Safety and Early Clinical Outcomes Following Repair of Very Large Hiatus Hernia in Octogenarians

We agree with Dr Li that large hiatal hernias present challenges, although we contend that fitness for surgery is the more common conundrum faced when considering elderly populations. Whilst some elderly patients with large hiatus hernias have kyphosis, or occasionally scoliosis, our experience suggests spinal deformity presents greater challenges when operating via an open midline abdominal incision as it shortens the xiphoid to pubis distance. This has less impact when operating laparoscopically. We reported conversion to open surgery was only required in 4.7% of the patients aged > 80, and no conversions resulted from difficulties due to “spinal deformity” [1]. We do not preclude these patients from laparoscopic repair as experienced surgeons rarely encounter difficulties. About fundoplication type, we add a fundoplication as a gastropexy to anchor the stomach to the hiatal rim, and concurrently deal with any reflux. Operations in our series were all performed after 2000. Before this, we conducted 3 randomised trials comparing anterior partial with Nissen fundoplication [2, 3]. As these trials demonstrated good reflux control, less side effects (i.e., better ability to burp) and low rates of recurrent hiatus hernia, we add an anterior fundoplication. In patients without large hiatus hernias who undergo fundoplication for reflux, we construct an anterior fundoplication in 80%–90% and a Nissen fundoplication in 10%–20%. Our choice is supported by the trial outcomes, and preoperative discussion with each patient so they can consider trade-offs between reflux control and side effects for different fundoplications to then make an informed decision. Finally, we wish to correct Dr Li's statement that “most patients had mesh repair.” Table 3 in our paper stated that mesh was used in 11%–14% of the study groups, i.e. a minority [1]. The indication for mesh in these patients was participation in a randomised trial evaluating sutured versus mesh repair [4, 5]. Mesh reinforcement was used in 2 of 3 study groups and entailed either a lightweight nonabsorbable monofilament mesh or Surgisis absorbable mesh, with these meshes used in equal numbers. The mesh configuration was a posterior on-lay reinforcement of a sutured posterior hiatal repair. Circumferential mesh was not used due to concerns about mesh complications, including erosion. Objective trial follow-up to 5 years revealed no advantages for mesh, and a poorer symptom outcome with absorbable mesh [4]. When considering recurrence rates after hiatus hernia repair, it is important to understand that rates are impacted by the definition of “recurrence” and how “recurrence” is identified. We previously reported most recurrences after laparoscopic repair of large hiatus hernia are small, asymptomatic, unlikely to progress, and are not clinically important [5]. In our randomised trial, hernias were identified by radiology or gastroscopy at 3–4 years in 46.5% [4]. However, hernias > 2 cm were seen in only 10.5% [4]. Most recurrences were asymptomatic, whereas significant hernias requiring intervention were uncommon, with 4.8% undergoing revision surgery for hernia recurrence by 5 years [4]. This reinforces our view that most recurrences are not significant [5]. We would like to thank Dr Li for showing an interest in our work and appreciate the opportunity to clarify our recently published results. David I. Watson: conceptualization, writing – original draft. Mathew A. Amprayil: writing – review and editing, conceptualization. Sarah K. Thompson: writing – review and editing, conceptualization. Tim Bright: writing – review and editing, conceptualization. The authors have nothing to report. The authors declare no conflicts of interest.