title: The laparoscopic Nissen-Hill hybrid: pilot study of a combined antireflux procedure.
abstract: BACKGROUND
  Laparoscopic antireflux surgery is highly effective in patients with uncomplicated gastroesophageal reflux disease (GERD). However, long-term failure rates in paraesophageal hernia (PEH) and Barrett's metaplasia (BE) are higher and warrant a more durable repair. Outcomes for the laparoscopic Nissen fundoplication (LNF) and Hill repair (LHR) are equivalent, but their anatomic components are different and may complement each other (Aye R Ann Thorac Surg, 2012). We designed and tested the feasibility and safety of an operation that combines the essential components of each repair.
  
  
  METHODS
  A prospective, phase II pilot study was performed on patients with symptomatic giant PEH hernias and/or GERD with nondysplastic Barrett's metaplasia. Pre- and postoperative esophagogastroduodenoscopy (EGD), upper gastrointestinal study (UGI), 48-hour pH testing, manometry, and three quality-of-life metrics were obtained.
  
  
  RESULTS
  Twenty-four patients were enrolled in the study. Three patients did not complete the planned procedure, leaving 21 patients, including 12 with PEH, 7 with BE, and 2 with both. There were no 30-day or in-hospital mortalities. At a median follow-up of 13 (range 6.4-30.2) months, there were no reoperations or clinical recurrences. Two patients required postoperative dilation for dysphagia, with complete resolution. Mean DeMeester scores improved from 54.3 to 7.5 (p < 0.0036). Mean lower esophageal sphincter pressures (LESP) increased from 8.9 to 21.3 mmHg (p < 0.013). Mean short-term and long-term QOLRAD scores improved from 4.09 at baseline to 6.04 and 6.48 (p < 0.0001). Mean short-term and long-term GERD-HQRL scores improved from 22.9 to 7.5 and 6.9 (p < 0.03). Mean long-term Dysphagia Severity Score Index improved from 33.3 to 40.6 (p < 0.064).
  
  
  CONCLUSIONS
  The combination of a Nissen plus Hill hybrid reconstruction of the gastroesophageal junction (GEJ) is technically feasible, safe, and not associated with increased side effects. Short-term clinical results in PEH and BE suggest that this may be an effective repair, supporting the value of further study.
authors.affiliation: University of Toronto, Toronto, ON, Canada.
authors.forename: Alia P
authors.initials: AP
authors.lastname: Qureshi
authors.forename: Ralph W
authors.initials: RW
authors.lastname: Aye
authors.forename: Gordon
authors.initials: G
authors.lastname: Buduhan
authors.forename: Ariel
authors.initials: A
authors.lastname: Knight
authors.forename: Jeraldine
authors.initials: J
authors.lastname: Orlina
authors.forename: Alexander S
authors.initials: AS
authors.lastname: Farivar
authors.forename: Oliver J
authors.initials: OJ
authors.lastname: Wagner
authors.forename: Sean
authors.initials: S
authors.lastname: McHugh
authors.forename: Brian E
authors.initials: BE
authors.lastname: Louie
mesh_terms: D001471:Barrett Esophagus / Q000601:surgery*; D005240:Feasibility Studies; D005260:Female; D018662:Fundoplication / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000601:surgery*; D006551:Hernia, Hiatal / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D011182:Postoperative Care; D011788:Quality of Life; D013536:Suture Techniques; D016896:Treatment Outcome