Laparoscopic antireflux surgery has no mortality and a low morbidity. Symptoms and esophagitis are resolved in >90% of patients. Despite these favorable results, however, this type of surgery is not yet as widely employed in Italy as in other countries.

We thank Dr. Hazebroek and Dr. Smith [1] for their interest in our article and their kind comments on our results. They are concerned about a single aspect of our study population: median age. We report on 54 consecutive patients with large (more than one-third of the stomach in the chest), type III hiatal hernias. The patients' median age was 64.5 years with an interquartile range (IQR) of 59-68 years, which means that one-fourth of our patients were [68 years old. As reported in a recent review, ''the average patient diagnosed with paraesophageal hernia is aged between 60 and 70 years'' [2]. In fact, the median age of patients with a large hiatal hernia undergoing laparoscopic repair in the largest published series ranged from 63 to 68 years [3][4][5][6][7].Of our 11 (of 54; 20%) elderly patients (C 70 years old), 9 underwent a mesh repair and 2 had simple suture hiatal closure. Conversion occurred in one patient (9%) early in our experience; there was one intraoperative complication-damage to the spleen requiring splenectomy-(9%) and no 30-day mortality. The overall complication rate was 9% (bleeding from a trocar site in one patient that required reoperation). The median hospital stay was 5 days. At a median symptomatic follow-up of 49 months and objective (radiological/endoscopic) follow-up of 23 months, there has been one case of early dysphagia, which required redo fundoplication and repositioning of the mesh on

Aims There is considerable controversy regarding optimal management of patients with paraesophageal hiatus hernia (pHH). This survey aims at identifying recommended strategies for work-up, surgical therapy, and postoperative follow-up using Delphi methodology. Methods We conducted a 2-round, 33-question, web-based Delphi survey on perioperative management (preoperative work-up, surgical procedure and follow-up) of non-revisional, elective pHH among European surgeons with expertise in upper-GI. Responses were graded on a 5-point Likert scale and analyzed using descriptive statistics. Items from the questionnaire were defined as “recommended” or “discouraged” if positive or negative concordance among participants was > 75%. Items with lower concordance levels were labelled “acceptable” (neither recommended nor discouraged). Results Seventy-two surgeons with a median (IQR) experience of 23 (14–30) years from 17 European countries participated (response rate 60%). The annual median (IQR) individual and institutional caseload was 25 (15–36) and 40 (28–60) pHH-surgeries, respectively. After Delphi round 2, “recommended” strategies were defined for preoperative work-up (endoscopy), indication for surgery (typical symptoms and/or chronic anemia), surgical dissection (hernia sac dissection and resection, preservation of the vagal nerves, crural fascia and pleura, resection of retrocardial lipoma) and reconstruction (posterior crurorrhaphy with single stitches, lower esophageal sphincter augmentation (Nissen or Toupet), and postoperative follow-up (contrast radiography). In addition, we identified “discouraged” strategies for preoperative work-up (endosonography), and surgical reconstruction (crurorrhaphy with running sutures, tension-free hiatus repair with mesh only). In contrast, many items from the questionnaire including most details of mesh augmentation (indication, material, shape, placement, and fixation technique) were “acceptable”. Conclusions This multinational European Delphi survey represents the first expert-led process to identify recommended strategies for the management of pHH. Our work may be useful in clinical practice to guide the diagnostic process, increase procedural consistency and standardization, and to foster collaborative research.