The TIF (transoral incisionless fundoplication) 2.0 procedure is indicated for patients with a hiatal hernia less than 2 cm. Many patients with gastroesophageal reflux disease (GERD) require hiatal hernia repair. This study examined the safety and efficacy when repairing defects in 2 anatomical structures (hiatus and lower esophageal sphincter) in a concomitant set of procedures in patients with hiatal hernias between 2 and 5 cm. Methods. Prospective data were collected from 99 patients who underwent hiatal hernia repair followed immediately by the TIF procedure (HH + -TIF). GERD-HRQL (Health-Related Quality of Life), RSI (Reflux Symptom Index), and GERSS (Gastroesophageal Reflux Symptom Score) questionnaires were administered before the procedure and mailed at 6 and 12 months. Results. Ninety-nine patients were enrolled, and all were symptomatic on PPI medications with hiatal hernias between 2 and 5 cm. Overall baseline GERD-HRQL scores indicated daily bothersome symptoms. At 12-month follow-up, median GERD-HRQL scores improved by 17 points, indicating that subjects had no bothersome symptoms. The median GERSS scores decreased from 25.0 at baseline to 1.0 and 90% of subjects reported having effective symptom control (score <18) at 12 months. Seventy-seven percent of subjects reported effective control of laryngopharyngeal reflux (LPR) symptoms at 12 months with an RSI score of 13 or less. At 12 months, 74% of subjects reported that they were not using proton pump inhibitors. All measures were statistically improved at P < .05. There were no adverse effects reported. Conclusion. HH + TIF provides significant symptom control for heartburn and regurgitation with no long-term dysphagia or gas bloat normally associated with traditional antireflux procedures. Most patients reported durable symptom control and satisfaction with health condition at 12 months.

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Introduction Combined aortic and mitral valve disease is usually of rheumatic origin. In these patients we often encounter problem of small valve annuli particularly with aortic annulus. It is still debated whether a small prosthesis should be used or aortic root should be enlarged to prevent Patient Prosthesis Mismatch (PPM). This study was undertaken to review our strategy and feasibility of Aortic Root Enlargement (ARE) in patient undergo Double Valve Replacement (DVR) to avoid mismatch without increase in cost of treatment, morbidity or mortality. Materials and methods We reviewed 11 patients who underwent double valve replacement along with aortic root enlargement between January 2010 and December 2010. Patients at high risk for PPM and whose aortic annulus did not admit minimum of 19 mm aortic valve were selected for aortic root enlargement. Operative procedure involved extension of aortotomy incision between left and non coronary cusp without entering left atrium and reconstructing the defect with autologous Pericardium and implanting appropriate size valve to avoid or decrease PPM Results There were no operative or in hospital mortality. Mean age of patients was 33.83 years (range 12-50).Average body surface area was 1.37 m2 (range 1.1-1.65). Most patients underwent root enlargement for stenotic lesion. Mean cardiopulmonary bypass time was 179 min (range 150-238 min). And mean cross clamp time was 120 min (range 91-155 min). With root enlargement one size bigger valve was replaced in 10 patients and PPM was eliminated in 6 patients while in 5 patient PPM was reduced to moderate level. Other variables like inotropic requirement, duration of ventilation, blood product used and Intensive Care Unit (ICU) stay were comparable to a routine double valve replacement without root enlargement. Conclusions Aortic root enlargement can be safely done even in patients undergoing concomitant aortic and mitral valve replacement. With ARE patients benefit bigger size prosthesis without additional mortality and morbidity.

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