Dear Sir

The authors are to be commended on the above article. The reporting of 5-year follow-up from the randomised control trial of prosthetic or suture repair in large hiatus hernia is of great benefit. However, we have some comments.

The authors report that quality of life is not different between those patients with and without recurrence. This is not consistent with our previous findings and may be related to bias secondary to incomplete follow-up (60 % of patients at 58 months). It may also be related to the QOL tool utilised as rather than heartburn or regurgitation we have found that patients with symptomatic recurrence report chest pain or dysphagia. Cardiac and respiratory symptoms, frequently occur secondary to the hernia the cause of which is not widely known, may also have merited consideration in this population.1 , 2

Improved QOL may be a secondary concern with the prevention of severe complications being the priority. We have also reported on the natural history of recurrent hiatus hernia in this situation where it appears to be relatively stable and not likely to result in reoperation; however, the long-term outcome is unknown.3 It would be desirable therefore to limit recurrence to its lowest possible rate, and its least possible size for both safety and quality of life.

It may be that larger recurrences are more likely to lead to symptoms and the requirement for reoperation. The findings that 30 % of patients had a recurrence of greater than 4 cm in size therefore raises the concern that this population may suffer complications, progression in size, or the need for reoperation in the longer term. Older publications of operations based upon the Menguy- or Hill-type procedure in the open era have delivered recurrence rates vastly superior to those reported in this study. In our experience, this sort of surgery is technically feasible by laparoscopy.4 We have recently submitted an article for peer review with 99 % objective follow-up in 100 patients. Using the authors’ definition of recurrent hiatus hernia, we would have demonstrated an early recurrence rate of 2 %; however, we would prefer to report it as an anatomical recurrence rate of 9 %: seven patients having hernia less than 2 cm and two patients greater.

The authors have shown that the use of mesh reinforcement leads to no improvement in long-term recurrence. It is our belief that the long-term outcomes in this study can be bettered with a mesh free, laparoscopic repair involving COJ pexy.