title: Surgery for Type III-IV hiatal hernia: anatomical recurrence and global results after elective treatment of short oesophagus with open and minimally invasive surgery.
abstract: OBJECTIVE
  Type III-IV hiatal hernia (HH) is associated with a true short oesophagus in more than 50% of cases; dedicated treatment of this condition might be appropriate to reduce the recurrence rate after surgery. A case series of patients receiving surgery for Type III-IV hernia was examined for short oesophagus, and the results were analysed.
  
  
  METHODS
  From 1980 to 1994, 60 patients underwent an open surgical approach, and the position of the oesophago-gastric junction was visually localized; from 1995 to 2013, 48 patients underwent a minimally invasive approach, and the oesophago-gastric junction was objectively localized using a laparoscopic-endoscopic method. The patients underwent a timed clinical-instrumental follow-up that included symptoms assessment, barium swallow and endoscopy. The results were considered to be excellent in the absence of symptoms and oesophagitis; good, if symptoms occurred two to four times a month in the absence of oesophagitis; fair, if symptoms occurred two to four times a week in the presence of hyperaemia, oedema and/or microscopic oesophagitis; and poor, if symptoms occurred on a daily basis in the presence of any grade of endoscopic oesophagitis, HH of any size or type, or the need for antireflux medical therapy. The follow-up time was calculated from the time of surgery to the last complete follow-up.
  
  
  RESULTS
  Among the open surgery patients, 78% underwent abdominal fundoplication, 10% the Belsey Mark IV procedure, 8% laparotomic Collis-Nissen fundoplication and 3% the Pearson operation. Among the minimally invasive surgery patients, 44% underwent a laparoscopic floppy Nissen procedure and 56% a left thoracoscopic Collis-laparoscopic Nissen procedure. The postoperative mortality and complication rates were 1.6% (1/60) and 15% for open surgery and 4.1% (2/48) and 12.5% for minimally invasive surgery. A total of 105 patients were followed up for a median period of 96 months. Five relapses occurred after open surgery (5/59, 8%) and two after minimally invasive surgery (2/46, 4%). Among the 105 patients, excellent, good, fair and poor outcomes were observed in 38%, 44%, 9% and 9%, respectively.
  
  
  CONCLUSIONS
  These data suggested that the selective treatment of short oesophagus in association with a Type III-IV hernia reduced the anatomical recurrence rate and achieved satisfactory outcomes.
  
  
  BACKGROUND
  NCT01606449.
authors.affiliation: Division of Thoracic Surgery, Alma Mater Studiorum, University of Bologna, Bologna, Italy Center for the Study and Research on Diseases of the Oesophagus, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
authors.forename: Marialuisa
authors.initials: M
authors.lastname: Lugaresi
authors.affiliation: Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
authors.forename: Benedetta
authors.initials: B
authors.lastname: Mattioli
authors.affiliation: Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
authors.forename: Niccolò
authors.initials: N
authors.lastname: Daddi
authors.affiliation: Center for the Study and Research on Diseases of the Oesophagus, Alma Mater Studiorum, University of Bologna, Bologna, Italy Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
authors.forename: Massimo Pierluigi
authors.initials: MP
authors.lastname: Di Simone
authors.affiliation: Division of Thoracic Surgery, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
authors.forename: Ottorino
authors.initials: O
authors.lastname: Perrone
authors.affiliation: Division of Thoracic Surgery, Alma Mater Studiorum, University of Bologna, Bologna, Italy Center for the Study and Research on Diseases of the Oesophagus, Alma Mater Studiorum, University of Bologna, Bologna, Italy Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum, University of Bologna, Bologna, Italy GVM Care & Research, Cotignola, Italy sandro.mattioli@unibo.it.
authors.forename: Sandro
authors.initials: S
authors.lastname: Mattioli
mesh_terms: D000368:Aged; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000379:methods / Q000706:statistics & numerical data; D004947:Esophagus / Q000601:surgery*; D005764:Gastroesophageal Reflux / Q000601:surgery; D006551:Hernia, Hiatal / Q000453:epidemiology / Q000601:surgery*; D006801:Humans; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods / Q000706:statistics & numerical data; D011183:Postoperative Complications; D012008:Recurrence; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Gastro-oesophageal reflux disease; Hiatal hernia; Minimally invasive surgery; Para-oesophageal hernia