Robotic-assisted versus laparoscopic repair of type II, III and IV hiatal hernias: A retrospective study comparing adverse outcomes

Objective:Robotic-assisted surgery(RAS)is continuing to expand in use in surgical specialties,including foregut surgery.The available data on its use in large hiatal hernia(HH)repair are limited and conflicting.This study sought to determine whether there are significant differences in adverse outcomes following HH repair performed with a robotic approach vs.a laparoscopic approach.This study was limited to outcomes in patients with type II,III,and IV HHs,as these hernias are typically more challenging to repair.Methods:A retrospective analysis was performed from data obtained from TriNetX,a large deidentified clinical database,over a 10-year period.Adult patients who underwent type II,III,or IV HH repair were included in the study.HH with robotic repair was compared to laparoscopic repair.Cohorts were propensity score matched for demographic information and comorbidities.Risk ratios,risk differences(RDs)with 95%confidence intervals(CIs),and t test for each examined adverse outcome were used to estimate the effects of robotic repair vs.laparoscopic repair.Results:In total,20,016 patients who met the inclusion criteria were identified;1,515 patients utilized RAS,and 18,501 used laparoscopy.Prior to matching,there were significant differences in age,sex,comorbidity,and BMI between the two cohorts.After 1:1 propensity score matching,analyses of 1,514 well-matched patient pairs revealed no significant differences in demographics or comorbidities.Patients who underwent robotic repair were more likely to experience major complications,including venous thromboembolism(RD:0.007,95%CI:0.003,0.011;p?0.002),critical care(RD:0.023,95%CI:0.007,0.039;p?0.004),urinary/renal complications(RD:0.027,95%CI:0.014,0.041;p<0.001),and respiratory complications(RD:0.046,95%CI:0.028,0.064;p<0.001).RAS was associated with a significantly shorter length of stay(32.4±27.5 h vs.35.7±50.1 h,p?0.031),although this finding indicated a reduction in the length of stay of less than 4 hours.No statistically significant differences in risk of esophageal perforation,infection,postprocedural shock,bleeding,mortality,additional emergency room visits,cardiac complications,or wound disruption were found.Conclusions:Patients who undergo robotic-assisted large HH repair are at increased risk of venous thromboembolism,need critical care,urinary or renal complications and respiratory complications.Due to variations in RAS technique,experience,and surgical volumes,further study of this surgical approach and complication rates is warranted.

Determining the need for a thoracoscopic approach to treat a giant hiatal hernia when abdominal access is poor

BACKGROUND Giant hernias present a significant challenge for digestive surgeons.The approach taken(laparoscopic vs thoracoscopic)depends largely on the preferences and skills of each surgeon,although in most cases today the laparoscopic approach is preferred.AIM To determine whether patients presenting inadequate laparoscopic access to the intrathoracic hernial sac obtain poorer postoperative results than those with no such problem,in order to assess the need for a thoracoscopic approach.METHODS For the retrospective series of patients treated in our hospital for hiatal hernia(n=112),we calculated the laparoscopic field of view and the working area accessible to surgical instruments,by means of preoperative imaging tests,to assess the likely outcome for cases inaccessible to laparoscopy.RESULTS Patients with giant hiatal hernias for whom a preoperative calculation suggested that the laparoscopic route would not access all areas of the intrathoracic sac presented higher rates of perioperative complications and recurrence during follow-up than those for whom laparoscopy was unimpeded.The difference was statistically significant.Moreover,the insertion of mesh did not improve results for the non-accessible group.CONCLUSION For patients with giant hiatal hernias,it is essential to conduct a preoperative evaluation of the angle of vision and the working area for surgery.When parts of the intrathoracic sac are inaccessible laparoscopically,the thoracoscopic approach should be considered.

Gasless Laparoscopic Surgery plus Abdominal Wall Lifting for Giant Hiatal Hernia——Our Single-center Experience

Giant hiatal hernia（GHH） comprises 5% of hiatal hernia and is associated with significant complications.The traditional operative procedure,no matter transthoracic or transabdomen repair of giant hiatal hernia,is characteristic of more invasion and more complications.Although laparoscopic repair as a minimally invasive surgery is accepted,a part of patients can not tolerate pneumoperitoneum because of combination with cardiopulmonary diseases or severe posterior mediastinal and neck emphesema during operation.The aim of this article was to analyze our experience in gasless laparoscopic repair with abdominal wall lifting to treat the giant hiatal hernia.We performed a retrospective review of patients undergoing gasless laparoscopic repair of GHH with abdominal wall lifting from 2012 to 2015 at our institution.The GHH was defined as greater than one-third of the stomach in the chest.Gasless laparoscopic repair of GHH with abdominal wall lifting was attempted in 27 patients.Mean age was 67 years.The results showed that there were no conversions to open surgery and no intraoperative deaths.The mean duration of operation was 100 min（range：90–130 min）.One-side pleura was injured in 4 cases（14.8%）.The mean postoperative length of stay was 4 days（range：3–7 days）.Median follow-up was 26 months（range：6–38 months）.Transient dysphagia for solid food occurred in three patients（11.1%）,and this symptom disappeared within three months.There was one patient with recurrent hiatal hernia who was reoperated on.Two patients still complained of heartburn three months after surgery.Neither reoperation nor endoscopic treatment due to signs of postoperative esophageal stenosis was required in any patient.Totally,satisfactory outcome was reported in 88.9% patients.It was concluded that the gasless laparoscopic approach with abdominal wall lifting to the repair of GHH is feasible,safe,and effective for the patients who cannot tolerate the pneumoperitoneum.

Gastroesophageal flap valve status distinguishes clinical phenotypes of large hiatal hernia

AIM: To investigate two distinct clinical phenotypes of reflux esophagitis and intra-hernial ulcer (Cameron lesions) in patients with large hiatal hernias. METHODS: A case series study was performed with 16 831 patients who underwent diagnostic esophagogastroduodenoscopy for 2 years at an academic referral center. A hiatus diameter ≥ 4 cm was defined as a large hernia. A sharp fold that surrounded the cardia was designated as an intact gastroesophageal flap valve (GEFV), and a loose fold or disappearance of the fold was classified as an impaired GEFV. We studied the associations between large hiatal hernias and the distinct clinical phenotypes (reflux esophagitis and Cameron lesions), and analyzed factors that distinguished the clinical phenotypes. RESULTS: Large hiatal hernias were found in 49 (0.3%) of 16 831 patients. Cameron lesions and reflux esopha-gitis were observed in 10% and 47% of these patients, and 0% and 8% of the patients without large hiatal hernias, which indicated significant associations between large hiatal hernias and these diseases. However, there was no coincidence of the two distinct disorders. Univariate analysis demonstrated significant associations between Cameron lesions and the clinico-endoscopic factors such as nonsteroidal anti-inflammatory drug (NSAID) intake (80% in Cameron lesion cases vs 18% in non-Cameron lesion cases, P=0.015) and intact GEFV (100% in Cameron lesion cases vs 18% in non-Cameron lesion cases, P=0.0007). In contrast, reflux esophagitis was linked with impaired GEFV (44% in reflux esophagitis cases vs 8% in non-reflux esophagitis cases, P = 0.01). Multivariate regression analysis confirmed these significant associations. CONCLUSION: GEFV status and NSAID intake distinguish clinical phenotypes of large hiatal hernias. Cameron lesions are associated with intact GEFV and NSAID intake.

Contrast-enhanced ultrasound using SonoVue mixed with oral gastrointestinal contrast agent to evaluate esophageal hiatal hernia: Report of three cases and a literature review

BACKGROUND Due to a thicker abdominal wall in some patients,ultrasound artifacts from gastrointestinal gas and surrounding tissues can interfere with routine ultrasound examination,precluding its ability to display or clearly show the structure of a hernial sac(HS)and thereby diminishing diagnostic performance for esophageal hiatal hernia(EHH).Contrast-enhanced ultrasound(CEUS)imaging using an oral agent mixture allows for clear and intuitive identification of an EHH sac and dynamic observation of esophageal reflux.CASE SUMMARY In this case series,we report three patients with clinically-suspected EHH,including two females and one male with an average age of 67.3±16.4 years.CEUS was administered with an oral agent mixture(microbubble-based SonoVue and gastrointestinal contrast agent)and identified a direct sign of supradiaphragmatic HS(containing the hyperechoic agent)and indirect signs[e.g.,widening of esophageal hiatus,hyperechoic mixture agent continuously or intermittently reflux flowing back and forth from the stomach into the supradiaphragmatic HS,and esophagus-gastric echo ring(i.e.,the“EG”ring)seen above the diaphragm].All three cases received a definitive diagnosis of EHH by esophageal manometry and gastroscopy.Two lesions resolved upon drug treatment and one required surgery.The recurrence rate in follow-up was 0%.The data from these cases suggest that the new non-invasive examination method may greatly improve the diagnosis of EHH.CONCLUSION CEUS with the oral agent mixture can facilitate clear and intuitive identification of HS and dynamic observation of esophageal reflux.

Preoperative calculation of angles of vision and working area in laparoscopic surgery to treat a giant hiatal hernia

BACKGROUND Giant hiatal hernias still pose a major challenge to digestive surgeons,and their repair is sometimes a highly complex task.This is usually performed by laparoscopy,while the role of the thoracoscopic approach has yet to be clearly defined.AIM To preoperatively detect patients with a giant hiatal hernia in whom it would not be safe to perform laparoscopic surgery and who,therefore,would be candidates for a thoracoscopic approach.METHODS In the present study,using imaging test we preoperatively simulate the field of vision of the camera and the working area(instrumental access)that can be obtained in each patient when the laparoscopic approach is used.RESULTS From data obtained,we can calculate the access angles that will be obtained in a preoperative computerised axial tomography coronal section,according to the location of the trocar.We also provide the formula for performing the angle calculations If the trocars are placed in loss common situations,thus enabling us to determine the visibility and manoeuvrability for any position of the trocars.CONCLUSION The working area determines the cases in which we can operate safely and those in which certain areas of the hernia cannot be accessed,which is when the thoracoscopic approach would be safer.

Laparoscopic Repair of Esophageal Hiatal Hernia

This study was to appraise safety and feasibility of laparoscopic approach and investigate the clinical effects of laparoscopic tension-free repair of esophageal hiatal hernia using mesh. From August 2006 to July 2009, 24 patients with esophageal hiatal hernia underwent laparoscopic repair. Twenty-three patients received laparoscopic tension-free repair using mesh, at the same time, Toupet or Dor partial fundoplication was performed. One patient was converted to open surgery. The average operating time was 90 min （70-210 min） and the blood loss was between 10-110 mL. There was no death. The mean postoperative hospital stay was 5 days （3-30 days）. During a follow-up period of 12-20 months （mean 15 months）, there was no recurrence of the hernia, and no complication with use of mesh.The present study suggested that laparoscopic approach was secure and minimally invasive operation for esophageal hiatal hernia and the use of mesh could reduce recurrence rate.

Cardiovascular Complications of Large Hiatal Hernias: Expanding the Indications for Robotic Surgical Anatomic and Physiologic Repair: A Review

Background: Historically, the pathophysiology of Hiatal Hernias (HH) has not been fully understood. As a result, the surgical therapy of HH has focused primarily on gastrointestinal symptoms and Gastroesophageal Reflux (GERD). This treatment strategy has been associated with poor relief of symptoms and poor long-term outcomes. In fact, until recently, most patients with HH have been watched and referred for surgery as a last resort. Recent experience has shown that a large (giant) Hiatal Hernia (GHH) is a common problem known to impact adjacent organs such as the hearts and lungs. Those referred for surgical repair often complain of dyspnea, which is erroneously attributed to pulmonary compression or aspiration, but has been shown to be from tamponade caused from compression of the heart by herniated abdominal contents. This article reviews the present understanding of GHH, the cardiac complications which result from GHH, and the most advanced robotic minimally invasive surgical approach to the anatomic and physiologic repair of GHH. Methods: In a prospective cohort study, we evaluated patients undergoing RRHH with at least a 2-year follow-up. All patients undergoing elective (RRHH) were identified preoperatively and enrolled prospectively in this study. Preoperative characteristics, medical comorbidities, and clinical information were all recorded prospectively and recorded into a secure surgical outcomes database. All patients received the previously validated Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire preoperatively and at postoperative time points of 1 month, 1 year, and 2 years. Patients routinely had a barium swallow postoperatively before discharge but did not undergo a barium swallow, an endoscopy, or a CT scan study at the 1-month time point unless indicated by symptoms. At 6 months, 1 year, and yearly intervals thereafter, all patients received an endoscopy study to ascertain the presence of a recurrence, regardless of symptoms. Recurrence was defined as over 2 cm or 10% of the stomach above the diaphragm detected by CT, esophagogram or endoscopy. In addition, an extensive search was conducted using Pub Med in order to extract references to the cardiovascular complications of HH. Results: 423 patients underwent RRHH. With a long-term follow-up, there was a significant decrease in the Median Symptom Severity Score from 42.0 preoperatively, to 3.0 postoperatively. Recurrence was seen in 5 patients (5/423) for a recurrence rate of 1.1%. Conclusion: This experience has been the basis of two important realizations: 1) all patients with GHH have at least some degrees of clinically relevant compression of the inferior vena cava and the left atrium which causes tamponade and cardiogenic dyspnea which completely resolves after successful surgical repair;and 2) primary care providers and gastroenterologists who usually treat patients for GHH repair rarely recognize cardiac compression and tamponade as the cause of the shortness of breath and gradual increase in dyspnea on exertion and progressive fatigability in these patients. This article reviews the present understanding of GHH, the cardiac complications which result from GHH and the most advanced robotic minimally invasive surgical approach to the anatomic and physiologic repair of GHH.

Robotic Laparoscopic Transdiaphragmatic Repair of Large Hiatal Hernias

Introduction: Although laparoscopic Nissen fundoplication is the most common procedure for the repair for hiatal hernia (HH) repair, HH recurrence due to breakdown of the hiatoplasty has been reported as a common mechanism of failure after primary repair. Left transthoracic anatomic and physiologic repair (AFR) of HH is associated with lower incidence of leak and reoperation but greater morbidity. Adopting the transthoracic approach to a robotic laparoscopic platform may represent the ideal approach to the repair of HH. This study reviews the results of this technique. Methods: A retrospective review was performed on patients who had robotic AFR (RAFR) of large HH. All patients received the previously validated Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire preoperatively and postoperatively. Objectively, symptoms were graded using the Visick Scale. Recurrence was defined as greater than 2 cm or 10% of the stomach above the diaphragm detected by either CT, esophagogram or endoscopy. The preoperative data was compared to the results at 2 years. Results: 396 patients underwent RAPR. The Median GERD-HRQL score was 42 (range 38 - 45) preoperatively and 6 (range 0 - 14) at two years (p < 0.05). Preoperatively 87% of patients were graded as Visick IV. At two years, 95% were graded as Visick I. HH recurrence occurred in 4/396 patients (1%). Conclusion: RAFR of HH is associated with excellent symptom relief and low recurrence rate. RAFR should be considered when deciding on what operation to perform in patients with large paraesophageal hiatal hernias.

Hiatal Hernia by Rolling Revealed by Respiratory Symptoms: A Rare Condition and Atypical Presentation

Hiatal hernia by rolling is a rare pathology estimated at 5% of all diaphragmatic hernias. It is usually asymptomatic. Sometimes, it can be accompanied by different symptoms, such as post prandial bloating, dysphagia, regurgitation, retro sternal pain, even respiratory symptoms. The aim of this article is to show that a hiatus hernia by rolling can cause a misleading clinical picture that may be taken wrongly for a heart or respiratory disease. We report the case of an 80-year-old patient whose presentation was suggestive of an acute heart condition, but the scan confirmed a rolling diaphragmatic hernia. Because of the rarity and the atypical presentation of this case, we have found it desirable to bring this new observation.

Laparoscopic repair of giant hiatal hernia:analysis of 25 cases

Objective To investigate the clinical characteristics and feasibility of laparoscopic repair of giant hiatal hernia. Methods From January 2008 to August 2010,25 consecutive patients with giant hiatal hernia underwent laparoscopic repair. Crural closure was performed by means of two or three interrupted nonabsorbable sutures plus a tailored PTFE / ePTFE composite mesh. It was patched across the defect and secured to each crura with staples. Laparoscopic fundoplication was performed concomitantly in 16 cases according to the specific conditions of patients. Para-operative clinical parameters

Mechanism of antireflux procedures in treating sliding hiatal hernia

Objective To investigate the mechanism of antireflux procedures in treating sliding hiatal hernia and the effectiveness of the method of cardia position by clock to evaluate the outcome of antireflux procedures. Methods From 1992 to 2008,136 patients with sliding hiatal hernia underwent transabdominal antireflux surgery:

Dual-sided composite mesh repair of hiatal hernia: Our experience and a review of the Chinese literature

AIM:To summarize our experience in the application of Crurasoft for antireflux surgery and hiatal hernia(HH)repair and to introduce the work of Chinese doctors on this topic.METHODS:Twenty-one patients underwent HH repair with Crurasoft reinforcement.Gastroesophageal reflux disease(GERD)and HH-related symptoms including heartburn,regurgitation,chest pain,dysphagia,and abdominal pain were evaluated preoperatively and 6mo postoperatively.A patient survey was conducted by phone by one of the authors.Patients were asked about"recurrent reflux or heartburn"and"dysphagia".An internet-based Chinese literature search in this field was also performed.Data extracted from each study included:number of patients treated,hernia size,hiatorrhaphy,antireflux surgery,follow-up period,recurrence rate,and complications(especially dysphagia).RESULTS:There were 8 typeⅠ,10 typeⅡand 3 typeⅢHHs in this group.Mean operative time was 119.29min(range 80-175 min).Intraoperatively,length and width of the hiatal orifice were measured,(4.33±0.84and 2.85±0.85 cm,respectively).Thirteen and eight Nissen and Toupet fundoplications were performed,respectively.The intraoperative complication rate was9.52%.Despite dysphagia,GERD-related symptoms improved significantly compared with those before surgery.The recurrence rate was 0%during the 6-mo follow-up period,and long-term follow-up disclosed a recurrence rate of 4.76%with a mean period of 16.28mo.Eight patients developed new-onset dysphagia.The Chinese literature review identified 12 papers with213 patients.The overall recurrence rate was 1.88%.There was no esophageal erosion and the rate of dysphagia ranged from 0%to 24%.CONCLUSION:The use of Crurasoft mesh for HH repair results in satisfactory symptom control with a low recurrence rate.Postoperative dysphagia continues to be an issue,and requires more research to reduce its incidence.

Laparoscopic repair of hiatal hernia with mesenterioaxial volvulus of the stomach

Although mesenterioaxial gastric volvulus is an uncommon entity characterized by rotation at the transverse axis of the stomach, laparoscopic repair procedures have still been controversial. We reported a case of mesenterioaxial intrathoracic gastric volvulus, which was successfully treated with laparoscopic repair of the diaphragmatic hiatal defect using a polytetrafluoroethylene mesh associated with Toupet fundoplication. A 70-year-old Japanese woman was admitted to our hospital because of sudden onset of upper abdominal pain. An upper gastrointestinal series revealed an incarcerated intrathoracic mesenterioaxial volvulus of the distal portion of the stomach and the duodenum. The complete laparoscopic approach was used to repair the volvulus. The laparoscopic procedures involved the repair of the hiatal hernia using polytetrafluoroethylene mesh and Toupet fundoplication. This case highlights the feasibility and effectiveness of the laparoscopic procedure, and laparoscopic repair of the hiatal defect using a polytetrafluoroethylene mesh associated with Toupet fundoplication may be useful for preventing postoperative recurrence of hiatal her-nia, volvulus, and gastroesophageal reflux.

Robotic Foregut Surgery: One Surgeon’s Experience with Nissen Fundoplication, Esophagomyotomy, and Hiatal Hernia Repair

Purpose: The purpose of the study was to review a single surgeon, seven-year experience, using the Da Vinci Telerobotic system performing 124 foregut operations. Methods: Data review from 2002-2009 including 71 Nissen fundoplications, 26 esophagomyotomies, and 27 hiatal hernia repairs was performed. Parameters collected included gender, age, body mass index (BMI), estimated blood loss (EBL), port set up time (PST), robot operating time (ROT), total case time (TCT), length of stay (LOS), complications, conversions, and resident involvement. Statistical analysis was con-ducted. Results: 124 foregut operations: 45 males, 79 females, mean age of 54.8 ± 16.7 (18 - 85) years, mean TCT 174.4 ± 45.0 (102 - 321) min. Nissen fundoplication: mean BMI of 30.8 ± 3.9 (22.4 - 46.8) kg/m2, EBL 30.2 ± 21.8 (5 - 100) ml, PST 32.3 ± 9 (14 - 63) min, ROT 111.4 ± 37.3 (51 - 229) min, TCT 175.0 ± 46.4 (102 - 321) min, median LOS 1 (0 - 9) day, complication rate 7.0% (5/71), conversion rate 5.6%, resident involvement 69.0% (49/71). Esophagomyotomy: mean BMI of 26.5 ± 6.1 (15.4 - 36.6) kg/m2, EBL 39.1 ± 41.7 (10 - 200) ml, PST 28.0 ± 8.6 (16 - 47) min, ROT 122.9 ± 45 (31 - 217) min, and TCT 178.0 ± 40.5 (105 - 262) min, median LOS 1 (0 - 6) day, complication rate 15.4% (4/26), conversion rate 0%, resident involvement 69.2% (18/26). Hiatal hernia repair: mean BMI of 28.4 ± 4.2 (21.9 - 36.8) kg/m2, EBL 38.4 ± 32.7 (10 - 150) ml, PST 28.8 ± 8.0 (17 - 52) min, ROT 109.0 ± 44.5 (49 - 250) min, and TCT 169.2 ± 46.5 (102 - 299) min, median LOS 1 (1 - 14) day, complication rate 11.1% (3/27), conversion rate 3.7%, resident involvement 66.7% (18/27). Conclusion: Robotic-assisted foregut surgery is safe and effective. This series compares favorably with other robotic studies in length of hospital stay, total case time, and complication and conver-sion rates. Foregut surgery is an excellent robotic training ground for residents.

Intrathoracic major duodenal papilla with transhiatal herniation of the pancreas and duodenum:A case report and review of the literature

Transhiatal herniation of the pancreas is an extremely rare condition.In the published literature we found only eleven cases reported in the period of 1958 to 2011.A coincidental hiatal herniation of the duodenum is described in two cases only.To our knowledge,we report the first case with a hiatal herniation of the complete duodenum and proximal pancreas presenting an intrathoracic major duodenal papilla with consecutive intrahepatic and extrahepatic cholestasis.A 72-yearold Caucasian woman was admitted to our department with a hiatal hernia grade Ⅳ for further evaluation.According to our recommendation of surgical hernia repair soon after the diagnosis of a transhiatal herniation of the proximal pancreas and entire duodenum,we had to respect the declared intention of the patient for a conservative procedure.So we were forced to wait for surgical repair within an emergency situation complicated by a myocardial infarction and reduced general condition.We discuss the therapeutic decision making process and a complete literature review of this rare entity.

Rare sequalae of hiatal hernia causing pancreatitis and hepatitis:A case report

Hiatal hernia(HH) contents commonly include stomach, transverse colon, small intestine, and spleen but herniation of the pancreas is an extremely rare phenomenon.79-year-old female with multiple comorbidities presented to emergency department with complaints of weight loss for 6 mo and abdominal pain for one day. Physical examination revealed cachectic and dehydrated female and bowel sounds could be auscultated on the right side of chest. Computed tomography of the chest and abdomen revealed interval enlargement of a massive HH,containing stomach and much of the bowel as well as pancreas and distal extrahepatic biliary duct, probably responsible for obstructive effect upon same. There was increased prominence of the pancreas consistent with pancreatitis. There was a large HH causing obstructive effect with dilated biliary system along gall bladder wall edema and pancreatitis. Patient clinical status improved with conservative treatment.HH presenting with acute pancreatitis is a serious diagnostic and therapeutic challenge. The initial management is conservative, even if the abdominal content has herniated to mediastinum. The incentive spirometry can be utilized in the conservative of the large HH. After stabilization of the patient, elective surgical intervention remains the mainstay of the management. Definitive treatment will vary from case to case depending on the acuity of situation and comorbidities.

Long-term outcome of laparoscopic Nissen-Rossetti fundoplication versus Thal fundoplication in children with esophageal hiatal hernia: a retrospective report from two children's medical centers in Shanghai

Background: This study was undertaken to investigatethe intraoperative and postoperative complications,efficacy and outcome of two laparoscopic fundoplicationsfor the treatment of esophageal hiatal hernia in children.Methods: To find a rational procedure, we performeda retrospective analysis of 136 children with esophagealhiatal hernia who underwent laparoscopic Nissen-Rossettior Thal fundoplication at two children's hospitals inShanghai over 13 years. The median follow-up time of thechildren was 42 months (range: 1-138 months). Their agevaried from 1 month to 11 years (median: 18.6 months).Results: All the children underwent laparoscopicfundoplications (72 cases of Nissen-Rossetti and 60 casesof Thal fundoplication) and 4 children converted to opensurgery. The mean age of the children at the time ofoperation was 1.6±1.9 years, and the mean weight was9.1±5.6 kg. Gastroesophageal refl ux was signifi cantly moresevere after a Thal fundoplication (P=0.003) and slightesophageal stenosis was signifi cant after a Nissen-Rossettifundoplication (P=0.02). The recurrent rate of hiatal herniawas 2.8% (2/72) after Nissen-Rossetti fundoplication incontrast to 5% (3/60) after Thal fundoplication. No deathoccurred after surgery.Conclusions: There was no statistical difference ofrecurrence between laparoscopic Nissen-Rossetti and Thalfundoplication in the long-term outcomes. The rate of slightdysphagia was higher in the Nissen-Rossetti group. TheThal group had a significantly higher recurrence rate ofgastroesophageal reflux. There still exited learning curvefor this procedure. The incidence rate of complications issignifi cantly related to the profi ciency of pediatric surgeon.

Evaluation of the Quality of Life in Pre- and Post-Operatory in Patients Submitted to Surgical Treatment of Reflux Disease and Hiato Hernia

Gastroesophageal reflux disease affects 40% of the population in industrialized countries. GERD has a negative impact on the quality of life of affected patients. Although PPIs induce a good response in the control of symptoms, the need for prolonged use of the medication and the fact that more than a third of the patients have symptoms even after its correct use, make surgery, an alternative for the treatment of the disease. The aims of this study were to compare the quality of life related to GERD before and after MIS surgical treatment of GERD and/or hiatus hernia, and to analyze the results and complications of the MIS treatment of GERD. Methods: For retrospective analysis, the electronic database of patients with indications for surgical treatment due to GERD and/or patients with sliding or paraesophageal hernias was examined. The study included patients from Hospital Universitário Gaffrée e Guinle and the Postgraduate Course in General Surgery at PUC-Rio (Rio de Janeiro, Brazil) who underwent surgery using video laparoscopy or robotic surgery between January 2013 and March 2020. This is an observational, longitudinal, descriptive study with retrospective analysis of the data. Surgical treatment was indicated due to incomplete response to clinical treatment, young age with persistent symptoms, or complications of GERD. Patients with hiatus and/or paraesophageal hernia with indication for surgical treatment were included. Results: The study evaluated 160 patients who underwent anti-reflux surgery by laparoscopic or robotic surgery in the period from 2013 to 2020. A total of 88 women and 72 men were operated, mean 46.6 ± 13.7 years. An improvement in the preoperative QS-GERD scores compared to the postoperative scores was observed (27.56 ± 10.93 vs 1.4 ± 2.47, p < 0.01). Additionally, it was observed that there was no association between worse prognosis and failure rate with gender, sex, age, body mass index, surgical technique, or the number of sutures on the fundoplication valve. The length of hospital stay was 24 hours in 74.2% of patients, 48 hours in 19.3%, and 72 hours in 4.6%, with a global median of 24 hours and a mean of 28.7 hours. No patient required blood transfusion;none had early postoperative complications (seroma, wound infection, or eventration), or died. Conclusion: A significant drop in the QS-GERD score was found before and after the surgical treatment of GERD and or hiatus hernia. The MIS surgical treatment of GERD controlled the symptoms in most of the treated individuals, presenting a low rate of complications without mortality.

Investigating causal links between gastroesophageal reflux disease and essential hypertension

Gastroesophageal reflux disease(GERD)is a prevalent global health concern with a rising incidence.Various risk factors,including obesity,hiatal hernia,and smo-king,contribute to its development.Recent research suggests associations bet-ween GERD and metabolic syndrome,cardiac diseases,and hypertension(HTN).Mechanisms linking GERD to HTN involve autonomic dysfunction,inflammatory states,and endothelial dysfunction.Furthermore,GERD medications such as pro-ton-pump inhibitors may impact blood pressure regulation.Conversely,antihy-pertensive medications like beta-blockers and calcium channel blockers can exacerbate GERD symptoms.While bidirectional causality exists between GERD and HTN,longitudinal studies are warranted to elucidate the precise relationship.Treatment of GERD,including anti-reflux surgery,may positively influence HTN control.However,the interplay of lifestyle factors,comorbidities,and medications necessitates further investigation to comprehensively understand this relation-ship.In this editorial,we comment on the article published by Wei et al in the recent issue of the World Journal of Clinical Cases.We evaluate their claims on the causal association between GERD and HTN.