Heard, Jessica

Background: The study aims to evaluate the postoperative outcomes of hiatal hernia repair with cruroplasty alone compared to the addition of fundoplication. We theorize that previously reported inferiority with crural-only repairs resulted from a lack of real-time feedback regarding the effectiveness of the repair. EndoFLIP TM allows for intraoperative assessment of the gastroesophageal junction. We predict equivalent postoperative outcomes will be achieved between hiatal hernia repairs performed by cruroplasty alone and with fundoplication when the final distensibility index (DI) is similar. Methods: This retrospective cohort review includes patients who underwent hiatal hernia repair with intraoperative EndoFLIP TM between 2020 and 2022. Propensity score-matching was utilized to identify cruroplasty alone and fundoplication patients with a final DI within 0.5 mm 2 /mmHg of one another. Postoperative development of dysphagia, reflux, or hernia recurrence were primary outcomes of interest. Results: Forty-two patients were included in the analysis. While the cruroplasty-alone cohort had an increased age at the time of surgery, 50% more redo repairs, and a slightly higher BMI, there were no significant preoperative or intraoperative differences between groups. Overall, the median duration of follow-up was 111 (IQR 213) days. During that time, there were no differences in the development of postoperative reflux or dysphagia between cohorts ( P = .228 and P = .451, respectively). Kaplan-Meier curve analysis did not demonstrate a significant difference in time-to-event for either outcome. There were 3 radiographic recurrences, with 2 occurring after fundoplication ( P = .000). Conclusions: This is the first study to utilize intraoperative EndoFLIP TM to determine the need for fundoplication during hiatal hernia repair. The results demonstrate no additional short-term benefit from fundoplication performance. These findings argue against routine fundoplication when an acceptable DI can be achieved after cruroplasty. Further research is needed to validate these results.

Hepatic resection (HR) and liver transplantation (LT) are curative-intent treatments for hepatocellular carcinoma (HCC). Patients without cirrhosis are typically analyzed as a single group, obscuring potentially important differences between those with histologically normal liver and those with non-cirrhotic parenchymal disease. We aimed to characterize long-term outcomes following HR stratified by underlying parenchymal quality, with a contemporary LT cohort as an external benchmark. Retrospective cohort study of 662 adults undergoing curative-intent surgery for HCC at 2 tertiary centers (2010–2024). Resection patients (n=380) were stratified by non-tumor parenchymal histology into HR-Normal (n=84), HR-Diseased non-cirrhotic (n=159), and HR-Cirrhotic (n=137). A total of 282 LT recipients served as an external reference but were not entered into comparative models. Overall survival (OS) was analyzed by Kaplan–Meier and multivariable Cox regression, and recurrence by Fine–Gray competing-risks regression. Ninety-day mortality was low across resection strata (1.2%–3.2%). OS differed significantly across parenchymal groups (log-rank p =0.01), driven by superior outcomes in HR-Normal patients compared with both HR-Cirrhotic ( p =0.008) and HR-Diseased ( p =0.005). HR-Cirrhotic and HR-Diseased did not differ ( p =0.97). Five-year OS was 74.4%, 59.8% and 57.2%, respectively. On multivariable Cox regression, both cirrhosis (HR 2.03, 95% CI 1.16–3.54, p =0.01) and diseased non-cirrhotic parenchyma (HR 2.04, 95% CI 1.21–3.43, p =0.008) independently predicted death versus normal liver. Fine–Gray analysis confirmed higher recurrence risk in cirrhotic (sHR 2.09, p =0.01) and diseased non-cirrhotic (sHR 1.80, p =0.04) groups. The LT benchmark cohort achieved a 5-year OS of 82.4%. Histologically normal liver identifies a distinct HR subgroup with favorable oncologic outcomes. The conventional cirrhotic/non-cirrhotic dichotomy underestimates the prognostic impact of underlying parenchymal disease.