We wish to thank Dr Conijn and Drs Rice and Blackstone for their letters and for their interest in our work on the use of biologic mesh for paraesophageal hernias (PEH)* and for the opportunity to respond.Dr Conijn asked whether we analyzed the relationship between hernia recurrence and symptoms. We have, and it was the primary aim of our recently published paper.2 In that analysis, we found that patients with recurrent hernias ^4 cm experienced slightly greater heartburn than those with no recurrence, but there was no difference in all other symptoms. This confirmed our clinical suspicion that if a well-constructed fundoplication is added at the time of treatment of a PEH, a recurrence might result in some degree of gastroesophageal reflux, but is unlikely to lead to obstructive symptoms of the kind with which patients with PEHs often present.
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