There are several advanced situations in antireflux surgery: these include giant hiatal hernias (PEH), the short esophagus and the use of meshes to minimize recurrences.
PEH is a disease of the diaphragm more than one of the esophagus, recurrence rates at 5 to 10 years are very high (>50%) due to intrinsic defects of the connective tissue of the diaphragm. Keys to surgical repair include: reduction of the mediastinal hernia sac, extensive mobilization of the esophagus to bring the GE junction into the abdomen, reinforced repair of the diaphragm. Gastropexy can occasionally be a useful adjunct. Reinforced repair of the diaphragm can involve pledgets, relaxing incisions, or mesh. Mesh remains a controversial subject. The lowest reherniation rates in the literature are with plastic mesh but such a mesh is associated with esophageal erosions. The existence of the short esophagus is controversial, most agree it exists 3 to 5% of the time. The optimal treatment is extensive mediastinal mobilization and, if that fails, to perform a laparoscopic Collis gastroplasty. There are several techniques for Collis including transthoracic or wedge gastroplasty. All result in good functional results but the ectopic gastric mucosa that results often secretes acid and requires the patient to stay on anti-acid medication.