{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T08:46:45Z","timestamp":1785746805312,"version":"3.56.0"},"reference-count":6,"publisher":"Oxford University Press (OUP)","issue":"4","license":[{"start":{"date-parts":[[2026,7,2]],"date-time":"2026-07-02T00:00:00Z","timestamp":1782950400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,7,2]]},"abstract":"<jats:title>SUMMARY<\/jats:title>\n                  <jats:p>Large paraesophageal hernias represent a heterogeneous clinical entity, with variation in anatomical configuration, symptom profile, esophageal physiology, and patient-related operative risk. Unlike many other heterogeneous surgical conditions, a single anatomical problem may compromise multiple functional systems simultaneously, including gastric transit, reflux physiology, and respiratory function. Despite this multi-system involvement, contemporary literature and practice frequently evaluate these patients as a single group, applying uniform operative paradigms and outcome measures that do not account for differing operative priorities. We propose a phenotype-based conceptual framework to structure operative prioritization based on four preoperative domains: anatomical configuration, dominant clinical presentation, esophageal physiology, and patient-related risk. Integration of these domains identifies the dominant clinical driver shaping operative priorities in the individual patient, anchored in the factor that most impairs quality of life and most strongly motivates the expectation of benefit from surgery. Four phenotypes are described\u2014mechanical, reflux-dominant, respiratory, and risk-constrained\u2014with the risk-constrained phenotype functioning as a hierarchical modifier rather than a competing functional pattern. Within this framework, outcomes are interpreted in relation to operative intent rather than uniform endpoints such as radiological recurrence. This approach supports context-specific interpretation of outcomes and enables surgical strategies to be evaluated against the clinical objective they are intended to achieve. Further refinement will follow through structured consensus and prospective collaborative evaluation.<\/jats:p>","DOI":"10.1093\/dote\/doag079","type":"journal-article","created":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T11:49:44Z","timestamp":1784116184000},"source":"Crossref","is-referenced-by-count":0,"title":["Beyond uniform repair: making operative intent explicit in large paraesophageal hernias"],"prefix":"10.1093","volume":"39","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8426-6169","authenticated-orcid":false,"given":"Francesco","family":"Di Maggio","sequence":"first","affiliation":[{"name":"Croydon University Hospital, Croydon Health Service NHS Trust , London ,","place":["UK"]},{"name":"South Tees Hospital NHS Foundation Trust , Middlesbrough ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3880-1172","authenticated-orcid":false,"given":"Yirupaiahgari","family":"Viswanath","sequence":"additional","affiliation":[{"name":"South Tees Hospital NHS Foundation Trust , Middlesbrough ,","place":["UK"]},{"name":"British Benign Upper GI Society (BBUGSS) , Paignton ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,8,3]]},"reference":[{"key":"2026080304102425200_ref1","doi-asserted-by":"crossref","first-page":"9013","DOI":"10.1007\/s00464-023-10511-1","article-title":"EAES multidisciplinary rapid guideline: systematic review, meta-analysis, GRADE assessment and evidence-informed recommendations on the surgical management of paraesophageal hernias","volume":"37","author":"Markar","year":"2023","journal-title":"Surg Endosc"},{"key":"2026080304102425200_ref2","doi-asserted-by":"crossref","first-page":"226","DOI":"10.1016\/j.amjsurg.2015.07.007","article-title":"A systematic review and meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair","volume":"211","author":"Tam","year":"2015","journal-title":"Am J Surg"},{"key":"2026080304102425200_ref3","doi-asserted-by":"crossref","first-page":"453","DOI":"10.1007\/s11605-011-1743-z","article-title":"Laparoscopic paraesophageal hernia repair: defining long-term clinical and anatomic outcomes","volume":"16","author":"Oelschlager","year":"2012","journal-title":"J Gastrointest Surg"},{"key":"2026080304102425200_ref4","doi-asserted-by":"crossref","first-page":"424","DOI":"10.1001\/jamasurg.2015.25","article-title":"Long-term quality of life and risk factors for recurrence after laparoscopic paraesophageal hernia repair","volume":"150","author":"Lidor","year":"2015","journal-title":"JAMA Surg"},{"key":"2026080304102425200_ref5","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1186\/s12893-020-00772-1","article-title":"Health-related quality of life after laparoscopic repair of giant paraesophageal hernia: how does recurrence in CT scan compare to clinical success?","volume":"20","author":"Hietaniemi","year":"2020","journal-title":"BMC Surg"},{"key":"2026080304102425200_ref6","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1097\/SLA.0000000000003734","article-title":"Five-year follow-up of a randomized controlled trial of laparoscopic repair of very large hiatus hernia with sutures versus absorbable versus nonabsorbable mesh","volume":"272","author":"Watson","year":"2020","journal-title":"Ann Surg"}],"container-title":["Diseases of the Esophagus"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/dote\/article-pdf\/39\/4\/doag079\/70462303\/doag079.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/dote\/article-pdf\/39\/4\/doag079\/70462303\/doag079.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,3]],"date-time":"2026-08-03T08:10:29Z","timestamp":1785744629000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/dote\/article\/doi\/10.1093\/dote\/doag079\/8749506"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,2]]},"references-count":6,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2026,7,2]]}},"URL":"https:\/\/doi.org\/10.1093\/dote\/doag079","relation":{},"ISSN":["1120-8694","1442-2050"],"issn-type":[{"value":"1120-8694","type":"print"},{"value":"1442-2050","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,8]]},"published":{"date-parts":[[2026,7,2]]},"article-number":"doag079"}}