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Hiatal dissection, restoration of esophageal intra-abdominal length, and crural closure are key components of successful antireflux surgery. The necessity of addressing these components prior to magnetic sphincter augmentation (MSA) has been questioned. We aimed to compare outcomes of MSA between groups with differing hiatal dissection and closure. We retrospectively reviewed 259 patients who underwent MSA from 2009 to 2017. Patients were categorized based on hiatal treatment: minimal dissection (MD), crural closure (CC), formal crural repair (FC), and extensive dissection without closure (ED). The primary outcome was normalization of postoperative DeMeester score (≤ 14.72). Univariable and multivariable logistic regression was used to assess which preoperative predictors achieved normalization. Of the 197 patients, MD was used in 81 (41%); FC in 42 (22%); CC in 40 (20%); and ED in 34 (17%). Normalization occurred in 104 (53%) patients, with MD achieving normalization in 45/81 (56%); FC in 25/42 (60%); CC in 21/40 (53%); and ED 13/34 (38%). After regression, FC was most likely to normalize acid exposure. The presence of a hiatal hernia, defective LES, and higher preoperative DeMeester score were less likely to achieve normalization. Hiatal dissection with restoration of esophageal length and crural closure during MSA increases the likelihood of normalizing acid exposure.

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. A retrospective case-controlled analysis of 106 consecutive patients with short esophagus undergoing Hill-Nissen (HN) or Collis-Nissen (CN) was compared to a cohort of 105 matched patients without short esophagus undergoing primary Nissen fundoplication (NF). At a median follow-up of 27 months, all groups (HN:CN:NF) improved significantly over preoperative baseline with no differences in overall complications (18 vs 16 vs 19%, p = 0.78), DeMeester score (11.1 vs 19.1 vs 14.2, p = 0.49), postoperative PPI use (16 vs 22 vs 15%, p = 0.24), anatomic recurrences (11.7 vs 5.5 vs 7%, p = 0.43), or quality of life (6.8 vs 6.7 vs 6.4, p = 0.3). The management of shortened esophagus with Hill-Nissen is safe and as effective as Collis gastroplasty with Nissen fundoplication. Both options appear to produce similar outcomes to patients requiring only a Nissen fundoplication suggesting a shortened esophagus does not beget an inferior outcome.

Per oral endoscopic myotomy (POEM) is increasingly utilized to treat patients with achalasia. Early results have demonstrated significant improvement of symptoms, but there are concerns about postoperative reflux. With only limited comparative data available, we sought to compare POEM to laparoscopic Heller myotomy (LHM) with partial fundoplication. This is a retrospective review of 42 POEM and 84 LHM patients undergoing primary myotomy for achalasia. Patients were matched by achalasia type, by Eckardt and dysphagia scores, and by quality of life (QOL) metrics. Analysis at 6–12-month follow-up evaluated these metrics, PPI use, pH, manometric, and endoscopic data. We matched 25 patients with achalasia types I (6), II (13), and III (6). Follow-up was longer for LHM at 158.1 (36.5–272.9) weeks versus 36.2 (22.2–41.2) weeks (p = 0.001). Eckardt scores, QOL metrics, and dysphagia significantly improved in both groups. DeMeester scores and total percent time less than 4 were abnormal in both groups and comparable (p = 0.925 and p = 0.838). Esophagitis was seen in 53.4 % (POEM) and 31.6 % (LHM) (Yates’ p = 0.91), and PPI use was equivalent at 36 %. Early clinical outcomes are excellent with POEM and comparable to the standard of care LHM. Long-term follow-up is required as concerns for reflux persist.

We compared clinical and objective outcomes of combined Nissen-Hill hybrid (HYB) to Nissen fundoplication (LNF) for repair of paraesophageal hernia (PEH). This study is a single-institution retrospective chart review of prospectively collected data for consecutive patients undergoing PEH repair from 2006 to 2015 with at least 6 months of follow-up. Quality of life metrics (QOLRAD, HRQL, and dysphagia), manometry, radiographic imaging, and pH testing were administered pre- and postoperatively. With 319 repairs (HYB = 141, LNF = 178), the groups were comparable in age and gender, but HYB had a higher BMI (30.95 vs 29.27, p

Laparoscopic Nissen fundoplication is comprised of: a wrap thought responsible for the lower esophageal sphincter function and crural closure performed to prevent herniation. We hypothesized gastroesophageal junction competence effected by Nissen fundoplication results from closure of the crural diaphragm and creation of the fundoplication. Patients with uncomplicated reflux undergoing Nissen fundoplication were prospectively enrolled. After hiatal dissection, patients were randomized to crural closure followed by fundoplication (group 1) or fundoplication followed by crural closure (group 2). Intra-operative high-resolution manometry collected sphincter pressure and length data after complete dissection and after each component repair. Eighteen patients were randomized. When compared to the completely dissected hiatus, the mean sphincter length increased 1.3 cm (p