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Background: An increasing number of reflux patients opt for magnetic sphincter augmentation (MSA) instead of fundoplication. However, few studies compare the medium-term efficacy and safety of the procedures. Methods: We conducted a retrospective single-center analysis of consecutive MSA and Nissen fundoplication cases between 01/2015 and 06/2020. Patients underwent surgery, including hiatoplasty, for medical treatment-resistant reflux due to hiatal hernia. Surgical revision and proton pump inhibitor (PPI) reuptake rates were the primary outcomes. We also compared adverse event rates. Patients with severe preoperative dysphagia/motility disorders were assigned different treatment pathways and excluded from the analysis. We used propensity-score matching to reduce confounding between treatments. Results: Out of 411 eligible patients, 141 patients who underwent MSA and 141 with fundoplication had similar propensity scores and were analyzed. On average, patients were 55 ± 12 years old and overweight (BMI: 28 ± 5). At 3.9 years of mean follow-up, MSA was associated with lower surgical revision risk as compared to fundoplication (1.2% vs 3.0% per year, respectively; HR: 0.38; 95% CI 0.15–0.96; p = 0.04), and similar PPI-reuptake risk (2.6% vs 4.2% per year; HR: 0.59; 95% CI 0.30–1.16; p = 0.12). Adverse event rates during primary stay were similar (MSA vs. fundoplication: 1% vs. 3%, p = 0.68). Fewer patients experienced adverse events in the MSA group after discharge (24% vs. 33%, p = 0.11), driven by higher rates of self-limiting dysphagia (1% vs. 9%, p < 0.01) and gas/bloating (10% vs. 18%, p = 0.06) after fundoplication. Differences between MSA and fundoplication in dysphagia requiring diagnostic endoscopy (11% vs. 8%, p = 0.54) or surgical revision (2% vs. 1%, p = 1.0) were non-significant. The device explantation rate was 4% (5/141). Conclusion: MSA reduces the re-operation risk compared to fundoplication and may decrease adverse event rates after discharge. Randomized head-to-head studies between available surgical options are needed. [ABSTRACT FROM AUTHOR]

Background: Globus pharyngeus is a clinical condition, wherein, a patient senses a lump or a foreign body in the throat with a tightening or choking feeling. A strong association between globus pharyngeus and gastroesophageal reflux disease (GERD) was reported. Therefore, we sought to investigate the predictive factors of globus pharyngeus in patients with established GERD and fit a predictive scoring model for globus pharyngeus. Methods: In this case-control study, 143 patients having globus pharyngeus along with GERD (case) and 109 patients having globus pharyngeus without GERD (control) were enrolled. Data comprising demographics, comorbidities, and psychosocial stress levels were recorded. The predictive factors of globus pharyngeus in patients with GERD were unraveled, and a predictive scoring model was fit for globus pharyngeus. Results: Proton pump inhibitor usage in the case group was significantly higher compared to controls (63.63% vs 24.78%, P < 0.001), and differences in Hiatus Hernia and Stress levels were highly significant between the two groups (P < 0.001). Multivariate logistic regression revealed that variates, Hiatus Hernia, psychosocial stress, and age were highly significant (P < 0.001) independent predictors of globus pharyngeus. Using the regression coefficients of all the independent predictor variables, a predictive scoring model was fitted, which yielded an area under receiver operating characteristic (AUROC) curve of 78.9. Conclusion: Hiatus hernia, psychosocial stress, and age are significant independent predictors of globus pharyngeus in GERD, and our predictive scoring model may help in identifying patients at higher odds of experiencing globus pharyngeus and modulate treatment accordingly. [ABSTRACT FROM AUTHOR]

The aim of this report is to describe the management of an iatrogenic diaphragmatic eventration following surgery to relieve neurogenic symptoms of thoracic outlet syndrome in a patient with a prior history of sleeve gastrectomy. We discuss the case of a 46-year-old woman with a 6-month history of gastro-oesophageal reflux and dyspnoea. Imaging demonstrated a left hemidiaphragm eventration and hiatus hernia. The patient underwent laparoscopic plication of the left hemidiaphragm, repair of the hiatus hernia, and an omega loop gastric bypass, with satisfactory resolution of her symptoms. This demonstrates that surgical diaphragmatic plication has good outcomes in cases where the abdominal anatomy is already altered as a result of previous bariatric surgery, and that concurrent hiatus hernia repair, plication of iatrogenic diaphragm eventration, and sleeve to gastric bypass conversion satisfactorily relieve reflux and dyspnoea in a morbidly obese patient. [ABSTRACT FROM AUTHOR]

Introduction: The anatomy of the esophageal hiatus is altered during esophagogastric surgery with an increased risk of postoperative hiatus hernia (HH). The purpose of this article was to examine the current evidence on the surgical management and outcomes associated with HH after esophagogastric surgery for cancer. Materials and methods: Systematic review and meta-analysis. Web of Science, PubMed, and EMBASE data sets were consulted. Results: Twenty-seven studies were included for a total of 404 patients requiring surgical treatment for HH after esophagogastric surgery. The age of the patients ranged from 35 to 85 years, and the majority were males (82.3%). Abdominal pain, nausea/vomiting, and dyspnea were the commonly reported symptoms. An emergency repair was required in 51.5%, while a minimally invasive repair was performed in 48.5%. Simple suture cruroplasty and mesh reinforced repair were performed in 65% and 35% of patients, respectively. The duration between the index procedure and HH repair ranged from 3 to 144 months, with the majority (67%) occurring within 24 months. The estimated pooled prevalence rates of pulmonary complications, anastomotic leak, overall morbidity, and mortality were 14.1% (95% CI = 8.0–22.0%), 1.4% (95% CI = 0.8–2.2%), 35% (95% CI = 20.0–54.0%), and 5.0% (95% CI = 3.0–8.0%), respectively. The postoperative follow-up ranged from 1 to 110 months (mean = 24) and the pooled prevalence of HH recurrence was 16% (95% CI = 13.0–21.6%). Conclusions: Current evidence reporting data for HH after esophagogastric surgery is narrow. The overall postoperative pulmonary complications, overall morbidity, and mortality are 14%, 35%, and 5%, respectively. Additional studies are required to define indications and treatment algorithm and evaluate the best technique for crural repair at the index operation in an attempt to minimize the risk of HH. [ABSTRACT FROM AUTHOR]

Introduction: Symptomatic paraesophageal hernia (PEH) is an indication for surgical repair. Laparoscopic suture repair has high recurrence rates. Many surgeons prefer mesh repair to reduce PEH recurrence. Several types of mesh, synthetic and biological, are in use. Synthetic mesh has a risk of erosion and stricture, hence we preferred biological mesh repair. Our aim in this study is to assess medium-term outcomes of PEH repair with the use of biological mesh reinforcement over the cruroplasty. We also aimed to correlate clinical recurrences with radiological recurrences. Materials and Methods: This is a retrospective study of 154 consecutive patients from a single centre who underwent a standardized laparoscopic suture repair of the hiatus reinforced with an on-lay patch of Surgisis (porcine small intestine submucosa) and fundoplication. The mean age of the patients was 65 years. All patients were called for regular clinical follow-up and a barium study. Modified GERD-HRQL symptom severity instrument was used to assess postoperative symptoms and satisfaction. Results: The mean follow-up for barium swallow and clinical assessment were 28.42 ± 21.2 and 33.69 ± 23.46 months. The mean patient satisfaction score after surgery was 4.43 ± 1.09 (0-5). Follow-up barium swallow was performed in 122 (79.22%), 87 (56.49%) patients completed clinical follow-up questionnaire, and 77 (50%) had both. Symptomatic recurrence was noted in 25 (28.73%), recurrence on barium swallow 25(20.4%), and 10 (12.98%) had both. The reoperation rate was 3.25%. Mann-Whitney U test showed no statistical significance in reflux-related score between radiological recurrence group compared with no radiological recurrence (P = .06). Conclusions: Biological mesh repair of PEH is safe and well accepted by patients. There is significantly high PEH recurrence rate in long-term follow-up, even with mesh repair. Majority of these recurrences are small, asymptomatic, and the reoperation rate is very low. [ABSTRACT FROM AUTHOR]

Background: Hiatus herniae are commonly seen at endoscopy. Many patients with a large hiatus hernia are endoscoped for symptoms associated with the hernia and many of these will progress to surgical treatment. However, little is known about the natural history of small to medium size hiatus herniae, and their risk of progressing to a larger hernia requiring surgery. This study aims to determine the need for subsequent surgery in these patients. Methods: A retrospective audit of the endoscopy database at Flinders Medical Centre and the Repatriation General Hospital in Adelaide, South Australia for the 2‐year period 2002–2003 was performed to identify all patients with a hiatus hernia. Patients under the age of 65 and with a sliding hiatus hernia <5 cm in length were selected for this study, and sent a questionnaire which determines the long‐term (>10 years) outcome of these herniae. Results: Small‐ to medium‐sized hiatus herniae (<5 cm length) were found at 10% of endoscopies performed. In this group, 38% had reflux as the indication for endoscopy. 1.5% subsequently progressed to anti‐reflux surgery or hiatus hernia repair. Thirty‐nine percent reported being on proton pump inhibitors for symptom control. No patients required emergency surgical repair of their hiatus hernia. Conclusion: While patients with small‐ to medium‐sized sliding hiatus hernia commonly have symptomatic reflux, an acute problem requiring emergency surgery is unlikely over long‐term follow‐up. [ABSTRACT FROM AUTHOR]

Background: To investigate the relationship between endoscopic and esophageal manometric hiatus hernia (HH).Methods: Forty-six gastroesophageal reflux disease patients with endoscopic HH under maintenance therapy were recruited. Endoscopy was performed on all patients in a fully conscious state. Endoscopic HH was defined as apparent separation greater than 1 cm of the lower margin of the esophageal palisade vessels and the diaphragm hiatus on endoscopy under deep inspiration. Esophageal manometry was conducted using high-resolution manometry (HRM). The length between the lower margin of the lower esophageal sphincter and pulmonary inversion point was measured 10 times. The mean and maximum of the length was then calculated.Results: The mean HH length on HRM was 0 cm (0-0) [median (25th to 75th percentile)], 0 cm (0-0), 0.5 cm (0-1.1), and 2.2 cm (1.3-2.5) in the groups with endoscopic HH lengths of 1-2, 2-3, 3-4, and 4-5 cm, respectively. The maximum HH length on HRM was 0 cm (0-0), 0 cm (0-0), 0.8 cm (0-1.4), and 2.4 cm (1.5-2.9) in the 1-2, 2-3, 3-4, and 4-5 cm endoscopic HH groups, respectively. The mean and maximum HH lengths increased significantly in the group with an endoscopic HH length of 4-5 cm compared with the other groups, but did not differ significantly among the 1-2, 2-3, and 3-4 cm groups. Of patients with endoscopic HH less than 3 cm, few had esophageal manometric HH greater than 2 cm.Conclusions: Endoscopic diagnosis of HH under deep inspiration is not consistent with esophageal manometric diagnosis, leading to overdiagnosis. [ABSTRACT FROM AUTHOR]

Cameron lesions, as defined by erosions and ulcerations at the diaphragmatic hiatus, are found in the setting of gastrointestinal ( GI) bleeding in patients with a hiatus hernia ( HH). The study aim was to determine the epidemiology and clinical manifestations of Cameron lesions. We performed a retrospective cohort study evaluating consecutive patients undergoing upper endoscopy over a 2-year period. Endoscopy reports were systematically reviewed to determine the presence or absence of Cameron lesions and HH. Inpatient and outpatient records were reviewed to determine prevalence, risk factors, and outcome of medical treatment of Cameron lesions. Of 8260 upper endoscopic examinations, 1306 (20.2%) reported an HH. When categorized by size, 65.6% of HH were small (<3 cm), 23.0% moderate (3-4.9 cm), and 11.4% were large (≥5 cm). Of these, 43 patients (mean age 65.2 years, 49% female) had Cameron lesions, with a prevalence of 3.3% in the presence of HH. Prevalence was highest with large HH (12.8%). On univariate analysis, large HH, frequent non-steroidal anti-inflammatory drug ( NSAID) use, GI bleeding (both occult and overt), and nadir hemoglobin level were significantly greater with Cameron lesions compared with HH without Cameron lesions ( P ≤ 0.03). Large HH size and NSAID use were identified as independent risk factors for Cameron lesions on multivariate logistic regression analysis. Cameron lesions are more prevalent in the setting of large HH and NSAID use, can be associated with GI bleeding, and can respond to medical management. [ABSTRACT FROM AUTHOR]

Laparoscopic paraoesophageal hernia repair is a challenging procedure, both in surgical technical difficulty and in prevention of recurrence, in the setting of operating on an older patient cohort with associated co-morbidities. However, modifications based on sound surgical principles can lead to better outcomes. This article describes and illustrates in detail the technique for the laparoscopic repair of paraoesophageal hernia without mesh with cardio-oesophageal junction fixation. The data and results of the study supporting this technique have been published previously by Gibson et al. (Surgical Endoscopy 27: 618-623, ). The previously published article has reported on the numbers of patients, mean age, American Society of Anesthesiologists Physical Status Classification System, body mass index, duration of follow-up, complications, Visick scores and quality of life pre- and post-operatively. The principles of complete reduction of the hernia sac, preservation of both crura, mobilisation of the phreno-oesophageal ligament and phreno-gastric attachments, adequate mediastinal mobilisation of the oesophagus and the cardio-oesophageal junction into the abdomen without tension, preservation of both vagi, a tension-free crural repair including the fascial aspects adjacent to the diaphragm, an anterior hiatal repair in combination with the recognised posterior approximation, a loose fundoplication and a secure cardiopexy to the median arcuate ligament and multiple points of attachment; we have found leads to good operative results(Gibson et. al.) without the need for mesh. This article outlines in detail the operative technique guided by these principles with annotated intra-operative photographs illustrating the anatomy and procedure. The technique used by our team since March 2009 for the last 154 cases, based on the experience of an aggregate of 544 cases since 1999, we believe results in an acceptable level of symptomatic and anatomic recurrence without using mesh. [ABSTRACT FROM AUTHOR]

Esophagitis is a condition found in a large population with gas- troesophageal reflux disease and may be erosive or non-erosive. Ero- sive esophagitis reflux is defined as the presence of endoscopically visible erosions in the mucosa of the distal esophagus. This study aims to investigate the relationship between the various grades of esophagitis and hiatal hernia size, and see if there is a direct relationship or not the size of hiatal hernia with esophagitis grade of the patients studied. We used data from examinations endoscopies from January to July 2011 of Digestive Endoscopy Service Regional Hospital João de Freitas, being included in the study patients with endoscopic findings of esophagitis with or without hiatal hernia, totaling 478 patients. Were excluded from the study patients without esophagitis, those with eosinophilic esophagitis, because it sets up another pathological entity and does not fit in reflux esophagitis and all patients with any signs of surgical manipulation of the esophagus and stomach. The endoscopic data were divided among grades of esophagitis of Los Angeles and classification related to the size of hiatal hernia or the absence of such a condition. We observed the presence of hiatal hernia in 46.23% of patients with esophagitis. The probability of small hiatal hernia and esophagitis was 41.63%, the probability of hiatal hernia and esophagitis average was 3.56% and the probability of large hiatal hernia and esophagitis was 1.05%. Discussion: statistical analysis using the chi-square test α = 5%, it was observed that Fo = Fe, ie, there is no significant difference between the grades of esophagitis and size of hiatal hernia. A relationship exists between hiatal hernia and esophagitis, as evidenced by the ratio of 46.23% between the two conditions. The most important was between grade A esophagitis and hiatal hernia small, with 41.63%. This shows the importance of this issue, which should be the object of further studies for the progress of medical treatments involving these two conditions. [ABSTRACT FROM AUTHOR]

Objective: Recurrent abdominal pain (RAP) by itself is one of the common reasons in child-aged patients to refer to a clinician. Some of these patients are presented with more serious features, so-called the "red flag". The most important issue in management of RAP is to distinguish the type of it, whether it is functional or organic. In this study we aimed to assess the redundancy of red-flagged RAP with findings of esophago-gastro-deudonoscopy. Methods: In a 2 year prospective study 150 consecutive children with RAP who showed red flags underwent esophago-gastro-deudonoscopy. The prevalence of each finding was recorded. Overall positive predictive value of predicting an endoscopic finding while having a red-flag was calculated. Findings: Among all the patients, 126 cases showed at least a positive finding in their endoscopy that corresponded to the positive predictive value of 84% for predicting the presence of an endoscopic finding according to red flags. Interestingly, 20% of patients showed hiatus hernia when surveyed. Conclusion: Comprehensive physical examination is needed to avoid performing esophago-gastro-deudonoscopy without indication in patients with recurrent abdominal pain. [ABSTRACT FROM AUTHOR]

Introduction: Swallowing sounds can be heard in the lower esophagus by xiphoid auscultation. We hypothesize that the xiphoid sound analysis could provide information concerning the integrity of the esophagogastric junction (EGJ), i.e., superposition of the lower esophageal sphincter (LES) and the diaphragm to assess clinical diagnosis of gastroesophageal reflux disease (GERD) and results of Nissen fundoplication (NF). The aim was to evaluate the changes in sound parameters using our acoustic technique after reorganization of the EGJ after NF.Methods: For 21 patients with GERD and hiatus hernia, two microphones were placed below the cricoid and on the xiphoid cartilages. The frequency and duration of xiphoid sounds, esophageal transit time were calculated. We defined the xiphoid sound as composed of vibration groups separated by periods >100 ms. The number of vibration groups, number of vibrations per group, and interval between groups were also calculated.Results: The xiphoid sound frequency was increased after NF, and the esophageal transit time and xiphoid sound duration were significantly decreased. A significant correlation was found between xiphoid sound duration and LES-diaphragm displacement. The number of vibration groups and interval between groups were reduced after NF.Conclusion: The acoustic technique for swallowing revealed the effects of NF upon the dynamic profile of the EGJ. The organization of vibration groups at the EGJ suggested that the passage of the bolus was modified by hiatus hernia, i.e., dissociation between the LES and the diaphragm and regularized by NF. Concomitant acoustic and radiologic study should contribute to better understanding of sound related to EGJ structure and boli. [ABSTRACT FROM AUTHOR]

Sixty years ago, Saint’s triad (hiatus hernia, diverticulosis of the colon, and gallbladder disease) was first described in three patients. Since then, the association of these conditions has been questioned. We tested the hypothesis that these conditions are associated, and, based on recent research, propose a common etiology. Data from the U.S. Veterans Integrated Service Network (VISN) 16 Data Warehouse were analyzed. Chi-square tests and calculated odds ratios (ORs) were utilized to describe the magnitude of association, and multivariable logistic regression models were used to determine the variables associated with Saint’s triad. Among 637,518 patient records (1996–2005), any hernia was diagnosed among 22,181 (3.5%) patients, hiatus hernia among 1,661 (0.3%), diverticulosis of the colon among 14,375 (2.3%), and gallbladder disease among 5,284 (0.8%). The following associations were observed: diverticulosis, hiatus hernia (OR: 6.9), hiatus hernia, gallbladder disease (OR = 3.8), and gallbladder disease, diverticulosis (OR = 5.9). Patients with both diverticulosis and gallbladder disease were more likely to have hiatus hernia (OR = 3.8; P = 0.0012) or any hernia (OR = 10.7; P < 0.0001). Diseases associated with Saint’s triad (incorporating any hernia) included chronic obstructive pulmonary disease (OR = 4.3), hypertension (OR = 3.1), aortic aneurysm (OR = 2.2), and diabetes (OR = 1.8). Herniosis, the systemic connective tissue disease known to cause diverticulosis and herniae, may be responsible for Saint’s triad. Diabetes, like aging, enhanced herniosis. Further research on the gallbladder wall pathology in patients with cholelithiasis or cholecystitis is needed. [ABSTRACT FROM AUTHOR]

Hiatus hernia refers to conditions in which elements of the abdominal cavity, most commonly the stomach, herniate through the oesophageal hiatus into the mediastinum. With the most common type (type I or sliding hiatus hernia) this is associated with laxity of the phrenooesophageal membrane and the gastric cardia herniates. Sliding hiatus hernia is readily diagnosed by barium swallow radiography, endoscopy, or manometry when greater than 2 cm in axial span. However, the mobility of the oesophagogastric junction precludes the reliable detection of more subtle disruption by endoscopy or radiography. Detecting lesser degrees of axial separation between the lower oesophageal sphincter and crural diaphragm can only be reliably accomplished with high-resolution manometry, a technique that permits real time localization of these oesophagogastric junction components without swallow or distention related artefact. [ABSTRACT FROM AUTHOR]

Hiatus hernia (HH) is a condition characterized by herniation of the intra-abdominal organs into the thorax. Of the several types that have been identified, the most common is type I (sliding) HH. Congenital predisposition and acquired factors, for example trauma and iatrogeny, have been identified as causative factors. There is a strong association between gastroesophageal reflux disease and HH-the prevalence of reflux in HH may reach 94%. Many methods have been used to treat reflux disease and HH, among which are laparoscopic techniques, which gained popularity as a safe method of treatment. Primary crural repair without mesh application was found to have a recurrence rate of up to 42%. This led to the introduction of mesh in HH repair, which was associated with a significant decrease in recurrence rate. Collagen and its relation to hernia have been investigated for several decades. Collagen has mechanical properties sufficient to enable it to support healed scars and other tissues. Nineteen distinct types of collagen have been recognized, the most common of which are types I and III. Type III collagen is the major constituent of early granulation tissue whereas type I predominates as healing proceeds. Collagen fibers are imbedded in extracellular matrix (ECM), which is in continuous process of synthesis and degradation under the action of matrix metalloproteinases. Many authors have studied the role of collagen in ventral hernia and have even defined hernia as a disease of the ECM. The relationship between collagen and HH, and its recurrence, is not fully understood and needs further investigation. [ABSTRACT FROM AUTHOR]

Gastric outlet obstruction initiated by acute gastric volvulus is rare but potentially fatal. An unusual case of intrathoracic acute gastric volvulus complicated by distal stomach and transverse colon herniation into retrocardial space is reported. Prompt clinical diagnosis was followed by emergency laparoscopic de-rotation and gastropexy. [ABSTRACT FROM AUTHOR]

One third of the general population may experience reflux symptoms, yet only a small fraction of patients with gastroesophageal reflux disease (GERD) have Barrett's esophagus. The aim of the present study was to compare the characteristics of GERD patients with and without Barrett's esophagus and identify potential risk factors for the appearance of Barrett's esophagus in reflux disease. Outpatients from a gastroenterology clinic who underwent upper gastrointestinal endoscopy, esophageal manometry, and 24-hr pH monitoring were recruited into a case-control study. A total of 256 case subjects with endoscopically and histologically proven Barrett's esophagus were compared to a control group of 229 subjects with nonerosive reflux disease. As compared to nonerosive reflux disease, Barrett's esophagus was strongly associated with more reflux episodes. Barrett's esophagus occurred more frequently among subjects with hiatus hernia and among subjects who consumed large amounts of alcohol or cigarettes. Frequent reflux episodes, hiatus hernia, smoking, and alcohol consumption were also risk factors for an increased length of Barrett's mucosa. Total esophageal mucosal acid contact time at pH < 4 was a significant risk factor for the length but not the presence of Barrett's esophagus. Intake of aspirin or NSAIDs was similar in patients with and without Barrett's esophagus. In conclusion, in comparison with nonerosive reflux disease, Barrett's esophagus is characterized by risk factors usually indicative of severe types of GERD. Mechanisms in addition to acid reflux must contribute to the development of Barrett's esophagus. [ABSTRACT FROM AUTHOR]

Patients with iron deficiency anemia sometimes have a large paraesophageal hernia and no other explanation for their chronic blood loss. The management of these patients can be a dilemma, especially when the hernia is otherwise asymptomatic. We aimed to determine whether a laparoscopic repair of the hernia could cure the anemia. We reviewed a consecutive series of 11 cases of iron deficiency anemia associated with a large paraesophageal hernia, many without associated linear gastric erosions, managed by laparoscopic repair and fundoplication. There was one conversion in a patient with dense adhesions from previous upper abdominal surgery. Another patient required a laparoscopic reoperation for an early recurrence. Major morbidity occurred in three patients and there was no mortality. There was no recurrence of anemia after a median follow-up of more than 2 years. Iron deficiency anemia in association with a large paraesophageal hernia can be treated by laparoscopic repair with acceptable morbidity and minimal mortality. The complications of a large paraesophageal hernia are also prevented. [ABSTRACT FROM AUTHOR]

Background Dysphagia can occur in patients with a small hiatus hernia (HH). Whether this relates to a pressure-flow variation through the esophagus or esophago-gastric junction (EGJ) is unknown. Methods High-resolution impedance manometry (HRIM) performed off therapy in 210 reflux patients and 25 age-matched healthy volunteers, recorded 10 × 5mL saline and likewise viscous bolus swallows. Esophageal pressure flow analysis (PFA) with AIMplot v8.0 was undertaken for valid bolus swallows. HRIM EGJ-subtype and endoscopic + /- fluoroscopic imaging enabled HH diagnosis (2–5 cm, > 5 cm excluded). Dysphagia was scored for difficulty swallowing 9 food types (Dakkak and Bennett; 0 none to 45 severe). ANOVA assessed differences in biomechanics of controls and HH + /- patients and dysphagia (D + , > 10/45). Results To date, findings for 135 patients (74M 61F, BMI 28, 19–41) with 70 HH + positive were compared with the 65 HH- negative and 25 healthy controls (7M 18F, BMI 27, 19–37)—see Table. Pressure-Flow Analysis in patients with regard to hiatus hernia (HH + /-) & dysphagia (D + /-) Mean of 10 swallows LIQUID  N  IBP Eso body TZ—CDP (mmHg)  IBP ramp rate during lumen closure (mmHg/sec)  Dist Press at lumen closure (mmHg)  Bolus-Flow latency, time of swallow to max distension (sec)  Impedance Ratio, TZ to CDP   EGJ_Bolus Presence Time (sec)  EGJ_Bolus Flow time (sec)  HH + D+   27  4.8 (2.8)  14.8 (21.0)  35 (35)  4.1 (1.8)  0.26 (0.24)  3.1 ± 1.9  1.1 (1.9)  HH + D-   43  5.3 (2.9)  14.1 (9.8)  32 (20)  3.9 (1.8)  0.32 (0.23)  3.3 ± 2.0  1.4 (2.2)  HH- D+   23  4.0 (5.4)  13.9 (22.9)  40 (52)  3.3 (1.4)  0.32 (0.17)  5.0 ± 1.7  2.7 (1.4)  HH- D-   42  4.1 (5.2)  16.4 (18.7)  42 (31)  3.8 (1.5)  0.27 (0.18)  4.8 ± 2.1  2.8 (2.4)  Controls   25  3.9 (3.6)  15.9 (23.9)  53 (40)  3.5 (1.1)  0.25 (0.13)  5.8 ± 1.5  3.0 (2.2)  P value     0.02  0.69  0.11  0.41  0.03  <0.001  <0.001  VISCOUS               mean ± SD  median (IQR)  HH + D+   27  7.1 (3.3)  16.1 (19.5)  37 (29)  5.2 ± 1.0  0.31 (0.19)  3.3 ± 2.2  1.6 (2.0)  HH + D-   43  6.5 (3.6)  15.0 (13.6)  27 (21)  5.2 ± 1.0  0.33 (0.13)  3.0 ± 2.0  1.6 (2.0)  HH- D+   23  6.3 (3.0)  17.1 (17.9)  30 (15)  6.0 ± 0.8  0.33 (0.18)  4.0 ± 1.2  2.8 (1.4)  HH- D-   42  5.3 (2.7)  22.7 (19.4)  45 (33)  5.8 ± 0.9  0.29 (0.11)  3.9 ± 1.5  2.7 (1.9)  Controls   25  6.3 (2.8)  20.6 (14.0)  47 (27)  5.5 ± 0.9  0.28 (0.09)  4.7 ± 1.2  3.4 (2.3)  P Value     0.04  0.03  0.003  0.01  0.13  0.001  <0.001  Mean of 10 swallows LIQUID  N  IBP Eso body TZ—CDP (mmHg)  IBP ramp rate during lumen closure (mmHg/sec)  Dist Press at lumen closure (mmHg)  Bolus-Flow latency, time of swallow to max distension (sec)  Impedance Ratio, TZ to CDP   EGJ_Bolus Presence Time (sec)  EGJ_Bolus Flow time (sec)  HH + D+   27  4.8 (2.8)  14.8 (21.0)  35 (35)  4.1 (1.8)  0.26 (0.24)  3.1 ± 1.9  1.1 (1.9)  HH + D-   43  5.3 (2.9)  14.1 (9.8)  32 (20)  3.9 (1.8)  0.32 (0.23)  3.3 ± 2.0  1.4 (2.2)  HH- D+   23  4.0 (5.4)  13.9 (22.9)  40 (52)  3.3 (1.4)  0.32 (0.17)  5.0 ± 1.7  2.7 (1.4)  HH- D-   42  4.1 (5.2)  16.4 (18.7)  42 (31)  3.8 (1.5)  0.27 (0.18)  4.8 ± 2.1  2.8 (2.4)  Controls   25  3.9 (3.6)  15.9 (23.9)  53 (40)  3.5 (1.1)  0.25 (0.13)  5.8 ± 1.5  3.0 (2.2)  P value     0.02  0.69  0.11  0.41  0.03  <0.001  <0.001  VISCOUS               mean ± SD  median (IQR)  HH + D+   27  7.1 (3.3)  16.1 (19.5)  37 (29)  5.2 ± 1.0  0.31 (0.19)  3.3 ± 2.2  1.6 (2.0)  HH + D-   43  6.5 (3.6)  15.0 (13.6)  27 (21)  5.2 ± 1.0  0.33 (0.13)  3.0 ± 2.0  1.6 (2.0)  HH- D+   23  6.3 (3.0)  17.1 (17.9)  30 (15)  6.0 ± 0.8  0.33 (0.18)  4.0 ± 1.2  2.8 (1.4)  HH- D-   42  5.3 (2.7)  22.7 (19.4)  45 (33)  5.8 ± 0.9  0.29 (0.11)  3.9 ± 1.5  2.7 (1.9)  Controls   25  6.3 (2.8)  20.6 (14.0)  47 (27)  5.5 ± 0.9  0.28 (0.09)  4.7 ± 1.2  3.4 (2.3)  P Value     0.04  0.03  0.003  0.01  0.13  0.001  <0.001  Pressure-Flow Analysis in patients with regard to hiatus hernia (HH + /-) & dysphagia (D + /-) Mean of 10 swallows LIQUID  N  IBP Eso body TZ—CDP (mmHg)  IBP ramp rate during lumen closure (mmHg/sec)  Dist Press at lumen closure (mmHg)  Bolus-Flow latency, time of swallow to max distension (sec)  Impedance Ratio, TZ to CDP   EGJ_Bolus Presence Time (sec)  EGJ_Bolus Flow time (sec)  HH + D+   27  4.8 (2.8)  14.8 (21.0)  35 (35)  4.1 (1.8)  0.26 (0.24)  3.1 ± 1.9  1.1 (1.9)  HH + D-   43  5.3 (2.9)  14.1 (9.8)  32 (20)  3.9 (1.8)  0.32 (0.23)  3.3 ± 2.0  1.4 (2.2)  HH- D+   23  4.0 (5.4)  13.9 (22.9)  40 (52)  3.3 (1.4)  0.32 (0.17)  5.0 ± 1.7  2.7 (1.4)  HH- D-   42  4.1 (5.2)  16.4 (18.7)  42 (31)  3.8 (1.5)  0.27 (0.18)  4.8 ± 2.1  2.8 (2.4)  Controls   25  3.9 (3.6)  15.9 (23.9)  53 (40)  3.5 (1.1)  0.25 (0.13)  5.8 ± 1.5  3.0 (2.2)  P value     0.02  0.69  0.11  0.41  0.03  <0.001  <0.001  VISCOUS               mean ± SD  median (IQR)  HH + D+   27  7.1 (3.3)  16.1 (19.5)  37 (29)  5.2 ± 1.0  0.31 (0.19)  3.3 ± 2.2  1.6 (2.0)  HH + D-   43  6.5 (3.6)  15.0 (13.6)  27 (21)  5.2 ± 1.0  0.33 (0.13)  3.0 ± 2.0  1.6 (2.0)  HH- D+   23  6.3 (3.0)  17.1 (17.9)  30 (15)  6.0 ± 0.8  0.33 (0.18)  4.0 ± 1.2  2.8 (1.4)  HH- D-   42  5.3 (2.7)  22.7 (19.4)  45 (33)  5.8 ± 0.9  0.29 (0.11)  3.9 ± 1.5  2.7 (1.9)  Controls   25  6.3 (2.8)  20.6 (14.0)  47 (27)  5.5 ± 0.9  0.28 (0.09)  4.7 ± 1.2  3.4 (2.3)  P Value     0.04  0.03  0.003  0.01  0.13  0.001  <0.001  Mean of 10 swallows LIQUID  N  IBP Eso body TZ—CDP (mmHg)  IBP ramp rate during lumen closure (mmHg/sec)  Dist Press at lumen closure (mmHg)  Bolus-Flow latency, time of swallow to max distension (sec)  Impedance Ratio, TZ to CDP   EGJ_Bolus Presence Time (sec)  EGJ_Bolus Flow time (sec)  HH + D+   27  4.8 (2.8)  14.8 (21.0)  35 (35)  4.1 (1.8)  0.26 (0.24)  3.1 ± 1.9  1.1 (1.9)  HH + D-   43  5.3 (2.9)  14.1 (9.8)  32 (20)  3.9 (1.8)  0.32 (0.23)  3.3 ± 2.0  1.4 (2.2)  HH- D+   23  4.0 (5.4)  13.9 (22.9)  40 (52)  3.3 (1.4)  0.32 (0.17)  5.0 ± 1.7  2.7 (1.4)  HH- D-   42  4.1 (5.2)  16.4 (18.7)  42 (31)  3.8 (1.5)  0.27 (0.18)  4.8 ± 2.1  2.8 (2.4)  Controls   25  3.9 (3.6)  15.9 (23.9)  53 (40)  3.5 (1.1)  0.25 (0.13)  5.8 ± 1.5  3.0 (2.2)  P value     0.02  0.69  0.11  0.41  0.03  <0.001  <0.001  VISCOUS               mean ± SD  median (IQR)  HH + D+   27  7.1 (3.3)  16.1 (19.5)  37 (29)  5.2 ± 1.0  0.31 (0.19)  3.3 ± 2.2  1.6 (2.0)  HH + D-   43  6.5 (3.6)  15.0 (13.6)  27 (21)  5.2 ± 1.0  0.33 (0.13)  3.0 ± 2.0  1.6 (2.0)  HH- D+   23  6.3 (3.0)  17.1 (17.9)  30 (15)  6.0 ± 0.8  0.33 (0.18)  4.0 ± 1.2  2.8 (1.4)  HH- D-   42  5.3 (2.7)  22.7 (19.4)  45 (33)  5.8 ± 0.9  0.29 (0.11)  3.9 ± 1.5  2.7 (1.9)  Controls   25  6.3 (2.8)  20.6 (14.0)  47 (27)  5.5 ± 0.9  0.28 (0.09)  4.7 ± 1.2  3.4 (2.3)  P Value     0.04  0.03  0.003  0.01  0.13  0.001  <0.001  In HH + there was increased resistance (intrabolus pressure) to bolus flow through the esophagus, while pressure during bolus clearance was lower. Further, a higher impedance ratio suggests less effective esophageal emptying, in addition to reduced EGJ outflow time. HH impairs transport of viscous and liquid swallows, affecting patients with HH + and troublesome dysphagia the most. Conclusion A small hiatus hernia alters biomechanics of bolus transport and hinders esophageal and esophago-gastric junction outflow, more so in patients with both dysphagia and hiatus hernia. These findings may relate to altered longitudinal muscle function associated with a short, flaccid esophagus when a hiatus hernia is present. Disclosure All authors have declared no conflicts of interest. [ABSTRACT FROM AUTHOR]

The article presents a case study of an 87-year-old woman with traumatic fracture at the right femoral neck. It says that type IV paraesophageal hernia was observed through computed tomography. In addition, hernias were found in her stomach, pancreas, and duodenum. Moreover, elective surgery of asymptomatic paraesophageal hernias was thought to prevent critical complications, however mortality rate from elective laparoscopic surgery is about 1.4%.