The Nissen-Hil Hybrid Repair: Experience with the First 500
Ralph W. Aye1, George Baison2, Hassan Ahmed5, Jeffrey Watkins3, Adam J. Bograd1, Steven DeMeester4, Alexander S. Farivar1, Brian E. Louie1
1Thoracic and Foregut Surgery, Swedish Medical Center, Seattle, Washington, United States, 2General Surgery, Tufts Medical Center, Boston, Massachusetts, United States, 3Northwest Minimally Invasive Surgery, Portland, Oregon, United States, 4Thoracic Surgery, Oregon Clinic, Portland, Oregon, United States, 5Surgical Oncology, North Texas Surgical Oncology Associates, Plano, Texas, United States
Objective: A new repair for gastroesophageal reflux and hiatal hernia, the Nissen-Hill hybrid repair (HYB), emerged from a randomized trial comparing laparoscopic Nissen and Hill repairs and the identification of differences in recurrence patterns. By combining the two, we theorized that the strength of 1 repair might offset the weakness of the other, with the aim of improved durability. Previously in several small series’ it has been shown to be safe, effective, and durable for paraesophageal hernia (PEH), Barrett’s esophagus (BE) and gastroesophageal reflux disease (GERD). This study represents our experience with the first 500 consecutive repairs for all indications, with emphasis on anatomic and functional outcomes .
Methods: Retrospective study of prospectively collected data for the first 500 consecutive HYB repairs from March 2006 to December 2016 including all indications for surgery. Three quality of life metrics, radiographic imaging, endoscopy, pH testing and selective manometry were administered before and at defined intervals after repair.
Results: 500 patients underwent HYB repair with median follow up of 6.1 years (IQR 4.1-7.7). Indications for surgery were GERD in 231 (46.2 %), PEH in 202 (40.4%), and re-operative repair in 67 (13.4%). The mean age was 59, with BMI of 30 and 63% female. A minimally invasive approach was used in 492 (98%). Median length of stay was 2 days with a Clavien-Dindo major complication rate of 4%, no operative mortality and thirty-day mortality of 0.2%.
Short term objective testing and symptom scores were available for 390 patients (78%) at a median follow-up of 7.2 months. The median DeMeester score improved from 45.9 to 2.7 and 92% were normalized. Anatomic recurrence (>2 cm) was found on UGI in 8/351 patients (2.3%). Post-operatively there were significant improvements in quality of life (QOLRAD 4 to 6.9, range 0-7, p<0.05), reflux symptoms (GERD-HRQL 22 to 2, range 0-54, p<0.001), and swallowing score (Dakkak 37.5 to 41, range 0-45, p<0.05). Proton pump inhibitor use dropped from 460 (92%) to 24 (5%).
Long-term quality of life scores were obtained for 425 patients (85%) at a median of 6.1 years Median QOLRAD, GERD-HRQL and Dysphagia scores were similar to short-term. PPI use was 10%. Anatomic recurrence was seen by UGI in 13.7% and was primarily herniation of the fundus alone, with the GE junction below the diaphragm. Fourteen patients (3%) underwent re-operation for persistent or recurrent symptoms.
Conclusion: The combined Nissen-Hill hybrid repair may provide advantages in terms of reduced hernia recurrence rate with excellent quality of life and elimination of reflux by objective testing compared to either the Hill procedure or a Nissen fundoplication alone. Likely the Hill sutures unload cephalad stress while the fundoplication augments the reflux barrier in these patients.
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