[Hiatus hernia and recurrence : the Achilles heel of antireflux surgery?]

Long-term studies show good postoperative results after laparoscopic antireflux surgery, but still approximately 10% of patients suffer from new or recurrent symptoms of gastroesophageal reflux disease. In the majority of cases the symptoms are caused by morphological changes of the fundic wrap or are related to the hiatal closure. Closure of the esophageal hiatus is therefore becoming more and more the key point of antireflux surgery. The aim of this study was to show the problems caused by the esophageal hiatus and to offer possible solutions. Therefore 1,201 laparoscopic antireflux procedures and 240 refundoplications performed in our department between 1993 and 2007 were analyzed with respect to morphologic reasons for failures and the corresponding symptoms. The most common morphological reason for complications after surgery was failure of the hiatal closure with consecutive intrathoracic migration of the fundic wrap, the so-called slipped Nissen. In the past the typical problems after open antireflux surgery were either that the wrap was too loose, a breakdown of the wrap or a so-called telescope phenomenon, all caused by failure of the fundic wrap and now a rarity since laparoscopic surgery. Even after repeated laparoscopic refundoplications the main problem was always the hiatus. This shows the importance of the crural closure and the necessity of a specific definition of size and form of the hiatus.The aim of this study was to initiate a discussion leading to a new definition of the hiatus with the focus on the "hiatal surface area" for a better basis for comparison of the published results of antireflux or hiatal surgery.