Understanding Fundamental Differences in Symptomatic Outcomes of Hiatal versus Paraoesophageal Hernia Robotic Repairs

Understanding Fundamental Differences in Symptomatic Outcomes of Hiatal versus Paraoesophageal Hernia Robotic Repairs | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Understanding Fundamental Differences in Symptomatic Outcomes of Hiatal versus Paraoesophageal Hernia Robotic Repairs Arham Aslam, Michal Hubka, Joel Sternbach, Madhan Kuppusamy This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5104879/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Dec, 2024 Read the published version in Journal of Robotic Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Background: Hiatal hernia (HH), or type I paraoesophageal hernias (PEH), can commonly be grouped along with types II-IV PEHs. The fundamental operation performed for repair is similar for all types. We question whether the clinical outcomes following surgical repair differ. The objective of this study is to determine the differences in clinical outcomes when comparing robotic assisted surgical repair of HH versus types II-IV PEHs. Design: This is a retrospective study analyzing 602 consecutive patients that underwent robotic assisted repair of a PEH between August 2018 and June 2024. Data was retrieved from an IRB approved database (IRB21-014). Setting: Tertiary referral center. Participants: Eligibility criteria included patients with objective findings of a PEH on diagnostic testing. 184 patients were excluded due to: emergent operation, repeat operations, conversion to open operation, patients pending follow up, patients lost to follow up. Patient demographics were consistent with a population-based sample. Interventions: All patients underwent robotic assisted laparoscopic PEH repair with a fundoplication using the Da Vinci Xi robotic system (Intuitive Surgical, Sunnyvale, CA). No mesh implantation was used. Measurements: The primary study outcome was postoperative symptomatic improvement when comparing HH repairs versus types II-IV PEH repairs. Secondary outcomes included other perioperative outcomes. The hypothesis was formulated before data collection started. Results: Patients in the HH cohort showed significant reflux symptom improvement postoperatively (98% vs 12.2%, p<0.01). PEH patients also showed similar improvements in reflux symptoms (84.8% vs 25%, p<0.01). Symptomatic improvement of dysphagia was found to be significant only in the PEH cohort (54% vs 17.8%, p<0.01) Conclusion: HHs and PEHs are two distinct entities that present with different symptoms; however, the fundamental operation is similar. Symptomatic outcomes differ between the two patient populations, even with the same surgical management. Figures Figure 1 Background The diaphragm and the lower esophageal sphincter apparatus work in tandem to prevent gastric contents from refluxing retrograde into the esophagus. Disruptions to either of these two mechanisms can lead to gastroesophageal reflux, which includes symptoms of heartburn, chest pain, regurgitation, dyspnea and cough. Persistent reflux symptoms can lead to complications such as erosive esophagitis, Barrett’s esophagus, stricture formation, and even malignancy. The laxity of the diaphragmatic hiatus and the phrenoesophageal membrane can lead to migrations of intra-abdominal tissues into the chest cavity, referred to as a diaphragmatic hernia. Diaphragmatic hernias are classified into four distinct categories. Type I is referred to as a hiatal or “sliding-type”, this occurs when the gastroesophageal junction migrates cranially above the diaphragm hiatus (Fig. 1 ) 1 . In type II, the gastroesophageal junction remains at the level of the diaphragm, however the gastric cardia migrates into mediastinum through a defect in the phrenoesophageal membrane (Fig. 1 ) 1 . Type III, also called “mixed-type”, contains elements of both Types I and II, where the gastroesophageal junction migrates cranially and the cardia of the stomach migrates into the mediastinum through a phrenoesophageal defect. Type IV occurs when non-gastric structures migrate into the mediastinum through a phrenoesophageal defect. This may include the small bowel, large bowel, spleen, or pancreas. Collectively, types II-IV are referred to as paraoesophageal type (Fig. 1 ) 1 . The widely accepted definition of a “giant” hernia is when > 50% of the stomach has herniated into the thoracic cavity. Hiatal hernias (HH) account for most diaphragmatic hernias, while the paraoesophageal types make up only 5–10%. 2 Patients suffering from hiatal hernias commonly present with gastroesophageal reflux (GERD) symptoms. Approximately 110,000 individuals are hospitalized with GERD symptoms annually in the United States. 3 Paraoesophageal hernias can be incidentally identified on chest x-ray, computed tomography (CT), or magnetic resonance imaging (MRI). Confirmatory testing is mandatory to establish the diagnosis. Additional work up includes esophagogastroduodenoscopy (EGD) to visually confirm the presence of herniation. Esophageal manometry and pH testing can also be used to measure abnormal pressures within the esophagus and the presence of gastric contents refluxing. Hiatal hernias are initially managed with lifestyle changes, with or without a proton pump inhibitor. If this therapy fails to resolve reflux symptoms, then an anti-reflux operation can be offered to the patient. Paraoesophageal hernias (PEH) can also present in a similar way, however, they have increased risk of leading to volvulus or obstruction. For the paraoesophageal types, surgical repair has historically been advised to prevent acute complications. Indications for surgical repair as recommended by the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) include repairing type 1 hernias only if patients have failed non-operative management and remain symptomatic. For patients with types II-IV who are currently asymptomatic, determining repair versus surveillance should be a shared decision between patient and surgeon. Objective reflux in the asymptomatic patient may warrant repair. Fundoplication is recommended due to large benefit versus small harm, including reduced recurrence rates. The use of mesh has shown equivocal benefits and risks. No evidence-based recommendation was made for the use of mesh. 4 HHs and PEHs are often grouped together as a single entity. However, the presentation, post-operative course, and overall management differ. The primary reason for repair of a HH is to mitigate reflux symptoms and prevent long term complications such as strictures, Barrett’s esophagus, and malignancy. The primary reason for repair of a PEH is to mitigate dysphagia and prevent incarceration or strangulation. Recurrence rate of HHs after repair can be up to 48% in patients presenting with a large (> 5cm) initial hiatal hernia. 5 Hernias < 5cm have been shown to have less than 25% chance of recurrence within 3 years. 5 The need for reoperation heavily depends on the severity of symptoms. Although HHs and PEHs are commonly lumped into the same category, their presentations, postoperative courses, and management differ. In this study we aim to compare the symptomatic and clinical outcomes in patients undergoing robotic repair of HHs versus PEHs at our institution. Methods The data were prospectively collected from an IRB-approved database (IRB21-014) and retrospectively analyzed. Consecutive patients who underwent robotic assisted repair of either HH or PEH between August 2018 and June 2024 at our institution were analyzed. Electronic medical records were reviewed for each patient. Assessment included presenting symptoms, post-operative symptoms, length of stay (LOS), average surgery duration, post-operative day 1 (POD1) esophagram, pain score on day 0, pain score on discharge, time to first ambulation, time to return of bowel function. Patients were separated into two groups, either HH or PEH repair. Inclusion criteria were defined as patients who received initial elective hernia repair. Emergent presentations, repeat operations, conversion to open operation, patients who are pending follow-up or who failed to follow up were all excluded. All ages, races, and sexes were included. The primary outcome included symptomatic and clinical outcomes comparing HH versus PEH repair. Secondary outcomes included surgical outcomes including LOS, complications, duration of surgery, time to first ambulation, time to return of bowel function, and pain scores. All patients underwent EGD and manometry testing pre-operatively. HH patients underwent additional pH testing. All operations were performed using Da Vinci Xi robotic system (Intuitive Surgical, Sunnyvale, CA). A six-port access technique was utilized with four 8mm robot ports, one 5mm port for liver retraction, and a 12mm port for an assistant. Once appropriate visualization has been achieved, a VesselSealer device is used to take down the gastrohepatic ligament and short gastric vessels. The contents of the hernia sac are then reduced into the abdominal cavity. The hernia sac commonly extends into the mediastinum and must be mobilized off intrathoracic structures. This is achieved by blunt dissection of the sac following an avascular place. The anterior and posterior vagus nerves are carefully preserved. The esophagus is then mobilized so that at least 3cm of the distal esophagus lies in the abdomen. This is done to lower the chance of recurrence. Usually, this is able to be achieved with high mediastinal dissection. If mobilization is inadequate, an esophageal lengthening procedure (Collis Gastropexy) can be performed. The diaphragmatic hiatus is closed primarily with pledget-reinforced 0 Ethibond Excel (Ethicon US, LLC, NJ) suture for a tension free repair. Mesh was not used in any of the operations performed. Fundoplication was then performed. The type of fundoplication utilized was dependent on the patient’s symptomatology, anatomy, and esophageal function. The majority of patients underwent a Toupet fundoplication. Each patient's postoperative course followed an institutional enhanced recovery after surgery (ERAS) pathway. This consists of admission to inpatient recovery on a surgical floor with same day ambulation. On POD1, each patient's diet is advanced in a standardized fashion. Starting with thin liquids at 15cc/hr for four hours. Advancing to 30cc/hr for four hours and finishing at 2/3cup/hr for four hours. POD1 esophagrams were used selectively in cases which were especially challenging. Scheduled post-operative follow up was scheduled at three months and one year after discharge. Symptomatic improvement was assessed based on patient interview. All follow ups were performed by the operating surgeon or specialty trained ARNP in the thoracic clinic. The most common symptoms included odynophagia, dysphagia, and reflux. Symptoms were defined as pre-operative if they were present before surgery. Symptoms were defined as post-operative if they were present at postoperative follow up visit. Symptom improvement was defined as symptoms that were present preoperatively and not present postoperatively. Electronic medical records were reviewed for all the considered variables. Distributive analysis, including means and standard deviations, were calculated for quantitative normally distributed values. Student's t-test was used for analysis of continuous data. Results of all statistical tests were considered statistically significant when the P-value was less than 0.05. All statistical analysis was performed using Microsoft Excel XLMiner Analysis ToolPak. Results Of a total of 602 consecutive patients undergoing robotic assisted surgery, 254 patients underwent HH repair, and 348 patients underwent PEH repair. The majority of patients were female in each group. Height, weight, and body mass index (BMI) were comparable also (Table 1). P-values were found to be insignificant for the majority of the demographics, other than age in the PEH cohort. Analyzing the presenting symptoms, dysphagia was more common in the PEH group at 54.0% (Table 2b). Reflux symptoms were observed to be common in both cohorts (Table 2a, 2b). Odynophagia was found to be an uncommon presenting symptom for both groups. Postoperatively, the improvement of odynophagia was found to be insignificant for both the HH and PEH groups. Improvement of dysphagia was found to be significant only in the PEH group with P<0.01 (Table 2b). Both cohorts showed a significant improvement in reflux with P<0.01 (Table 2a, 2b). LOS did not differ greatly between the HH and PEH groups (Table 3a). The inclusion of a POD1 esophagram, based on increased case complexity decided by the surgeon, did show slightly longer LOS on average (Table 3b). However, these findings were not significant. Duration of surgery was noted to be significantly higher in the PEH group with an average of 48.5 minutes greater (Table 3a). This difference was statistically significant (P<0.01). Other perioperative outcomes, such as time to bowel function, time to oral medications, time to first and second ambulation, time to nutrition assessment, and NGT requirements, were all similar (Table 3a). Pain scores on POD0 versus day of discharge, both groups showed significant improvement of pain with P<0.01 (Table 3c). Complications observed included capnothorax, esophageal hematoma, diaphragm hematoma, posterior vagotomy, liver lacerations, and pulmonary emboli. Complication rates were similar between both cohorts with P-value of 0.898 (Table 3d). Discussion Our study highlights the differences in clinical presentation and surgical outcomes of HHs and PEHs. In routine clinical practice, HH’s are grouped together with the rest of the PEHs when referring to symptomatology and general management. However, the symptomatic presentation of patients with HH versus PEH differs. HHs and PEHs can both present with reflux symptoms, however, dysphagia is much more commonly present in the setting of PEH. The management also differs between the two, with HHs initially being managed non-operatively with lifestyle modifications with addition of a proton pump inhibitor. Surgical intervention can be offered to patients with a HH who’s symptoms fail to resolve with conservative therapies. PEHs are at risk of incarceration and strangulation, for which reason surgical correction is offered initially. Due to these differences between HHs and PEHs, we wanted to assess whether there were additional differences between these two patient populations after undergoing a robotic-assisted hernia repair. We found that both patient populations commonly presented with reflux symptoms, refer to Table 2 a. Postoperatively both patient groups showed improvement in reflux symptoms that were noted to be statistically significant, refer to Table 2 a. These results indicate that reflux symptoms can present commonly in both the setting of HH and PEH, this is consistent with the findings published by Cocco and collegaues. 7 Surgical intervention did significantly improve dysphagia symptoms for the PEH cohort, however, the HH group showed no significant improvement in dysphagia symptoms postoperatively. The average LOS for the PEH group versus HH group was noted to be at 1.4d versus 1.3d, however, this was found to not be statistically significant with P-value of 0.808 (Table 3 a). This finding is consistent with the prospective study published by Ross and collegues. 6 When analyzing patients who received POD1 esophagrams due to surgical complexities, the PEH group had a higher LOS at 1.6d versus 1.4d but this showed no statistical significance (Table 3 b). This relationship may be explained by greater technical challenges to the surgeons faced in the repair. In a retrospective analysis performed by Oude Nijhuis and colleagues, they found complications such as strangulation to be as high as 8.1% in patients with giant PEHs being managed non-operatively. 9 This increased risk of complications is why PEHs are initially managed with surgical repair. The average duration of surgery differed by a larger margin, with the PEH cohort taking 48.6min longer on average. Previous meta-analysis by Cheng and colleagues revealed complications rates to double with procedures lasting greater than 2 hours and increase in a stepwise fashion every 30 minutes of operative time. In our experience, both HH and PEH repairs can be performed robotically with a similar safety profile. The average pain scores from POD0 to discharge dropped from 4.4 to 3.9 (-0.5) in the PEH group, with a statistically significant difference. Average pain scored from POD0 to discharge in the HH group dropped from 4.7 to 4.1 (-0.6), also statistically significant. Other variables analyzed included average time to bowel function, with PEH group at 13.3 hours and HH group at 15.4 hours. Average time to oral medication for the PEH group was 20.5 hours, with the HH group slightly higher at 20.8 hours. The average time to first ambulation was lower in the HH group at 16.6 hours versus 17.9 hours in the PEH group. The selection bias inherent in non-randomized allocation and constraints of our single-center design may limit the broad applicability of our findings. In this study, the inherent differences in patient cohorts between HH and PEH repair reflect our population base. The difference in patient characteristics, such as age, BMI, and social history, may impact the outcomes independently of the surgical technique used. We acknowledge this as a limitation of our study, suggesting cautious interpretation of the comparative results. Conclusion HHs and PEHs are two distinct entities which may both present with reflux symptoms, however, dysphagia is more specific to PEHs. Robotic assisted repair can be safely performed in both HH and PEH groups. This study provides insight into the fundamental differences and similarities in surgical outcomes between hiatal and paraoesophageal hernia robotic repairs. Declarations Author Contribution A.A. and M.H. wrote the main manuscript text and prepared all figures and tables. M.H, J.S., M.K. performed all robotic operations which were included in this study. References Baiu I, Lau J. What Is a Paraesophageal Hernia? JAMA. 2019;322(21):2146. doi: 10.1001/jama.2019.17395 Dunbar K, Rohan Jeyarajah D. Abdominal hernias and gastric volvulus. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran’s gastrointestinal and liver disease. 10th ed. Philadelphia: E Saunders, 2016;407–425. Thukkani N, Sonnenberg A. The influence of environmental risk factors in hospitalization for gastro-oesophageal reflux disease-related diagnoses in the United States. Aliment Pharmacol Ther. 2010;31(8):852–61. doi: 10.1111/j.1365-2036.2010.04245.x. Epub 2010 Jan 22. PMID: 20102354. SAGES - Society of American Gastrointestinal and Endoscopic Surgeons, & Daly, S., et al. (2024). Guidelines for the Surgical Treatment of Hiatal Hernias - a SAGES publication . https://www.sages.org/publications/guidelines/guidelines-for-the-surgical-treatment-of-hiatal-hernias/ Simorov A, Ranade A, Jones R, et al. Long-term patient out- comes after laparoscopic anti-reflux procedures. J Gastrointest Surg 2014;18:157–163. Ross SB, Sucandy I, Trotto M, Christodoulou M, Pattilachan TM, Jattan J, Rosemurgy AS. A decade of experience with minimally invasive anti-reflux operations: robot vs. LESS. Surg Endosc. 2024;38(5):2641–2648. doi: 10.1007/s00464-024-10771-5. Epub 2024 Mar 19. PMID: 38503903. Cocco, A.M., Chai, V., Read, M. et al. Percentage of intrathoracic stomach predicts operative and post-operative morbidity, persistent reflux and PPI requirement following laparoscopic hiatus hernia repair and fundoplication. Surg Endosc 37, 1994–2002 (2023). https://doi.org/10.1007/s00464-022-09701-0 Cheng H, Clymer JW, Po-Han Chen B, Sadeghirad B, Ferko NC, Cameron CG, Hinoul P. Prolonged operative duration is associated with complications: a systematic review and meta-analysis. J Surg Res. 2018;229:134–144. doi: 10.1016/j.jss.2018.03.022. Epub 2018 Apr 24. PMID: 29936980. Oude Nijhuis RAB, Hoek MV, Schuitenmaker JM, Schijven MP, Draaisma WA, Smout AJPM, Bredenoord AJ. The natural course of giant paraesophageal hernia and long-term outcomes following conservative management. United European Gastroenterol J. 2020;8(10):1163–1173. doi: 10.1177/2050640620953754. Epub 2020 Aug 24. PMID: 32829676; PMCID: PMC7724529. Tables Table 1. Patient Demographics HH (n=254) P-value PEH (n=348) P-value Variables Age 56.4 ± 10.8 0.865 61.8 ± 12.7 <0.01 Sex (M/F) 120 (47.2)/134 (52.8) 0.470 154 (44.3) /194 (55.7) 0.890 Height (cm) 168.0 ± 10.6 0.808 167.2 ± 9.5 0.934 Weight (Kg) 80.3 ± 12.5 0.734 82.5 ± 10.3 0.350 BMI 28.3 ± 4.6 0.388 29.0 ± 5.4 0.489 Smoking (never/current/former) 161 (63.4) /66 (26.0) /27 (10.6) 0.365 245 (70.4) /28 (8.0) /75 (21.6) 0.110 Alcohol (never/current/former) 180 (70.9) /54 (21.3) /20 (7.9) 0.579 225 (64.7) /99 (28.4) /24 (6.9) 0.211 Table 2a. HH Preoperative and Postoperative Symptoms HH Pre-op Sx (n=254) HH Post-op Sx (n=254) P-Value Odynophagia 4 (1.6) 1 (0.4) 0.180 Dysphagia 73 (28.7) 56 (22.0) 0.059 Reflux 249 (98.0) 31 (12.2) <0.01 Table 2b. PEH Preoperative and Postoperative Symptoms PEH Pre-op Sx (n=348) PEH Post-op Sx (n=348) P-Value Odynophagia 4 (1.1) 3 (0.9) 0.66 Dysphagia 188 (54.0) 62 (17.8) <0.01 Reflux 295 (84.8) 87 (25.0) <0.01 Table 3a. Perioperative Outcomes HH (n=254) PEH (n=348) P-value LOS (days) 1.3 ± 0.04 1.4 ± 0.04 0.808 Surgery Duration (minutes) 131.0 ± 3.34 179.5 ± 3.82 <0.01 Time to Bowel Function (hours) 15.4 ± 1.22 17.9 ± 1.06 0.998 Time to Oral Medication (hours) 20.8 ± 0.72 20.5 ± 0.67 0.443 Time to 1st Ambulation (hours) 16.6 ± 1.00 17.9 ± 1.06 0.746 Time to 2nd Ambulation (hours) 24.6 ± 2.07 22.4 ± 1.62 1 Time to Nutrition Assessment (hours) 22.4 ± 0.32 21.1 ± 0.28 0.677 NGT Required (%) 18 (7.1) 23 (6.6) Table 3b. POD0 Esophagrams and Length of Stay POD0 Esophograms LOS P-value HH (n=254) 62 (24.4) 1.4 ± 0.04 0.509 PEH (n=348) 115 (33.0) 1.6 ± 0.04 0.827 Table 3c. POD0 Versus Discharge Pain Scores POD0 Pain Score Discharge Pain Score P-value HH (n=254) 4.7 ± 0.11 4.1 ± 0.14 <0.01 PEH (n=348) 4.4 ± 0.10 3.9 ± 0.12 <0.01 Table 3d. Complications HH (n=254) PEH (n=348) P-value Capnothorax 9 14 Esophageal Hematoma 1 0 Diaphragm Hematoma 1 0 Posterior Vagotomy 0 1 Liver Laceration 0 1 Bilateral Pulmonary Emboli 0 1 Total (%) 11 (4.3) 17 (4.9) 0.898 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 12 Dec, 2024 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 23 Nov, 2024 Reviews received at journal 22 Nov, 2024 Reviewers agreed at journal 14 Nov, 2024 Reviewers agreed at journal 10 Nov, 2024 Reviewers agreed at journal 09 Nov, 2024 Reviewers invited by journal 09 Nov, 2024 Editor assigned by journal 21 Sep, 2024 Submission checks completed at journal 21 Sep, 2024 First submitted to journal 17 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5104879","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":381786756,"identity":"9b7c26a6-dc5a-4f26-804e-06ef8d526748","order_by":0,"name":"Arham Aslam","email":"data:image/png;base64,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","orcid":"","institution":"Virginia Mason Medical Center","correspondingAuthor":true,"prefix":"","firstName":"Arham","middleName":"","lastName":"Aslam","suffix":""},{"id":381786759,"identity":"b986353a-e5a4-4287-a2b6-9a34d94211b2","order_by":1,"name":"Michal Hubka","email":"","orcid":"","institution":"Virginia Mason Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Michal","middleName":"","lastName":"Hubka","suffix":""},{"id":381786761,"identity":"91f3e92e-370d-43c1-b0b7-1516fc612598","order_by":2,"name":"Joel Sternbach","email":"","orcid":"","institution":"Virginia Mason Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Joel","middleName":"","lastName":"Sternbach","suffix":""},{"id":381786762,"identity":"7ec80897-f2f7-4cba-9c81-7dc1061b3140","order_by":3,"name":"Madhan Kuppusamy","email":"","orcid":"","institution":"Virginia Mason Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Madhan","middleName":"","lastName":"Kuppusamy","suffix":""}],"badges":[],"createdAt":"2024-09-17 17:13:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5104879/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5104879/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11701-024-02182-4","type":"published","date":"2024-12-12T15:57:20+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":70205063,"identity":"abb1cff8-5dfb-43d6-856f-49c1bd19216f","added_by":"auto","created_at":"2024-11-29 13:33:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":285881,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eParaesophageal Hernias\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5104879/v1/2fa4f6ba6fcf9e71a2e357fc.png"},{"id":71552434,"identity":"dd423468-3fc4-4c4b-b0f4-c3c4f080e850","added_by":"auto","created_at":"2024-12-16 16:06:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":804062,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5104879/v1/8853580d-2b90-4523-bdf5-6c7bde967ae4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Understanding Fundamental Differences in Symptomatic Outcomes of Hiatal versus Paraoesophageal Hernia Robotic Repairs","fulltext":[{"header":"Background","content":"\u003cp\u003eThe diaphragm and the lower esophageal sphincter apparatus work in tandem to prevent gastric contents from refluxing retrograde into the esophagus. Disruptions to either of these two mechanisms can lead to gastroesophageal reflux, which includes symptoms of heartburn, chest pain, regurgitation, dyspnea and cough. Persistent reflux symptoms can lead to complications such as erosive esophagitis, Barrett\u0026rsquo;s esophagus, stricture formation, and even malignancy. The laxity of the diaphragmatic hiatus and the phrenoesophageal membrane can lead to migrations of intra-abdominal tissues into the chest cavity, referred to as a diaphragmatic hernia.\u003c/p\u003e \u003cp\u003eDiaphragmatic hernias are classified into four distinct categories. Type I is referred to as a hiatal or \u0026ldquo;sliding-type\u0026rdquo;, this occurs when the gastroesophageal junction migrates cranially above the diaphragm hiatus (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. In type II, the gastroesophageal junction remains at the level of the diaphragm, however the gastric cardia migrates into mediastinum through a defect in the phrenoesophageal membrane (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Type III, also called \u0026ldquo;mixed-type\u0026rdquo;, contains elements of both Types I and II, where the gastroesophageal junction migrates cranially and the cardia of the stomach migrates into the mediastinum through a phrenoesophageal defect. Type IV occurs when non-gastric structures migrate into the mediastinum through a phrenoesophageal defect. This may include the small bowel, large bowel, spleen, or pancreas. Collectively, types II-IV are referred to as paraoesophageal type (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. The widely accepted definition of a \u0026ldquo;giant\u0026rdquo; hernia is when \u0026gt;\u0026thinsp;50% of the stomach has herniated into the thoracic cavity.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eHiatal hernias (HH) account for most diaphragmatic hernias, while the paraoesophageal types make up only 5\u0026ndash;10%.\u003csup\u003e2\u003c/sup\u003e Patients suffering from hiatal hernias commonly present with gastroesophageal reflux (GERD) symptoms. Approximately 110,000 individuals are hospitalized with GERD symptoms annually in the United States.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Paraoesophageal hernias can be incidentally identified on chest x-ray, computed tomography (CT), or magnetic resonance imaging (MRI). Confirmatory testing is mandatory to establish the diagnosis. Additional work up includes esophagogastroduodenoscopy (EGD) to visually confirm the presence of herniation. Esophageal manometry and pH testing can also be used to measure abnormal pressures within the esophagus and the presence of gastric contents refluxing. Hiatal hernias are initially managed with lifestyle changes, with or without a proton pump inhibitor. If this therapy fails to resolve reflux symptoms, then an anti-reflux operation can be offered to the patient. Paraoesophageal hernias (PEH) can also present in a similar way, however, they have increased risk of leading to volvulus or obstruction. For the paraoesophageal types, surgical repair has historically been advised to prevent acute complications.\u003c/p\u003e \u003cp\u003eIndications for surgical repair as recommended by the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) include repairing type 1 hernias only if patients have failed non-operative management and remain symptomatic. For patients with types II-IV who are currently asymptomatic, determining repair versus surveillance should be a shared decision between patient and surgeon. Objective reflux in the asymptomatic patient may warrant repair. Fundoplication is recommended due to large benefit versus small harm, including reduced recurrence rates. The use of mesh has shown equivocal benefits and risks. No evidence-based recommendation was made for the use of mesh.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHHs and PEHs are often grouped together as a single entity. However, the presentation, post-operative course, and overall management differ. The primary reason for repair of a HH is to mitigate reflux symptoms and prevent long term complications such as strictures, Barrett\u0026rsquo;s esophagus, and malignancy. The primary reason for repair of a PEH is to mitigate dysphagia and prevent incarceration or strangulation. Recurrence rate of HHs after repair can be up to 48% in patients presenting with a large (\u0026gt;\u0026thinsp;5cm) initial hiatal hernia.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Hernias\u0026thinsp;\u0026lt;\u0026thinsp;5cm have been shown to have less than 25% chance of recurrence within 3 years.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e The need for reoperation heavily depends on the severity of symptoms. Although HHs and PEHs are commonly lumped into the same category, their presentations, postoperative courses, and management differ. In this study we aim to compare the symptomatic and clinical outcomes in patients undergoing robotic repair of HHs versus PEHs at our institution.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe data were prospectively collected from an IRB-approved database (IRB21-014) and retrospectively analyzed. Consecutive patients who underwent robotic assisted repair of either HH or PEH between August 2018 and June 2024 at our institution were analyzed. Electronic medical records were reviewed for each patient. Assessment included presenting symptoms, post-operative symptoms, length of stay (LOS), average surgery duration, post-operative day 1 (POD1) esophagram, pain score on day 0, pain score on discharge, time to first ambulation, time to return of bowel function.\u003c/p\u003e \u003cp\u003ePatients were separated into two groups, either HH or PEH repair. Inclusion criteria were defined as patients who received initial elective hernia repair. Emergent presentations, repeat operations, conversion to open operation, patients who are pending follow-up or who failed to follow up were all excluded. All ages, races, and sexes were included. The primary outcome included symptomatic and clinical outcomes comparing HH versus PEH repair. Secondary outcomes included surgical outcomes including LOS, complications, duration of surgery, time to first ambulation, time to return of bowel function, and pain scores. All patients underwent EGD and manometry testing pre-operatively. HH patients underwent additional pH testing.\u003c/p\u003e \u003cp\u003eAll operations were performed using Da Vinci Xi robotic system (Intuitive Surgical, Sunnyvale, CA). A six-port access technique was utilized with four 8mm robot ports, one 5mm port for liver retraction, and a 12mm port for an assistant. Once appropriate visualization has been achieved, a VesselSealer device is used to take down the gastrohepatic ligament and short gastric vessels. The contents of the hernia sac are then reduced into the abdominal cavity. The hernia sac commonly extends into the mediastinum and must be mobilized off intrathoracic structures. This is achieved by blunt dissection of the sac following an avascular place. The anterior and posterior vagus nerves are carefully preserved.\u003c/p\u003e \u003cp\u003eThe esophagus is then mobilized so that at least 3cm of the distal esophagus lies in the abdomen. This is done to lower the chance of recurrence. Usually, this is able to be achieved with high mediastinal dissection. If mobilization is inadequate, an esophageal lengthening procedure (Collis Gastropexy) can be performed. The diaphragmatic hiatus is closed primarily with pledget-reinforced 0 Ethibond Excel (Ethicon US, LLC, NJ) suture for a tension free repair. Mesh was not used in any of the operations performed. Fundoplication was then performed. The type of fundoplication utilized was dependent on the patient\u0026rsquo;s symptomatology, anatomy, and esophageal function. The majority of patients underwent a Toupet fundoplication.\u003c/p\u003e \u003cp\u003eEach patient's postoperative course followed an institutional enhanced recovery after surgery (ERAS) pathway. This consists of admission to inpatient recovery on a surgical floor with same day ambulation. On POD1, each patient's diet is advanced in a standardized fashion. Starting with thin liquids at 15cc/hr for four hours. Advancing to 30cc/hr for four hours and finishing at 2/3cup/hr for four hours. POD1 esophagrams were used selectively in cases which were especially challenging.\u003c/p\u003e \u003cp\u003eScheduled post-operative follow up was scheduled at three months and one year after discharge. Symptomatic improvement was assessed based on patient interview. All follow ups were performed by the operating surgeon or specialty trained ARNP in the thoracic clinic. The most common symptoms included odynophagia, dysphagia, and reflux. Symptoms were defined as pre-operative if they were present before surgery. Symptoms were defined as post-operative if they were present at postoperative follow up visit. Symptom improvement was defined as symptoms that were present preoperatively and not present postoperatively.\u003c/p\u003e \u003cp\u003eElectronic medical records were reviewed for all the considered variables. Distributive analysis, including means and standard deviations, were calculated for quantitative normally distributed values. Student's t-test was used for analysis of continuous data. Results of all statistical tests were considered statistically significant when the P-value was less than 0.05. All statistical analysis was performed using Microsoft Excel XLMiner Analysis ToolPak.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf a total of 602 consecutive patients undergoing robotic assisted surgery, 254 patients underwent HH repair, and 348 patients underwent PEH repair. The majority of patients were female in each group. Height, weight, and body mass index (BMI) were comparable also (Table 1). P-values were found to be insignificant for the majority of the demographics, other than age in the PEH cohort. Analyzing the presenting symptoms, dysphagia was more common in the PEH group at 54.0% (Table 2b). Reflux symptoms were observed to be common in both cohorts (Table 2a, 2b). Odynophagia was found to be an uncommon presenting symptom for both groups. Postoperatively, the improvement of odynophagia was found to be insignificant for both the HH and PEH groups. Improvement of dysphagia was found to be significant only in the PEH group with P\u0026lt;0.01 (Table 2b).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBoth cohorts showed a significant improvement in reflux with P\u0026lt;0.01 (Table 2a, 2b). LOS did not differ greatly between the HH and PEH groups (Table 3a). The inclusion of a POD1 esophagram, based on increased case complexity decided by the surgeon, did show slightly longer LOS on average (Table 3b). However, these findings were not significant. Duration of surgery was noted to be significantly higher in the PEH group with an average of 48.5 minutes greater (Table 3a). This difference was statistically significant (P\u0026lt;0.01). Other perioperative outcomes, such as time to bowel function, time to oral medications, time to first and second ambulation, time to nutrition assessment, and NGT requirements, were all similar (Table 3a). Pain scores on POD0 versus day of discharge, both groups showed significant improvement of pain with P\u0026lt;0.01 (Table 3c). Complications observed included capnothorax, esophageal hematoma, diaphragm hematoma, posterior vagotomy, liver lacerations, and pulmonary emboli. Complication rates were similar between both cohorts with P-value of 0.898 (Table 3d).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study highlights the differences in clinical presentation and surgical outcomes of HHs and PEHs. In routine clinical practice, HH\u0026rsquo;s are grouped together with the rest of the PEHs when referring to symptomatology and general management. However, the symptomatic presentation of patients with HH versus PEH differs. HHs and PEHs can both present with reflux symptoms, however, dysphagia is much more commonly present in the setting of PEH. The management also differs between the two, with HHs initially being managed non-operatively with lifestyle modifications with addition of a proton pump inhibitor. Surgical intervention can be offered to patients with a HH who\u0026rsquo;s symptoms fail to resolve with conservative therapies. PEHs are at risk of incarceration and strangulation, for which reason surgical correction is offered initially.\u003c/p\u003e \u003cp\u003eDue to these differences between HHs and PEHs, we wanted to assess whether there were additional differences between these two patient populations after undergoing a robotic-assisted hernia repair. We found that both patient populations commonly presented with reflux symptoms, refer to Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003ea. Postoperatively both patient groups showed improvement in reflux symptoms that were noted to be statistically significant, refer to Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003ea. These results indicate that reflux symptoms can present commonly in both the setting of HH and PEH, this is consistent with the findings published by Cocco and collegaues.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Surgical intervention did significantly improve dysphagia symptoms for the PEH cohort, however, the HH group showed no significant improvement in dysphagia symptoms postoperatively. The average LOS for the PEH group versus HH group was noted to be at 1.4d versus 1.3d, however, this was found to not be statistically significant with P-value of 0.808 (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e3\u003c/span\u003ea). This finding is consistent with the prospective study published by Ross and collegues.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e When analyzing patients who received POD1 esophagrams due to surgical complexities, the PEH group had a higher LOS at 1.6d versus 1.4d but this showed no statistical significance (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e3\u003c/span\u003eb). This relationship may be explained by greater technical challenges to the surgeons faced in the repair. In a retrospective analysis performed by Oude Nijhuis and colleagues, they found complications such as strangulation to be as high as 8.1% in patients with giant PEHs being managed non-operatively.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e This increased risk of complications is why PEHs are initially managed with surgical repair.\u003c/p\u003e \u003cp\u003eThe average duration of surgery differed by a larger margin, with the PEH cohort taking 48.6min longer on average. Previous meta-analysis by Cheng and colleagues revealed complications rates to double with procedures lasting greater than 2 hours and increase in a stepwise fashion every 30 minutes of operative time. In our experience, both HH and PEH repairs can be performed robotically with a similar safety profile. The average pain scores from POD0 to discharge dropped from 4.4 to 3.9 (-0.5) in the PEH group, with a statistically significant difference. Average pain scored from POD0 to discharge in the HH group dropped from 4.7 to 4.1 (-0.6), also statistically significant. Other variables analyzed included average time to bowel function, with PEH group at 13.3 hours and HH group at 15.4 hours. Average time to oral medication for the PEH group was 20.5 hours, with the HH group slightly higher at 20.8 hours. The average time to first ambulation was lower in the HH group at 16.6 hours versus 17.9 hours in the PEH group.\u003c/p\u003e \u003cp\u003eThe selection bias inherent in non-randomized allocation and constraints of our single-center design may limit the broad applicability of our findings. In this study, the inherent differences in patient cohorts between HH and PEH repair reflect our population base. The difference in patient characteristics, such as age, BMI, and social history, may impact the outcomes independently of the surgical technique used. We acknowledge this as a limitation of our study, suggesting cautious interpretation of the comparative results.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eHHs and PEHs are two distinct entities which may both present with reflux symptoms, however, dysphagia is more specific to PEHs. Robotic assisted repair can be safely performed in both HH and PEH groups. This study provides insight into the fundamental differences and similarities in surgical outcomes between hiatal and paraoesophageal hernia robotic repairs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.A. and M.H. wrote the main manuscript text and prepared all figures and tables. M.H, J.S., M.K. performed all robotic operations which were included in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBaiu I, Lau J. What Is a Paraesophageal Hernia? JAMA. 2019;322(21):2146. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jama.2019.17395\u003c/span\u003e\u003cspan address=\"10.1001/jama.2019.17395\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDunbar K, Rohan Jeyarajah D. Abdominal hernias and gastric volvulus. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran\u0026rsquo;s gastrointestinal and liver disease. 10th ed. Philadelphia: E Saunders, 2016;407\u0026ndash;425.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThukkani N, Sonnenberg A. The influence of environmental risk factors in hospitalization for gastro-oesophageal reflux disease-related diagnoses in the United States. Aliment Pharmacol Ther. 2010;31(8):852\u0026ndash;61. doi: 10.1111/j.1365-2036.2010.04245.x. Epub 2010 Jan 22. PMID: 20102354.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSAGES - Society of American Gastrointestinal and Endoscopic Surgeons, \u0026amp; Daly, S., et al. (2024). \u003cem\u003eGuidelines for the Surgical Treatment of Hiatal Hernias - a SAGES publication\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.sages.org/publications/guidelines/guidelines-for-the-surgical-treatment-of-hiatal-hernias/\u003c/span\u003e\u003cspan address=\"https://www.sages.org/publications/guidelines/guidelines-for-the-surgical-treatment-of-hiatal-hernias/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSimorov A, Ranade A, Jones R, et al. Long-term patient out- comes after laparoscopic anti-reflux procedures. J Gastrointest Surg 2014;18:157\u0026ndash;163.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoss SB, Sucandy I, Trotto M, Christodoulou M, Pattilachan TM, Jattan J, Rosemurgy AS. A decade of experience with minimally invasive anti-reflux operations: robot vs. LESS. Surg Endosc. 2024;38(5):2641\u0026ndash;2648. doi: 10.1007/s00464-024-10771-5. Epub 2024 Mar 19. PMID: 38503903.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCocco, A.M., Chai, V., Read, M. \u003cem\u003eet al.\u003c/em\u003e Percentage of intrathoracic stomach predicts operative and post-operative morbidity, persistent reflux and PPI requirement following laparoscopic hiatus hernia repair and fundoplication. Surg Endosc 37, 1994\u0026ndash;2002 (2023). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00464-022-09701-0\u003c/span\u003e\u003cspan address=\"10.1007/s00464-022-09701-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng H, Clymer JW, Po-Han Chen B, Sadeghirad B, Ferko NC, Cameron CG, Hinoul P. Prolonged operative duration is associated with complications: a systematic review and meta-analysis. J Surg Res. 2018;229:134\u0026ndash;144. doi: 10.1016/j.jss.2018.03.022. Epub 2018 Apr 24. PMID: 29936980.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOude Nijhuis RAB, Hoek MV, Schuitenmaker JM, Schijven MP, Draaisma WA, Smout AJPM, Bredenoord AJ. The natural course of giant paraesophageal hernia and long-term outcomes following conservative management. United European Gastroenterol J. 2020;8(10):1163\u0026ndash;1173. doi: 10.1177/2050640620953754. Epub 2020 Aug 24. PMID: 32829676; PMCID: PMC7724529.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Patient Demographics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"647\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.8841%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.966%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHH (n=254)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2009%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8934%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePEH (n=348)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0556%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.8841%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.966%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2009%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8934%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0556%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.8841%;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.966%;\"\u003e\n \u003cp\u003e56.4 \u0026plusmn; 10.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2009%;\"\u003e\n \u003cp\u003e0.865\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8934%;\"\u003e\n \u003cp\u003e61.8 \u0026plusmn; 12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0556%;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.8841%;\"\u003e\n \u003cp\u003eSex (M/F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.966%;\"\u003e\n \u003cp\u003e120 (47.2)/134 (52.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2009%;\"\u003e\n \u003cp\u003e0.470\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8934%;\"\u003e\n \u003cp\u003e154 (44.3) /194 (55.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0556%;\"\u003e\n \u003cp\u003e0.890\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.8841%;\"\u003e\n \u003cp\u003eHeight (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.966%;\"\u003e\n \u003cp\u003e168.0 \u0026plusmn; 10.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2009%;\"\u003e\n \u003cp\u003e0.808\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8934%;\"\u003e\n \u003cp\u003e167.2 \u0026plusmn; 9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0556%;\"\u003e\n \u003cp\u003e0.934\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.8841%;\"\u003e\n \u003cp\u003eWeight (Kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.966%;\"\u003e\n \u003cp\u003e80.3 \u0026plusmn; 12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2009%;\"\u003e\n \u003cp\u003e0.734\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8934%;\"\u003e\n \u003cp\u003e82.5 \u0026plusmn; 10.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0556%;\"\u003e\n \u003cp\u003e0.350\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.8841%;\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.966%;\"\u003e\n \u003cp\u003e28.3 \u0026plusmn; 4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2009%;\"\u003e\n \u003cp\u003e0.388\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8934%;\"\u003e\n \u003cp\u003e29.0 \u0026plusmn; 5.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0556%;\"\u003e\n \u003cp\u003e0.489\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.8841%;\"\u003e\n \u003cp\u003eSmoking (never/current/former)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.966%;\"\u003e\n \u003cp\u003e161 (63.4) /66 (26.0) /27 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2009%;\"\u003e\n \u003cp\u003e0.365\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8934%;\"\u003e\n \u003cp\u003e245 (70.4) /28 (8.0) /75 (21.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0556%;\"\u003e\n \u003cp\u003e0.110\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.8841%;\"\u003e\n \u003cp\u003eAlcohol (never/current/former)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.966%;\"\u003e\n \u003cp\u003e180 (70.9) /54 (21.3) /20 (7.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2009%;\"\u003e\n \u003cp\u003e0.579\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 26.8934%;\"\u003e\n \u003cp\u003e225 (64.7) /99 (28.4) /24 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.0556%;\"\u003e\n \u003cp\u003e0.211\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2a. HH Preoperative and Postoperative Symptoms\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHH Pre-op Sx (n=254)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHH Post-op Sx (n=254)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdynophagia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.180\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDysphagia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e73 (28.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56 (22.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.059\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReflux\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e249 (98.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31 (12.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2b. PEH Preoperative and Postoperative Symptoms\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePEH Pre-op Sx (n=348)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePEH Post-op Sx (n=348)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdynophagia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDysphagia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e188 (54.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e62 (17.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReflux\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e295 (84.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e87 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3a. Perioperative Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHH (n=254)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePEH (n=348)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLOS (days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.3 \u0026plusmn; 0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.4 \u0026plusmn; 0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.808\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery Duration (minutes)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e131.0 \u0026plusmn; 3.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e179.5 \u0026plusmn; 3.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to Bowel Function (hours)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.4 \u0026plusmn; 1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17.9 \u0026plusmn; 1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.998\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to Oral Medication (hours)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20.8 \u0026plusmn; 0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20.5 \u0026plusmn; 0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.443\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to 1st Ambulation (hours)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16.6 \u0026plusmn; 1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17.9 \u0026plusmn; 1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.746\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to 2nd Ambulation (hours)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24.6 \u0026plusmn; 2.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22.4 \u0026plusmn; 1.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to Nutrition Assessment (hours)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22.4 \u0026plusmn; 0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.1 \u0026plusmn; 0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.677\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNGT Required (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23 (6.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3b. POD0 Esophagrams and Length of Stay\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"637\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5071%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40.5024%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePOD0 Esophograms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2104%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLOS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7802%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5071%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHH (n=254)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40.5024%;\"\u003e\n \u003cp\u003e62 (24.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2104%;\"\u003e\n \u003cp\u003e1.4 \u0026plusmn; 0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7802%;\"\u003e\n \u003cp\u003e0.509\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 21.5071%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePEH (n=348)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 40.5024%;\"\u003e\n \u003cp\u003e115 (33.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.2104%;\"\u003e\n \u003cp\u003e1.6 \u0026plusmn; 0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19.7802%;\"\u003e\n \u003cp\u003e0.827\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3c. POD0 Versus Discharge Pain Scores\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePOD0 Pain Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDischarge Pain Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHH (n=254)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.7 \u0026plusmn; 0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.1 \u0026plusmn; 0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePEH (n=348)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.4 \u0026plusmn; 0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.9 \u0026plusmn; 0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3d. Complications\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"left\" width=\"626\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHH (n=254)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePEH (n=348)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCapnothorax\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEsophageal Hematoma\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiaphragm Hematoma\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePosterior Vagotomy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLiver Laceration\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBilateral Pulmonary Emboli\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e11 (4.3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e17 (4.9)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.898\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5104879/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5104879/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eHiatal hernia (HH), or type I paraoesophageal hernias (PEH), can commonly be grouped along with types II-IV PEHs. The fundamental operation performed for repair is similar for all types. We question whether the clinical outcomes following surgical repair differ. The objective of this study is to determine the differences in clinical outcomes when comparing robotic assisted surgical repair of HH versus types II-IV PEHs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign: \u003c/strong\u003eThis is a retrospective study analyzing 602 consecutive patients that underwent robotic assisted repair of a PEH between August 2018 and June 2024. Data was retrieved from an IRB approved database (IRB21-014).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting: \u003c/strong\u003eTertiary referral center.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants:\u003c/strong\u003e Eligibility criteria included patients with objective findings of a PEH on diagnostic testing. 184 patients were excluded due to: emergent operation, repeat operations, conversion to open operation, patients pending follow up, patients lost to follow up. Patient demographics were consistent with a population-based sample.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterventions: \u003c/strong\u003eAll patients underwent robotic assisted laparoscopic PEH repair with a fundoplication using the Da Vinci Xi robotic system (Intuitive Surgical, Sunnyvale, CA). No mesh implantation was used.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasurements: \u003c/strong\u003eThe primary study outcome was postoperative symptomatic improvement when comparing HH repairs versus types II-IV PEH repairs. Secondary outcomes included other perioperative outcomes. The hypothesis was formulated before data collection started.\u003c/p\u003e\n\u003cp\u003eResults: Patients in the HH cohort showed significant reflux symptom improvement postoperatively (98% vs 12.2%, p\u0026lt;0.01). PEH patients also showed similar improvements in reflux symptoms (84.8% vs 25%, p\u0026lt;0.01). Symptomatic improvement of dysphagia was found to be significant only in the PEH cohort (54% vs 17.8%, p\u0026lt;0.01)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e HHs and PEHs are two distinct entities that present with different symptoms; however, the fundamental operation is similar. Symptomatic outcomes differ between the two patient populations, even with the same surgical management.\u003c/p\u003e","manuscriptTitle":"Understanding Fundamental Differences in Symptomatic Outcomes of Hiatal versus Paraoesophageal Hernia Robotic Repairs","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-29 13:33:43","doi":"10.21203/rs.3.rs-5104879/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-23T19:34:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-22T10:50:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"227198897810562630873204188494719895721","date":"2024-11-14T07:59:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"194157512195195910408230467519155017928","date":"2024-11-10T13:34:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58850511520974716443967073084562660811","date":"2024-11-09T13:21:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-09T12:57:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-22T01:53:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-21T12:58:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2024-09-17T17:10:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"0eafd81f-25ba-4b48-91df-9297a7cfa3f0","owner":[],"postedDate":"November 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-16T16:00:32+00:00","versionOfRecord":{"articleIdentity":"rs-5104879","link":"https://doi.org/10.1007/s11701-024-02182-4","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2024-12-12 15:57:20","publishedOnDateReadable":"December 12th, 2024"},"versionCreatedAt":"2024-11-29 13:33:43","video":"","vorDoi":"10.1007/s11701-024-02182-4","vorDoiUrl":"https://doi.org/10.1007/s11701-024-02182-4","workflowStages":[]},"version":"v1","identity":"rs-5104879","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5104879","identity":"rs-5104879","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}