In laparoscopic 'paraoesophageal hernia' (POH) repair, non-absorbable suture materials have been used to close the crural defects. More recently, various types of prosthetic mesh have been utilized to repair the defect. We conducted a systematic review with meta-analysis of the recent and up to-date studies incorporating 942 POH repairs. We examined the rates of recurrence, reoperation, and complication rates alongside operative time of these two techniques in the management POH. Randomized controlled trials (RCT) and observational studies comparing mesh hiatal hernioplasty versus Suture cruroplasty for Paraoesophageal hernia were selected by searching Medline, Embase, and Cochrane Central database published between January 1995 and December 2016. Predefined inclusion and exclusion criteria were applied to select the studies. The outcome variables analysed are recurrence of hiatal hernia, reoperation, operative time and complications. Nine studies (RCTs = 4 and Observational studies = 5) were analysed totalling 942 patients (Mesh = 517, Suture cruroplasty = 425). The pooled effect size for recurrence favoured mesh repair over suture cruroplasty (OR 0.48, 95% CI 0.32, 0.73, P < 0.05). But the operation time is significantly less in suture cruroplasty (SMD 15.40, 95% CI 7.92, 22.88, P < 0.0001). Comparable effect sizes were noted for both groups which included reoperation (OR 0.35, 95%CI 0.09, 1.31, P = 0.12) and complication rates (OR 1.30, 95%CI 0.74, 2.29, P = 0.36). Our systematic review and meta-analysis demonstrates that mesh hiatoplasty and suture cruroplasty produce comparable results with regards to reoperation rate and complications following the repair of paraoesophageal hernias (POH). Moreover, the study showed significant reduction of recurrence following mesh hiatoplasty.

Aim Restoration of bowel continuity after Hartmann's procedure (RoH) can be challenging and associated with considerable morbidity. A technique using single-incision laparoscopic surgery through the stoma site (SIL RoH) has been shown to be feasible and safe. In this study, we compared clinical outcomes of SIL RoH with conventional laparoscopic surgery (CL) and open surgery (OS).Methods This was a retrospective analysis of a prospectively maintained database between 2007 and 2017 in a UK colorectal unit. The access technique was decided by the surgeon on a case by case basis.Results A total of 106 patients underwent RoH. It was carried out for diverticular disease (n = 71, 67.6%), cancer (n = 19, 17.9%) and anastomotic leak (n = 4, 3.8%). The remainder (n = 12, 11.3%) were for miscellaneous reasons including trauma. Most RoHs were performed via OS (n = 87, 81.1%). The most common intended approaches for RoH were SIL (n = 56, 52.8%) and OS (n = 34, 32.1%) with fewer starting with CL (n = 16, 15.1%). Conversion to OS took place in five (8.9%) patients with SIL and six (37.5%) with CL (P = 0.005). Postoperative complications occurred in 17 (30.4%) for SIL, seven (43.8%) for CL and 17 (50.0%) for OS (P = 0.162). Median operating time for SIL was 146 min (range 44-389), 211 min (109-320) for CL and 211 min (85-420) for OS (P < 0.001). Median length of stay was 4 days (2-44) for SIL compared to 6 (3-34) for CL and 7 (4-34) for OS (P < 0.001). Discharge on or before day 5 was achieved in 41 (74.5%) patients for SIL compared to six (37.5%) for CL and seven (20.6%) for OS (P < 0.001).Conclusion Compared to OS and CL, SIL RoH appears to have shorter operating times and hospitalization, with no discernible difference in morbidity; this finding requires further evaluation in a randomized setting.Keywords Single-incision laparoscopic surgery, laparoscopic surgery, single-port laparoscopic surgery, reversal of Hartmann's procedure What does this paper add to the literature? There is little evidence for the efficacy and benefits of single-incision laparoscopic surgery for the reversal of Hartmann's procedure, but this study suggests potential better short-term clinical outcomes over conventional laparoscopic and open surgery. We believe that a prospective randomized control trial would add further support for adoption of this technique.

IntroductionGastro-oesophageal reflux disease (GORD) is usually treated with lifestyle modifications, combined with drug therapy (antacids, alginates and acid suppression drugs such as proton pump inhibitors and H2 receptor antagonists). Patients with inadequate response to lifestyle and medical treatments, or intolerant of medical therapy, are offered anti-reflux surgery with open or laparoscopic fundoplication which remains the gold standard.1,2 Stretta® is a minimally-invasive endoscopic treatment that delivers non-ablative radiofrequency (NARF) energy to improve and restore the function of the lower oesophageal sphincter muscle, thereby improving symptoms of GORD. The efficacy of the Stretta® procedure in achieving symptom control of GORD has been reported in previous international publications. A systematic review involving 20 studies with 1441 patients having a mean follow-up interval of 15 months showed significant improvements in GORD symptoms including disease-specific and global quality of life.3 UK data on the outcomes of Stretta® have not been reported, and this is the first report of the Stretta® procedure in the UK, carried out at a single centre since October 2014.MethodsPatients with confirmed GORD, unresponsive to medical management with standard or double dose PPI, were offered the Stretta ®procedure based on clinician and patient shared decision. Patients with an associated hiatus hernia of ≤2 cm on their index endoscopy were included. Patients needed to be symptomatic of reflux for at least 3 months on medication and all patients were administered a GERD Health Related Quality of Life (GERD-HRQL) questionnaire pre- and post-Stretta® procedure. The Stretta ® procedure was carried out either under general anaesthesia (early phase) or conscious sedation (later phase) by a single trained endoscopist using the manufacturers protocol. Up to 14 lesion sets or 56 RF applications to the LOS at 1 cm intervals were carried out using an automated generator (Mederi Therapeutics Inc, USA).Results26 patients underwent the Stretta procedure over a period of 12 months (October 2014 - September 2015).The mean follow-up period was 3.8 months (range 10.5) and there were no recorded procedural complications. All patients completed pre and post procedure GERD-HRQL questionnaires. The median heartburn score (scale 0–30) improved from 18 pre-procedure to 2.5 post-procedure. The overall median regurgitation score (scale 0–30) improved from 19 pre-procedure to 0 post procedure. The overall patient satisfaction was 78%. There was also an improvement in the median overall total GERD-HRQL score (scale 0–75) from 44 pre-procedure to 6 post-procedure. 3 patients had undergone previous anti-reflux surgery. There was again overall improvement of median heartburn scores (18 pre, 0 post), regurgitation scores (1 pre, 0 post) and total GERD-HRQL scores (27 pre, 0 post).Baseline and post-procedure GERD-HRQLscores in 27 patients, average follow-up of 3.8 months:Abstract PWE-087 Table 1Outcome variablesPre-StrettaPost-StrettaHeartbu...

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