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Eastern Cardiothoracic Surgical Society

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Outcomes of Minimally Invasive Hiatal Hernia Repair and Fundoplication in Patients with Severe Esophageal Dysmotility or Complete Esophageal Aperistalsis
Romulo Fajardo, Charles Bakhos, Roman Petrov, Henry Parkman, Zubair Malik, Abbas Abbas
Temple University Hospital, Philadelphia, PA, USA

OBJECTIVE: To investigate the safety and outcomes of hiatal hernia repair (HHR) and fundoplication in patients with severe esophageal dysmotility (SED) or complete esophageal aperistalsis (scleroderma-like esophagus).
METHODS: Retrospective review of patients with SED (distal contractile integral < 500 mm Hg/cm/s) on high resolution esophageal manometry (HREM), who underwent minimally invasive anti-reflux surgery from August 1, 2016 to September 1, 2019 at a single tertiary referral center.
RESULTS: Thirty-two patients with SED were identified, including 18 (56%) with scleroderma-like esophagus. Mean pre-operative Demeester score was 59.5. Approaches included robotic (28) or laparoscopic (4) and included Toupet (31) and Nissen (1) fundoplications. There was no 90-day mortality, and the mean length of stay was 2 ± 1.8 days (range 1-10 days). Oral diet was resumed at a mean of 1 day post-operatively, and only 2 patients required concomitant placement of a feeding tube, including one who required re-operation for primary repair of an iatrogenic duodenal injury. Four patients required esophageal dilation (1 during index operation and 3 postoperatively), and 1 patient required pyloric botulinum toxin injection. Symptomatic improvement was observed in 81% of patients (26/32), with 4 patients (13%) reporting complete resolution of preoperative symptoms. Median follow up duration was 20 months (range 2 weeks to 38 months).
CONCLUSIONS: Minimally invasive HHR and fundoplication is safe in patients with SED including complete aperistalsis and can result in significant symptomatic improvement. Objective post-operative studies and longer follow-up are warranted to confirm the benefits of anti-reflux surgery in this patient population.


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