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Background
High rates of recurrence have been reported in patients after traditional repair of Type III para-esophageal hernia (PEH), ranging from 10% at 6 months to 60% radiographic recurrence at 5 years. This study evaluates a new Hybrid antireflux operation that combines the components of Nissen fundoplication and the Hill repair, in managing these challenging hernias.
Methods
We performed a prospective study on the 1st 50 consecutive patients undergoing Hybrid repair for symptomatic Type III PEH, from July 2006 to Oct 2009. IRB approval was obtained. Demographic, operative, clinical and quality of life data were collected. Manometry, EGD, UGI, and 48-hour pH testing were obtained pre-operatively and at midterm (MT: 6-12 months post-operative) follow-up. Quality of life was measured with QOLRAD and Dysphagia Severity Scores (DSS) pre-operatively, and post-operatively at short term (ST: 1-3 months) as well as MT follow-up.
Results
Fifty patients (age 42-85 years, mean 66) with symptomatic PEH (mean hernia size=7 cm) underwent the Hybrid repair and were followed for an average of 19.8 ±15 months (range 3-62 months). There was no 30-day or in-hospital mortality. There were 5 major morbidities: 1 intra-operative bougie perforation repaired laparoscopically, 1 limited intra-op bleed, 1 early reoperation for esophageal obstruction, 1 re-admission with myocardial infarction, and 1 gastrotomy repaired laparoscopically. There were 2 deaths noted in MT follow-up, both unrelated to the primary procedure. Follow up data were available for 40/50 (80%) patients. On MT follow up, 33/38 (87%) patients had resolution of dysphagia, and 35/38 (92%) had resolution of heartburn. There was 1 clinical recurrence (2.5%) requiring reoperation at 3 years, and 3 (7.5%) asymptomatic radiographic fundic herniations. All recurrences had an intact, intra-abdominal gastro-esophageal junction (GEJ) and no objective evidence of reflux. Five patients (12.5%) had dysphagia on MT follow-up; 3 (7.5%) underwent dilation with symptom resolution. Two patients (5%) had resumed anti-secretory medications, without objective evidence of reflux. Mean DeMeester scores improved from 56.6 to 6.7 (p=0.008). Lower esophageal sphincter pressure showed no change (22.1 to 20.9, p=0.98). QOLRAD improved both in ST (3.1 to 5.7, p<0.001) and MT (3.1 to 6.6, p<0.001) follow up, as did the DSS (27.2 to 41.7, p<0.001).
Conclusions
Laparoscopic Nissen-Hill hybrid is an effective repair for patients with PEH. It anchors the GEJ securely in the abdomen, combining the axial integrity of the Hill repair with the radial strength of the Nissen. Early clinical as well as radiologic recurrence rates are lower than those reported for Nissen fundoplication, with symptom control equal to or exceeding the traditional anti reflux procedures. Long-term follow-up and direct comparisons to other repairs are needed.
Hybrid repair for PEH: Results

Parameter	Pre-op	Post-op	p-value
LESP	22.13 ± 14.63	20.9 ± 9.77	0.98
QOLRAD (Pre op to ST)	3.13 ± 1.85	5.74 ± 1.16	<0.0001
QOLRAD (Pre op to MT)	3.13 ± 1.85	6.6 ± 0.68	<0.0001
DSS	27.19 ± 16.58	41.67 ± 7.18	<0.0001
DeMeester Score	56.6 ± 41.63	6.67 ± 7.14	0.008