Prospective study of giant paraesophageal hernia repair with 1-year follow-up

Prospective study of giant paraesophageal hernia repair with 1-year follow up .By Stringham et al. The Journal of Thoracic and Cardiovascular Surgery 2017 (in press) This paper faces the unresolved problem of the evaluation of anatomical recurrence after surgery for big intra thoracic hiatus hernias. I do congratulate with the authors because they put in discussion the concept that after surgery for hiatal hernia (HH), a small recurrence is “good” . Several authors have stated that a relapsed hernia smaller than 2 cm is inconsequential to the final outcome, if the patient is asymptomatic [1,2]. We consider any type of anatomical relapse as a surgical failure because the primary aim of any hernia surgery is anatomical repair [3]. The evolution of sliding HH into massive, rolling, HH was clearly shown [4]. Recurred HH may not behave differently; unfortunately data on this aspect are only episodic. This manuscript, with the interesting comments of the surgeons attending at the presentation, offers to me also the opportunity to point out a few concepts that should help to clarify some aspects of the text and to answer a few questions raising from the text and the discussion. The reference to “ giant para esophageal hiatus hernia “ may be not appropriate because in para esophageal hernia the gastro-esophageal junction is located below the hiatus [5,6]. Landrenau distinguished non axial HH in type II (para-esophageal), type III and type IV, including in the latter types massive intra thoracic hernias of the stomach [7,8]. With the intra operative assessment of the position of the gastro-esophageal junction with respect to the hiatus [8, 9], we demonstrated that a true short esophagus is present in 57% of type III and IV HH and in 0% of type II ( para esophageal) HH [9] . In type II HH, the size of the rolled portion of the fundus aside the lower thoracic esophagus is never as big as the gastric herniation of types III and IV. According to the current classifications of HH and our study [9], the link among para esophageal HH, short esophagus and the Collis gastroplasty is not appropriate. With regard to 1) the follow up of patients operated upon for Type III-IV HH, 2) the recurrence rate of < 2 cm HH, 3) the HH recurrence in relation to the presence of short esophagus and the adoption of the Collis gastroplasty, I would offer some data of our group for discussion. Since the late seventies, we followed up patients submitted to HH and GERD surgery according to a prospective protocol based on clinical interview, UGI tract endoscopy and barium swallow. Controls were centralized, dedicated radiologists performed the barium swallow with the precise purpose to assess every minimal migration of the gastro-esophageal junction or of the fundoplication across or above the diaphragmatic hiatus, which was defined “hernia relapse”; in our reports, in the presence of any minimal anatomic relapse, result of surgery was quoted as poor. In one of our studies, we considered 105 patients operated upon for type III and IV HH with open (abdominal Nissen and Steichen Collis-Nissen, Belsey MKIV and Pearson operations) and minimally invasive (laparoscopic Nissen or laparoscopic-left thoracoscopic Collis-Nissen) procedures. For this case series, we judged subjectively the length of the esophagus, we performed the Collis gastroplasty when we felt that the gastro-esophageal junction was still above the hiatus after maximal esophageal mobilization. Patients were followed up for a median period of 96 months: 5 HH relapses occurred after open surgery (5/59, 8%) and 2 after minimally invasive surgery (2/46, 4%) [3]. In another study we considered 64 patients operated upon of left thoracoscopic Collis–laparoscopic Nissen for intra operatively assessed true short esophagus [10], of whom 40% had type III-IV HH. Satisfactory results were obtained in 94% (60/64 cases) with a median follow-up of 96 months; 2 of the poor outcomes were due to reflux esophagitis, and 2 were due to a < 2cm HH recurrence [10]. In the last 80 cases of type III-IV HH we operated upon, we actually performed the left thoracoscopic Collis gastroplasty in some 60%; when after extended esophageal mobilization, the submerged esophageal segment is still shorter than 1.5-2 centimeters, in overweight/obese patients we adopt the esophagus lengthening procedure. Since the early eighties, in all cases the diaphragmatic hiatus was carefully closed with interrupted non absorbable sutures reinforced with pledgets, any kind of mesh was avoided; in the long term we never had complications secondary to those “foreign bodies” [3,10]. Hoping to provide useful elements for future discussion and for clinical practice, I renewal my gratitude for this interesting paper. Yours cordially Sandro Mattioli MD FECTS FACS AATS. Bibliography 1. Luketich JD, Nason KS, Christie NA, Pennathur A, Jobe BA, Landreneau RJ et al. Outcomes after a decade of laparoscopic giant paraesophageal hernia repair. J Thorac Cardiovasc Surg 2010;139:395–404. 2. Low DE, Unger T. Open repair of paraesophageal hernia: reassessment of subjective and objective outcomes. Ann Thorac Surg 2005;80:287–94. 3. Lugaresi M, Mattioli B, Daddi N, Di Simone MP, Perrone O, Mattioli S. Surgery for Type III–IV hiatal hernia: anatomical recurrence and global results after elective treatment of short oesophagus with open and minimally invasive surgery. Eur J Cardiothorac Surg. 2016;49(4):1137-43. 4. Hiebert CA. Massive Incarcerated Hiatal Hernia. In: Esophageal Surgery. F.G. Pearson, Deslauriers J, Ginsberg RJ, Hiebert CA, McKneally MF, Urschel HC editors. Churchill-Livingstone, New York 1995: 267-271. 5. Skinner DB, Belsey RH. Surgical management of esophageal reflux and hiatus hernia. Long-term results with 1,030 patients. J Thorac Cardiovasc Surg. 1967 Jan;53(1):33-54. 6. Landreneau RJ, Johnson JA, Marshall JB, Hazelrigg SR, Boley TM, Curtis JJ. Clinical spectrum of paraesophageal herniation. Dig Dis Sci. 1992; 37(4):537-44. 7. Landreneau RJ, Del Pino M, Santos R. Management of paraesophageal hernias. Surg Clin North Am. 2005 Jun;85(3):411-32. 8. Mattioli S, Lugaresi ML, Costantini M, Del Genio A, Di Martino N, Fei L, Fumagalli U, Maffettone V, Monaco L, Morino M, Rebecchi F, Rosati R, Rossi M, Santi S, Trapani V, Zaninotto G The short esophagus: intraoperative assessment of esophageal length. J Thorac Cardiovasc Surg. 2008;136(4):834-41. 9. Lugaresi M, Mattioli S, Aramini B, D'Ovidio F, Di Simone MP, Perrone O.The frequency of true short oesophagus in type II-IV hiatal hernia. Eur J Cardiothorac Surg. 2013 ;43(2):e30-6. 10. Lugaresi M, Mattioli B, Perrone O, Daddi N, Di Simone MP, Mattioli S. Results of left thoracoscopic Collis gastroplasty with laparoscopic Nissen fundoplication for the surgical treatment of true short oesophagus in gastro-oesophageal reflux disease and Type III-IV hiatal hernia. Eur J Cardiothorac Surg. 2016 Jan;49(1):e22-30.