The use of small intestine submucosa in the repair of paraesophageal hernias: initial observations of a new technique

BACKGROUND: Recent reports suggest that when laparoscopy is used to repair paraesophageal hernias recurrence rates reach 20% to 40%. Tension-free hernia closure with synthetic mesh reduces recurrence but occasionally results in esophageal injury. We hypothesized that reinforcement of the hiatal closure with small intestine submucosa (SIS) mesh, in some unusually large hernias, might reduce recurrence rates without causing injury to the esophagus. METHODS: From January 2001 to March 2002 we treated 18 large paraesophageal hernias via a laparoscopic approach. In 9 of the largest hernias (one type II and 8 type III, of which 1 was recurrent) the repair was reinforced with SIS mesh (Surgisis, Cook Surgical) and represent the subjects of this study. Nissen fundoplication with gastropexy was performed in all patients. Clinical follow-up ranged from 3 to 16 months (median 8). Every patient was evaluated with barium esophagram or endoscopy or both 1 to 8 months (median 2) postoperatively. RESULTS: The presenting symptoms were postprandial pain/fullness (9 of 9), heartburn (4 of 9), anemia (4 of 9), dysphagia (3 of 9), regurgitation (3 of 9), and chest pain (3 of 9). One patient died of a hemorrhagic stroke within 30 days of the operation. Postoperatively, presenting symptoms resolved (83%) or improved (17%) in each of the remaining 8 patients. One patient required endoscopic dilation for mild dysphagia. Seven of 8 patients had a normal barium esophagram without evidence of hernia. One morbidly obese (body mass index = 47) patient had a small (2 cm) sliding hiatal hernia postoperatively. There were no other complications, and specifically no perforations or mesh erosions. CONCLUSIONS: These observations suggest that the use of SIS in the repair of paraesophageal hernias is safe and may reduce recurrence. Longer follow-up and a randomized study are needed to validate these results.     

Outcomes of laparoscopic‐assisted transhiatal esophagectomy for adenocarcinoma of the esophagus and esophago‐gastric junction

Esophagectomy is associated with substantial morbidity and mortality, yet it is the only modality that offers the possibility of cure for esophageal and gastroesophageal junction (E‐GEJ) adenocarcinoma. Several minimally invasive techniques have been developed to decrease the morbidity of the operation, but to date, the results have not led to its wide adoption in part due to their complexity. We developed a technique of laparoscopic‐assisted transhiatal esophagectomy (LA‐THE) with the idea of preserving some of the advantages of the minimally invasive approach while eliminating the degree of complexity and the time required to complete the operation solely using laparoscopy. The course of all patients who underwent LA‐THE for E‐GEJ adenocarcinoma at the University of Washington Medical Center was determined by analysis of all hospital records to determine perioperative variables, complications, and survival. Patients were also given a follow‐up survey in order to assess long‐term health‐related quality of life (Gastrointestinal Quality of Life Index or GIQLI). Seventy‐two patients underwent LA‐THE between 1995 and 2007. Median age was 64 years (range, 42–83 years), and the median body mass index was 28 (range 17–35). Twenty‐eight tumors (39%) were categorized as Siewert I, 41 (57%) as Siewert II, and 3 (4%) as Siewert III. Median operative time was 299 min (range, 212–700 min). All the resections were R‐0. The median number of lymph nodes harvested was 11 (range, 2–32). Using the Dindo‐Clavien classification of surgical complication, we had a total of 48 postoperative complications in 37 patients: 26 (53%) grade I, 20 (41%) grade II, 1 (2%) grade IIIb, 1 (2%) grade IVb, and 1 (2%) grade V complications. Median length of hospital stay was 9 days (range, 7–58 days). One patient (1.4%) died within 30 days. Overall, 3‐ and 5‐year survival (calculated Kaplan–Meier) was 68% and 63%, respectively. Forty‐nine patients (90% of those still alive) answered the GIQLI survey. Median follow‐up was 26 months (range, 6–144 months). The mean GIQLI score was 108 (range, 74–138) from a maximum possible value of 144. Our study shows that LA‐THE is feasible, safe, and effective in the treatment of adenocarcinoma of the esophagus and GEJ and should probably be considered an alternative to open esophagectomy and other minimally invasive techniques in the treatment of this disease.     

The safety of biologic mesh for laparoscopic repair of large,complicated hiatal hernia

Background  

Biologic mesh is widely used for repair of large, complicated hiatal hernias. Recently, there have been reports of complications after its implantation. We studied the course of a large group of patients who had undergone hiatal hernia repair with use of biologic mesh to determine the rate of immediate and late complications related to its use.     

Comprehensive evaluation of endoscopic fundoplication using the EsophyX<Superscript>TM</Superscript> device

Background  

There are limited studies that evaluate the efficacy of endoscopic fundoplication (EF) for gastroesophageal reflux disease (GERD) with the EsophyX^TM device, especially with the most recent procedural iteration (TIF-2). This study was a prospective evaluation of our early experience with this device and procedure.     

Laparoscopic sleeve gastrectomy: an alternative for recurrent paraesophageal hernias in obese patients.

BACKGROUND: Recurrent paraesophageal hernias in obese patients are technically challenging and have a high recurrence rate. We sought to develop an alternative to the traditional approaches for this problem. This article describes the use of a sleeve gastrectomy in an obese patient with a large recurrent paraesophageal hernia. CASE REPORT: A morbidly obese 70-year-old woman presented with a 1-year history of chest pain, cough, dysphagia, and dyspnea. She had undergone an open paraesophageal hernia repair 8 years earlier. Diagnostic workup revealed a recurrent large paraesophageal hernia. Laparoscopically, we took down all adhesions, excised the hernia sac, reduced the stomach and distal esophagus into the abdomen, and closed the hiatus. We then resected the greater curvature and fundus of the stomach, leaving the lesser curve in a sleeve configuration. Eighteen months after the operation, the patient's chest pain, cough, dyspnea, and dysphagia were resolved. In addition, she has lost 57 pounds (255 to 198). CONCLUSION: A sleeve gastrectomy is a potentially useful alternative to fundoplication or gastropexy, or both of these, in the treatment of obese patients with complex paraesophageal hernias.