSIONS AND RELEVANCE: Overall, laparoscopic repair of PEH with biological mesh results in excellent long-term QOL. The cause of recurrence is likely multifactorial and individualized to each patient. Further evaluation of novel techniques and unidentified patient factors is needed.

Psychological modulation in patients surgically intervened for gastroesophageal reflux disease.

Gastroesophageal reflux disease (GERD) has been related with certain psychological dimensions. The influence of mood, emotional intelligence, and perceived quality of life on clinical symptoms and outcome of antireflux surgery was evaluated in GERD patients with and without hiatal hernia. The study included 61 patients who were diagnosed with GERD between 2003 and 2008: 16 of them without hiatal hernia (group A) and 45 of them with hiatal hernia (group B). All of these patients had undergone laparoscopic antireflux surgery. Patients were clinically examined and evaluated with the following instruments: Short Form (SF)-36 Health Survey, Gastrointestinal Quality of Life Index, Hospital Anxiety and Depression (HAD) Scale, and Trait Meta-Mood Scale (TMMS)-24. Proportions were compared by using the chi-squared test; averages were compared by using the Student's t-test (with Bonferroni's correction). In general, our patients intervened for GERD showed results lower than normal or close to the lower limit of normal in the administered tests. Patients in the group without hernia were younger (P < 0.001) and with lower American Society of Anaesthesiologists risk. They showed higher scores in the SF-36 dimensions: Physical Functioning, Physical Role and Emotional Role, and lower scores in the Social Role (P < 0.001). They showed lower scores in the Emotional dimension of Gastrointestinal Quality of Life Index (P = 0.0068) and worse results in the Hospital Anxiety and Depression subscales of Anxiety (P < 0.001) and Depression (not significant). Men in the group without hernia showed higher scores than men in the group with hernia in the TMMS subscales corresponding to Emotional Clarity and Emotional Repair (P < 0.001). Women in the group with hernia showed higher scores than women in the group without hernia regarding Emotional Clarity (P = 0.0012). GERD patients showed poor results in all the tests, and patients without hiatal hernia compared with patients with hernia showed higher levels of anxiety, which interfered with their social life. Moreover, they showed lower tolerance to stress and higher frustration, fear, and worry. On the basis of such unfavorable phychoemotional results observed with GERD patients (especially those without hernia) in the different tests, we propose that improving our knowledge of the psychological profile of GERD patients - particularly those without hiatal hernia - could help in designing individualized medical and psychological therapies and increase success rates.

Management of large para-esophageal hiatal hernias.

Para-esophageal hernias are relatively rare and typically occur in elderly patients. The various presenting symptoms are non-specific and often occur in combination. These include symptoms of gastro-esophageal reflux (GERD) in 26 to 70% of cases, microcytic anemia in 17 to 47%, and respiratory symptoms in 9 to 59%. Respiratory symptoms are not completely resolved by surgical intervention. Acute complications such as gastric volvulus with incarceration or strangulation are rare (estimated incidence of 1.2% per patient per year) but gastric ischemia leading to perforation is the main cause of mortality. Only patients with symptomatic hernias should undergo surgery. Prophylactic repair to prevent acute incarceration should only be undertaken in patients younger than 75 in good condition; surgical indications must be discussed individually beyond this age. The laparoscopic approach is now generally accepted. Resection of the hernia sac is associated with a lower incidence of recurrence. Repair of the hiatus can be reinforced with prosthetic material (either synthetic or biologic), but the benefit of prosthetic repair has not been clearly shown. Results of prosthetic reinforcement vary in different studies; it has been variably associated with four times fewer recurrences or with no measurable difference. A Collis type gastroplasty may be useful to lengthen a foreshortened esophagus, but no objective criteria have been defined to support this approach. The anatomic recurrence rate can be as high as 60% at 12years. But most recurrences are asymptomatic and do not affect the quality of life index. It therefore seems more appropriate to evaluate functional results and quality of life measures rather than to gauge success by a strict evaluation of anatomic hernia reduction.

Defining recurrence after paraesophageal hernia repair: correlating symptoms and radiographic findings.

BACKGROUND: Laparoscopic repair of paraesophageal hernia (PEH) has been shown to result in excellent relief of symptoms and improved quality of life (QOL) despite a high radiographically identified recurrence rate. Because there is no uniform definition of PEH recurrence, it is difficult to compare studies reporting on this. This study attempts to introduce consistency to the definition of PEH recurrence based on correlation of symptoms and radiographic findings. METHODS: This is an analysis of data derived from an ongoing prospective study. From April 2009 to December 2012, we enrolled 101 patients who underwent elective laparoscopic PEH repair with bioprosthesis buttressed over a primary cruroplasty. A validated gastroesophageal reflux disease-specific QOL tool was administered to patients before, and at 2 and 12 months postoperatively. Upper gastrointestinal barium contrast examination (UGI) was performed at 1 year. RESULTS: Of 101 patients, 13 were not available for follow-up, 58 reached the 1-year milestone for interval UGI, and 1 patient required reoperation for symptomatic recurrent PEH. There was no relationship between total QOL score and radiographic recurrent hernia (RRH); however, significant deterioration in many symptoms was seen in RRH > 2 cm. Based on these findings, we defined recurrence as RRH > 2 cm and calculated our recurrence rate as 28% (n = 16). CONCLUSION: Our analysis of symptom scores after laparoscopic PEH repair suggests that significant worsening occurs with RRH > 2 cm. Given that there is no consistent description of recurrent PEH, we suggest this as a possible standardized definition. Overall, patients with recurrent PEHs continue to experience excellent QOL and rarely require reoperation.

Repair of symptomatic giant paraesophageal hernias in elderly (>70 years) patients results in improved quality of life.

INTRODUCTION: Giant paraesophageal hernias (PEH) involve herniation ofstomach and/or other viscera into the mediastinum. These are usually symptomatic and commonly occur in the elderly. The benefits and risks of operating on elderly patients with giant PEH have not been clearly elucidated. MATERIALS AND METHODS: We performed a retrospective chart review of consecutive patients aged 70 or greater with giant PEHs undergoing repair.Quality of life data were gathered using QOLRAD, GERD-HRQL and adysphagia severity score. RESULTS: Fifty-eight patients (34 females), median 78 years old, presented for repair. Nine patients presented urgently. There was no 30-day mortality. Major morbidity was 15.5%. At mean follow-up of 1.3 years, 81% were symptom free compared to baseline (p < 0.0001). Both short-term (p < 0.001) and long term QOLRAD (p < 0.001) scores improved significantly, as did GERD HRQL scores (p < 0.001). Dysphagia scores worsened in the short term but returned to baseline at long term follow up. CONCLUSIONS: Symptomatic giant PEH in this elderly population can be repaired with symptomatic improvement, minimal morbidity and mortality in both the elective and urgent setting. The decision to operate should be made by a physician experienced in managing this complex patient population.

Laparoscopic paraesophageal hernia repair: quality of life outcomes in the elderly.

Paraesophageal hernias (PEH) occur when there is herniation of the stomach through a dilated hiatal aperture. These hernias occur more commonly in the elderly, who are often not offered surgery despite the failure of medical treatment to address mechanical symptoms and life-threatening complications. The aim of this study was to assess the impact of laparoscopic repair of PEH on quality of life in an elderly population. Data were collected prospectively on 35 consecutive patients aged >70 years who had laparoscopic repair of a symptomatic PEH between December 2001 and September 2005. The change in quality of life was assessed using a validated questionnaire, the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD), and by patient interviews. Patients were assessed preoperatively, and at 6 weeks, 6 months, 12 months, 1 year, and 2 years postoperatively. Mean patient age was 77 years (range 70-85); mean American Society of Anesthesiologists class was 2.7 (range 1-3). There were 28 women and 7 men. There was one readmission for acute reherniation, which required open revision. Total complication rate was 17.1%. All complications were treated without residual disability. There was no 30-day mortality, and median hospital stay was 3 days (range 2-14). Completed questionnaires were obtained in 30 of 35 patients (85.7%). There was a significant improvement in quality of life, as measured with QOLRAD, at all postoperative time points (P < 0.001). Laparoscopic PEH repair can be performed with acceptable morbidity in symptomatic patients refractory to conservative treatment and is associated with a significant improvement in quality of life. Our data support elective repair of symptomatic PEH in the elderly, a population who may not always be referred for a surgical opinion.

Quality of life following primary vs. redo transthoracic paraesophageal hernia repairs.

The purpose of this study was to compare the quality of life (QOL) and functional results of 42 patients undergoing primary (60%) and 23 patients undergoing redo (40%) transthoracic paraesophageal hernia repairs. All patients had a floppy Nissen or Belsey anti-reflux repair with or without a Collis gastroplasty. Morbidity occurred in 12% of patients and was similar between groups (P=1.0). Overall QOL scores were not different between groups. Patients undergoing initial repair were found to have significantly higher QOL scores related to their GERD symptoms (P=0.02). Postoperative GERD symptom scores were not significantly different between groups for heartburn, regurgitation, epigastric/chest pain, or cough. Redo patients had more bloating (P=0.02) and dysphagia (P=0.04). Overall, total GERD scores were higher in the redo group compared to the initial group indicating worse GERD-related dysfunction in the redo group (15.8+/-3.8 vs. 6.3+/-1.6, P=0.03). Functional and QOL analysis of transthoracic paraesophageal hernia repairs indicates that redo procedures are associated with a higher incidence of specific gastrointestinal symptoms and worse GERD-related QOL when compared to initial procedures. These differences, while statistically significant, have limited clinical relevance as the overall QOL was not different between groups and low GERD symptom scores were found in both groups.

[Acute gastroduodenal lesions and stress]. / Lesioni gastroduodenali acute e stress.

Haemorrhagic gastroduodenitis together with complicated peptic ulcer, are--after trauma--the most common causes of urgent admission in hospital for young people. In the present paper the Authors deal with the role of emotional disturbances, generated by environmental stress, in the pathogenesis of many gastrointestinal diseases in the young. They observed a rise in the incidence of gastroduodenal pathology (especially of the erosive-haemorrhagic form) in young males during military service. So they hypothesized that such high incidence of acute GDD during military service, could be attributed to abrupt changes in lifestyle, generating a significant environmental stress. The results of a clinical study on 65 young conscripts out of 483 who underwent EGDS for acute digestive symptoms also tested for psychological evaluation to stress response, are reported. In the 60.7% of all patients, MMPI (Minnesota Multiphasic Personality Inventory) test showed pathological alterations. Correlating the pathological findings with MMPI results, the Authors found that the 25% of patients suffering from oesophagitis, the 36.3% of those with peptic ulcers, the 68% of aspecific gastroduodenitis and the 75% of erosive-haemorrhagic gastroduodenitis, had psychological disturbances. The study shows that GDD in the young is a very frequent pathology, which may be triggered off by abrupt changes in life style, especially in those patients who are unable to react positively to changes in the outer world. GD pathology arises most frequently during the first five months of military service, especially within the third and the fourth month. The Authors conclude that a correct management of GDD in the young needs a versatile approach based on EGDS to establish the correct diagnosis, and on psychopathological investigations.

The role of psychiatric factors in symptoms of hiatus hernia or gastric reflux.

The study comprised 26 patients with somatic symptoms indicating a hernia-reflux syndrome referred to a university hospital ear, nose and throat department. The aim was to throw light on the hypothesis that this syndrome is largely a psychosomatic problem. The patients were divided into two groups: subjects with and without laboratory findings of physical pathology of hernia and/or reflux. Intergroup comparisons were made of symptoms, a psychological test and psychiatric ratings. Those who had no laboratory findings of physical pathology often reported "phobia" and "feeling of lump in the throat", which were interpreted as signs of hysterical or somatizing mechanisms. Most of these patients showed a high level of anxiety in the psychological test. "Agitation", "depression" and "frustration" were characteristics of patients with laboratory findings of reflux. "Depression" was interpreted as a reaction to the somatic illness. The group with reflux contained more old male patients and that without more younger female patients.

[Recurrence of hiatal hernia. A study of 20 cases]. / Récidives de hernie hiatale. Etude de 20 dossiers.

After surgical correction, hiatus hernia recurs in 5--15%. Papers dealing with these recurrences are rare. Among 140 hiatus hernias operated in our service, quite a few had some residual symptoms such as intermittent dysphagia, epigastric pain and flatulence. Three of them had to be reoperated on for a recurrence. In this paper 20 patients operated for recurrent hiatus hernia are reviewed. Some factors predispose to recurrence: inadequate initial operation, stage 3--4 oesophagitis, kyphosis, very broad hiatal orifice at initial operation. When the cases reoperated upon are reviewed some of them are not improved. Most of these patients have psychosomatic problems or are under psychiatric treatment. This is why a patient coming for a recurrent hiatus hernia should be investigated thoroughly. Psychosomatic cases are as bad an indication for a second operation as they probably were for the first one. When reoperation has been decided, several procedures can be used. The choice depends on what was done at the first operation, on the radiological, endoscopic and peroperative findings. In the majority of the cases, an abdominal approach can be used, but occasionally a thoracic or thoraco-abdominal route is preferable. Associated vagotomy does not improve the results and adds its own morbidity.