Allograft dermal matrix hiatoplasty during laparoscopic primary fundoplication, paraesophageal hernia repair, and reoperation for failed hiatal hernia repair

Background

Hiatal repair failure is the nemesis of laparoscopic paraesophageal hernia repair as well as the major cause of failure of primary fundoplication and reoperation on the hiatus. Biologic prosthetics offer the promise of reinforcing the repair without risks associated with permanent prosthetics.

Design

Retrospective evaluation of safety and relative efficacy of laparoscopic hiatal hernia repair using an allograft (acellular dermal matrix) onlay. Patients with symptomatic failures underwent endoscopic or radiographic assessment of hiatal status.

Results

Greater than 6-month follow-up was available for 252 of 450 consecutive patients undergoing laparoscopic allograft-reinforced hiatal hernia repair between January 2007 and March 2011. No erosions, strictures, or persisting dysphagia were encountered. Adhesions were minimal in cases where reoperation was required. Failure of the hiatal repair at median 18 months (6–51 months) was significantly (p < 0.005) different between groups: group A (primary fundoplication with axial hernia ≤ 2 cm), 3.7 %; group B (primary fundoplication with axial hernia 2–5 cm), 7.1 %; group G (giant/paraesophageal), 8.8 %; group R (reoperative), 23.4 %. Additionally, mean time to failure was significantly shorter in group R (247 days) compared with the other groups (462–489 days).

Conclusions

Use of allograft reinforcement to the hiatus is safe at 18 months median follow-up. Reoperations had a significantly higher failure rate and shorter time to failure than the other groups despite allograft, suggesting that primary repairs require utmost attention and that additional techniques may be needed in reoperations. Patients with hiatal hernias >2 cm axially had a recurrence rate equal to that of patients undergoing paraesophageal hiatal hernia repair, and should be treated similarly.     

The Impact of Scoliosis Among Patients with Giant Paraesophageal Hernia

Background

Kyphoscoliosis is seen in approximately 1.4?C15% of the octogenarian population of the US. We hypothesized that patients with kyphoscoliosis are affected with a reduced intra-abdominal volume and progressive laxity of the diaphragmatic hiatal sling musculature leading to an increased risk of hiatal hernia formation and progression over time.

Methods

We retrospectively reviewed the clinical history and roentgenographic data of 320 paraesophageal hernia patients from 2003 to 2007. The prevalence of kyphoscoliosis among this patient cohort and the outcomes of surgical management were compared to paraesophageal hernia patients without kyphoscoliosis.

Results

Ninety-three of the 320 patients (29.1%) were found to have significant K/S (mean age 74; 83% female). Laparoscopic repair of paraesophageal hernia with fundoplication was performed in 91% of these patients. There was one death (1.1%; aspiration pneumonia) and 17.2% major postoperative morbidity. Mean length of hospital stay was 8 days (median?=?4; range 2?C71). Prolonged stays were related mainly to marginal pulmonary status. Kyphoscoliosis was associated with increased peri-operative pulmonary morbidity (16.1%) compared to patients without kyphoscoliosis (7.0%, p?=?0.02).

Conclusion

Kyphoscoliosis may contribute to the development and progression of paraesophageal hernias. Surgeons approaching paraesophageal hernia repair should be aware of the increased pulmonary morbidity and the postoperative care required in managing these patients.     

Omission of the calibration bougie in laparoscopic repair of paraesophageal hernia

Background

The use of an intraesophageal bougie has traditionally been an integral step in the repair of large hiatal hernia and fundoplication. Typically, the bougie is passed by the anesthesiologist or a member of the surgical team into the stomach to enable calibration of the hiatal repair and fundoplication. An inherent risk of esophagogastric perforation is associated with this maneuver. The authors report their experience comparing symptomatic outcomes for patients who have had a large hiatus hernia repaired with and without the use of a calibration bougie.

Methods

Data were collected prospectively for 28 consecutive patients undergoing elective laparoscopic repair of a paraesophageal hernia. A bougie was used in the first 14 patients. In the next 14 patients, the use of a bougie was omitted. Symptom and quality-of-life data were collected preoperatively and 6 months postoperatively for all the patients.

Results

All the patients were satisfied with their symptomatic outcome, as reflected in their postoperative quality-of-life scores. No patients required dilation for postoperative dysphagia. There was no difference in postoperative dysphagia scores between the two groups.

Conclusion

The current series of consecutively performed laparoscopic paraesophageal hernia repairs showed no benefit in terms of symptomatic outcome associated with the use of an intraesophageal bougie. Currently, the authors’ standard practice is to perform laparoscopic repair of the paraesophageal hernia and fundoplication without the aid of a calibration bougie.     

Diaphragmatic relaxing incisions during laparoscopic paraesophageal hernia repair

Background

Laparoscopic paraesophageal hernia (PEH) repair is associated with an objective recurrence rate exceeding 50 % at 5 years. Minimizing tension is a critical factor in preventing hernia recurrence. This study aimed to evaluate the outcomes of crural relaxing incisions in patients undergoing PEH repair.

Methods

Records were reviewed to identify patients who received a relaxing incision during laparoscopic PEH repair. The patients were followed by chest X-ray and videoesophagram at 3 months and then annually.

Results

From November 2010 to March 2013, 58 patients underwent PEH repair, and 15 patients received a relaxing incision to accomplish crural closure. The median age of the patients was 72 years (range 58–84 years). The relaxing incision was right-sided in 13 patients, left-sided in one patient, and bilateral in one patient. All the procedures were completed laparoscopically and included a fundoplication. Collis gastroplasty for a short esophagus was performed for 40 % of the patients. No major complications occurred. During a median follow-up period of 4 months, one patient had an asymptomatic mildly elevated left hemidiaphragm, and one patient had a trivial recurrent hernia, as shown on esophagogastroduodenoscopy (EGD).

Conclusion

Crural tension likely contributes to the high recurrence rate noted with laparoscopic PEH repair. Relaxing incisions are safe and allow crural approximation. Advanced laparoscopic surgeons should be aware of this option when faced with a large hiatus in a patient with PEH.     

Laparoscopic antireflux procedures with hepatic shoulder technique for the surgical management of large paraesophageal hernias and gastroesophageal reflux disease

Background

Large paraesophageal hernias are notoriously difficult to manage via laparoscopy and are associated with a significant recurrence rate. A novel laparoscopic approach was used to close the diaphragmatic defect in four patients diagnosed with large, paraesophageal hernias and gastroesophageal reflux disease symptomatology.

Methods

All procedures were performed via laparoscopy. Three patients underwent a reduction of the paraesophageal hernia with a Nissen fundoplication and one with Collis-Nissen fundoplication. Standard crural closure was performed over a #60 Fr Bougie in two patients, and two patients did not undergo a cruroplasty. In all four patients, the left hepatic lobe was freed, repositioned, and anchored under and inferior to the gastroesophageal junction, propping the gastroesophageal junction anteriorly. This maneuver entirely covers and closes the diaphragmatic defect.

Results

Postoperatively, all patients did well without notable, unusual complaints. Average length of stay was 2 days. Although not statistically significant, all patients had no recurrence of symptoms or of their paraesophageal hernia at 8, 9, 11, and 15 months after the procedure.

Conclusions

In selected patients, large paraesophageal hernias can safely be managed via a laparoscopic antireflux procedure with the hepatic shoulder technique. Although no long-term follow-up is available, this technique has shown good early postoperative results and may be used as an alternative to a laparoscopic Mesh reinforced fundoplication or difficult crural closure.     

The laparoscopic nissen-hill hybrid: pilot study of a combined antireflux procedure

Background

Laparoscopic antireflux surgery is highly effective in patients with uncomplicated gastroesophageal reflux disease (GERD). However, long-term failure rates in paraesophageal hernia (PEH) and Barrett’s metaplasia (BE) are higher and warrant a more durable repair. Outcomes for the laparoscopic Nissen fundoplication (LNF) and Hill repair (LHR) are equivalent, but their anatomic components are different and may complement each other (Aye R Ann Thorac Surg, 2012). We designed and tested the feasibility and safety of an operation that combines the essential components of each repair.

Methods

A prospective, phase II pilot study was performed on patients with symptomatic giant PEH hernias and/or GERD with nondysplastic Barrett’s metaplasia. Pre- and postoperative esophagogastroduodenoscopy (EGD), upper gastrointestinal study (UGI), 48-hour pH testing, manometry, and three quality-of-life metrics were obtained.

Results

Twenty-four patients were enrolled in the study. Three patients did not complete the planned procedure, leaving 21 patients, including 12 with PEH, 7 with BE, and 2 with both. There were no 30-day or in-hospital mortalities. At a median follow-up of 13 (range 6.4–30.2) months, there were no reoperations or clinical recurrences. Two patients required postoperative dilation for dysphagia, with complete resolution. Mean DeMeester scores improved from 54.3 to 7.5 (p < 0.0036). Mean lower esophageal sphincter pressures (LESP) increased from 8.9 to 21.3 mmHg (p < 0.013). Mean short-term and long-term QOLRAD scores improved from 4.09 at baseline to 6.04 and 6.48 (p < 0.0001). Mean short-term and long-term GERD-HQRL scores improved from 22.9 to 7.5 and 6.9 (p < 0.03). Mean long-term Dysphagia Severity Score Index improved from 33.3 to 40.6 (p < 0.064).

Conclusions

The combination of a Nissen plus Hill hybrid reconstruction of the gastroesophageal junction (GEJ) is technically feasible, safe, and not associated with increased side effects. Short-term clinical results in PEH and BE suggest that this may be an effective repair, supporting the value of further study.     

Paraesophageal hernia repair in the emergency setting: is laparoscopy with the addition of a fundoplication the new gold standard?

Background

Laparoscopic repair of paraesophageal hernia (PEH) with fundoplication is currently the preferred elective strategy, but emergent cases are often done open without an anti-reflux (AR) procedure. This study examined PEH repair in elective and urgent/emergent settings and investigated patient characteristic influence on the use of adjunctive techniques, such as AR procedures or gastrostomy tube (GT) placement.

Methods

Utilizing the University HealthSystem Consortium Clinical Database Resource Manager, selected discharge data were retrieved using International Classification of Disease 9 diagnosis codes for PEH and procedure specific codes. Chi-squared and paired t tests were applied (α = 0.05).

Results

Discharge data from October 2010 through June 2014 indicated 7950 patients (≥18 years) underwent PEH surgery, 84.7 % were performed laparoscopically and 15.3 % open. 24.6 % of cases were classified urgent/emergent upon admission, and almost 70 % of these were completed laparoscopically. Open paraesophageal hernia repairs (OHR) represented a higher proportion of urgent/emergent cases but were only 30 % of this total. Laparoscopic paraesophageal hernia repair (LHR) patients were more likely to receive an AR procedure in all situations (54.9 % LHR vs. 26.3 % OHR). Almost 90 % of elective PEH repairs in this cohort were laparoscopic. Elective cases were more commonly associated with AR procedures than emergent cases which frequently incorporated GT placement.

Conclusion

We demonstrate that laparoscopic PEH repair has become accepted in emergent cases. Open PEH repair is often reserved for emergent surgeries and less commonly includes an AR procedure. Laparoscopy with an AR procedure is clearly the standard of care in elective surgery. The decision to perform an open or laparoscopic surgery, with or without adjunctive techniques, may be based more on the physician’s comfort with laparoscopic surgery and surgical practices than the patient’s condition. Long-term follow-up studies are needed to determine the functional outcomes of these strategies.

     

Wait only to resuscitate: early surgery for acutely presenting paraesophageal hernias yields better outcomes

Introduction

Incarceration and obstruction of an intrathoracic stomach are potentially devastating complications of paraesophageal hernias (PEH). Gastric decompression and resuscitation are important elements of preoperative management of acutely presenting PEH. The optimal time for surgical repair after decompression is unknown. We hypothesized that in obstructed PEH, early surgery may improve outcomes.

Methods

From the 2005–2010 National Surgical Quality Improvement Project database, we selected PEH repairs with a diagnosis of obstruction. Patients were divided by time to surgery: ≤1 day of admission (early) or >1 day (interval). Outcomes were mortality and morbidity. Multivariable regression controlled for age and cardiopulmonary comorbidities.

Results

Of 224 patients, 149 (67 %) were early and 75 (33 %) were interval, with mean 3.6 days. Repairs were 89 % transabdominal, 9 % included fundoplication, and 18 % gastrostomy. Early and interval groups experienced similar morbidity 23 versus 31 % (p = 0.2) and mortality 5.4 versus 4 % (p = 0.7). Pulmonary, wound, or VTE complications were equivalent. Sepsis was less (2.7 vs. 13 %, p = 0.002) and length of stay was shorter (5 vs. 11 days, p < 0.001) for early vs. interval patients. On adjusted analysis, the early group had an 80 % reduction in sepsis (95 % confidence interval (CI), 0.05–0.6, p = 0.005). Odds of overall or other morbidity or mortality were statistically similar between groups.

Conclusions

Patients who required emergency surgery for PEH have disease complicated by strangulation, perforation, bleeding, or sepsis. Emergency surgery for PEH repair is inherently high-risk and preoperative resuscitation and decompression is critical. In our analysis, patients with an obstructed PEH had less postoperative sepsis and fewer days in the hospital if surgery was performed within the first hospital day. However, there was no difference in mortality between early and delayed treatment. Deferring surgery for resuscitation permits optimization, but prolonged delay may worsen patient outcomes.     

Differential regulation of MMP-2 in the gastrohepatic ligament of the gastroesophageal junction

Introduction

Ligamentous attachments maintain the normal anatomic position of the gastroesophageal (GE) junction. Failure of these elastic ligaments through an alteration in collagen synthesis, deposition, and metabolism may be a primary etiology of hiatal hernia formation. Differential expression of zinc-dependent matrix metalloproteinases (MMPs) is largely responsible for collagen remodeling. The purpose of this study was to survey baseline levels of MMPs in supporting ligaments of the GE junction from patients without hiatal hernia.

Methods

Following an institutional review board-approved protocol, plasma and tissue biopsies of the gastrohepatic ligament (GHL), gastrophrenic ligament (GPL), and phrenoesophageal ligament (PEL) were obtained in six patients without a hiatal hernia during laparoscopic anterior esophageal myotomy for achalasia. Total protein extracts from tissue biopsies were analyzed for elastases MMP-2, -9, and -12 and collagenases MMP-1, -3, -7, -8, and -13 using a multiplex profiling kit (R&D Systems, Minneapolis, MN). Data are reported as mean ± standard deviation. Statistical significance (p < 0.05) was determined using Tukey’s test and analysis of variance.

Results

In control patients without hiatal hernias, increased levels of MMP-2 (p < 0.02) were detected in the GHL compared with the GPL and PEL, respectively. Tissue levels of MMP-1, -12, and -13 were not detectable.

Conclusions

Gelatinase-A (MMP-2) is present in the GHL and plasma of control patients. The GHL may provide the primary GE junction supporting ligament to compare tissue from patients with type I (sliding) and type III (paraesophageal) hiatal hernias to examine the role of altered collagen metabolism in hiatal hernia formation.     

Laparoscopic Hiatal Hernia Repair with Falciform Ligament Buttress

Background

Using synthetic mesh to buttress the crural repair during laparoscopic hiatal hernia repair may be associated with dysphagia and esophageal erosions, while a biologic mesh is expensive and does not decrease long-term recurrence rates. This study documents outcomes of laparoscopic paraesophageal hernia repairs using the falciform ligament to reinforce the crural repair.

Methods

This is a prospective study of laparoscopic paraesophageal hernia repairs with a falciform ligament buttress. Preoperatively and at 6 and 12 months postoperatively, medications, radiologic studies, and symptom severity and frequency scores were recorded. Patients with a hiatal defect greater than 5 cm were included, while patients with recurrent hiatal hernia repairs or prior gastric surgery were excluded. Symptom scores were compared pre- and postoperatively with a p?<?0.05 considered significant.

Results

One hundred four patients were included with a mean age of 62.4 years, and 57 patients underwent an upper gastrointestinal series at least 12 months from the initial operation with a mean follow-up of 20.6 months. The mean symptom severity score decreased from 14.32?±?0.93 to 4.75?±?0.97 (p?<?0.001), mean symptom frequency score decreased from 14.99?±?0.97 to 5.25?±?0.99 (p?<?0.001), and mean total symptom score decreased from 29.31?±?1.88 to 10.00?±?1.95 (p?<?0.001). Five patients developed recurrent hiatal hernias on upper gastrointestinal series, but only three required operative intervention.

Conclusions

Laparoscopic paraesophageal hernia repair with a falciform ligament buttress is a viable option for a durable closure. Ongoing follow-up will continue to illuminate the value of this approach to decrease morbidity and recurrence rates for hiatal hernia repair.

     

Feasibility,safety, and short-term efficacy of the laparoscopic Nissen–Hill hybrid repair

Background

A novel antireflux procedure combining laparoscopic Nissen fundoplication and Hill repair components was tested in 50 patients with paraesophageal hernia (PEH) and/or Barrett’s esophagus (BE) because these two groups have been found to have a high rate of recurrence with conventional repairs.

Methods

Patients with symptomatic PEH and/or non-dysplastic BE underwent repair. Quality of life (QOL) metrics, manometry, EGD, and pH testing were administered pre- and postoperatively.

Results

Fifty patients underwent repair. There was no mortality and four major complications. At 13-month follow-up, there was one (2 %) clinical recurrence, and two (4 %) asymptomatic fundus herniations. Mean DeMeester scores improved from 57.2 to 7.7 (p < 0.0001). Control of preoperative symptoms was achieved in 90 % with 6 % resumption of antisecretory medication. All QOL metrics improved significantly.

Conclusions

The hybrid Nissen–Hill repair for patients with PEH and BE appears safe and clinically effective at short-term follow-up. It is hoped that the combined structural components may reduce the rate of recurrence compared to existing repairs.

     

Incidence of Delayed Gastric Emptying Associated with Revisional Laparoscopic Paraesophageal Hernia Repair

Background

Over the past 15 years, laparoscopic repair of primary paraesophageal hernias (PEH) has become the preferred operative approach. Today, more surgeons are approaching recurrent PEHs laparoscopically, though few studies exist on the long-term results of these revisional operations, particularly regarding the incidence of postoperative delayed gastric emptying (DGE).

Methods

A retrospective review was conducted of all laparoscopic repairs for recurrent PEH done by three surgeons at a single institution from 2003 to 2011. Data collected included age, sex, weight, BMI, pre- and postoperative symptoms, and operative data, but our primary focus was on those patients with pre- and postoperative delayed gastric emptying ultimately requiring operative intervention.

Results

Of 284 patients who underwent laparoscopic PEH repair, 91 (32 %) were performed for recurrent PEH. A sleeve gastrectomy was performed in ten of these patients (11 %) for concomitant morbid obesity which were excluded from our study group, leaving 81 study patients. The mean age was 56 years, and mean BMI was 30. All cases were completed laparoscopically; in 45 (56 %) either a partial or complete fundoplication was performed, and in 68 (84 %) a percutaneous gastrostomy tube (PEG) was placed at the time of revision. Sixty-eight patients underwent repair of a first recurrence, of which 8 (12 %) ultimately required a gastric emptying procedure to alleviate symptoms of DGE. There were nine patients who had a second recurrence repaired, and six (66 %) progressed to a gastric emptying procedure. Finally, of the four patients who had a third recurrence repaired, three (75 %) eventually needed a gastric emptying procedure.

Conclusion

While the incidence of DGE associated with initial PEH repair is low, DGE is a significantly more common finding in patients requiring reoperation for recurrent PEH. This risk increases significantly with repair of each subsequent recurrence. Our data suggest that DGE should be anticipated and patients counseled of the ramifications of this problem preoperatively. Surgeons performing revisional PEH surgery should preemptively develop protocols for the postoperative management of DGE from the time of operation.     

Length and Pressure of the Reconstructed Lower Esophageal Sphincter is Determined by Both Crural Closure and Nissen Fundoplication

Background

Laparoscopic Nissen fundoplication is comprised of: a wrap thought responsible for the lower esophageal sphincter function and crural closure performed to prevent herniation. We hypothesized gastroesophageal junction competence effected by Nissen fundoplication results from closure of the crural diaphragm and creation of the fundoplication.

Methods

Patients with uncomplicated reflux undergoing Nissen fundoplication were prospectively enrolled. After hiatal dissection, patients were randomized to crural closure followed by fundoplication (group 1) or fundoplication followed by crural closure (group 2). Intra-operative high-resolution manometry collected sphincter pressure and length data after complete dissection and after each component repair.

Results

Eighteen patients were randomized. When compared to the completely dissected hiatus, the mean sphincter length increased 1.3 cm (p?<?0.001), and mean sphincter pressure was increased by 13.7 mmHg (p?<?0.001). Groups 1 and 2 had similar sphincter length and pressure changes. Crural closure and fundal wrap contribute equally to sphincter length, although crural closure appears to contribute more to sphincter pressure.

Conclusion

The Nissen fundoplication restores the function of the gastroesophageal junction and thus the reflux barrier by means of two main components: the crural closure and the construction of a 360° fundal wrap. Each of these components is equally important in establishing both increased sphincter length and pressure.     

Evaluation of Gastrectomy in Patients With Delayed Gastric Emptying After Antireflux Surgery or Large Hiatal Hernia Repair

Background

Revision antireflux surgery and large hiatal hernia repair require extensive dissection at the gastroesophageal junction. This may lead to troublesome symptoms due to delayed gastric emptying, eventually requiring gastrectomy. The aim of this study was to evaluate the outcome of gastrectomy for severely delayed gastric emptying after large hiatal hernia repair or redo antireflux surgery.

Methods

Eleven patients were treated between 1995 and 2010 and entered in the study. Preoperative and operative data were retrospectively collected. Standardized questionnaires were sent to all of the patients to evaluate symptomatic outcome.

Results

The primary intervention was Nissen fundoplication in nine patients, Toupet fundoplication in one, and cruroplasty in another. The repairs were for refractory gastroesophageal reflux disease in five patients and a symptomatic large hiatal hernia in six. Subsequent gastrectomy was partial in four patients, subtotal in six, and total in one. There was one minor postoperative complication. After a mean (±SD) duration of 102 ± 59 months, nine patients were available for symptomatic follow-up. Eight patients experienced daily symptoms related to dumping. Daily symptoms indicative of delayed gastric emptying were present in seven patients at follow-up. Mean general quality of life was increased from 3.8 ± 2.2 before gastrectomy to 5.4 ± 1.8 at follow-up. Eight patients reported gastrectomy as worthwhile.

Conclusion

Gastrectomy after previous antireflux surgery or large hiatal hernia repair is safe with the potential to improve quality of life. Although upper gastrointestinal symptoms tend to persist, gastrectomy can be considered a reasonable, last-resort surgical option for alleviating upper gastrointestinal symptoms after this kind of surgery.     

Combined paraesophageal hernia repair and partial longitudinal gastrectomy in obese patients with symptomatic paraesophageal hernias

Background

Obesity is a risk factor for gastroesophageal reflux disease and hiatal hernia. Studies have demonstrated poor symptom control in obese patients undergoing fundoplication. The ideal operation remains elusive. However, addressing both obesity and the anatomic abnormality should be the goal.

Methods

This study retrospectively identified 19 obese (body mass index [BMI], >30?kg/m²) and morbidly obese (BMI, >40?kg/m²) patients who presented between December 2007 and November 2011 for management of large or recurrent paraesophageal hernia. All the patients underwent a combined primary paraesophageal hernia repair and longitudinal gastrectomy. Charts were retrospectively reviewed to collect preoperative, operative, and short-term postoperative results. Quantitative data were analyzed using Student??s t test and qualitative data with ??² testing.

Results

Laparoscopy was successful for all 19 patients. The mean preoperative BMI was 37.8?±?4.1?kg/m², and the mean operative time was 236?±?80?min. Preoperative endoscopy showed that 5 patients who had undergone prior fundoplication experienced anatomic failures, whereas the remaining 14 patients had type 3 and one type 4 paraesophageal Hernia. Mesh was used to reinforce the hiatus in 15 of the 19 cases. The postoperative complications included pulmonary embolism (n?=?1) and pulmonary decompensation (n?=?2) due to underlying chronic obstructive pulmonary disease. The mean hospital stay was 5.3?±?3?days. Upper gastrointestinal esophagography was performed for all the patients, with no short-term recurrence of paraesophageal hernia. Weight loss was seen for all the patients during the first month, with a mean BMI drop of 2.7?±?1?kg/m². All the patients experienced near to total resolution of their preoperative symptoms within the first month.

Conclusion

Combined laparoscopic paraesophageal hernia repair and longitudinal gastrectomy offer a safe and feasible approach for the management of large or recurrent paraesophageal hernias in well-selected obese and morbidly obese patients. In a short-term follow-up period, this approach demonstrated effective symptom control and weight loss.     

Long-Term Outcome and Quality of Life After Laparoscopic Treatment of Large Paraesophageal Hernia

Background

Laparoscopy has been widely used for surgical repair of large paraesophageal hernias (PEHs). The technique, however, entails substantial technical difficulties, such as repositioning the stomach in the abdominal cavity, sac excision, closure of the hiatal gap, and fundoplication. Knowledge of the long-term outcome (>10 years) is scarce. The aim of this article was to evaluate the long-term results of this approach, primarily the anatomic hernia recurrence rate and the impact of the repair on quality of life.

Methods

We identified all patients who underwent laparoscopic repair for PEH between November 1997 and March 2007 and who had a minimum follow-up of 48 months. In March 2011, all available patients were scheduled for an interview, and a radiologic examination with barium swallow was performed. During the interview the patients were asked about the existence/persistence of symptoms. An objective score test, the gastrointestinal quality of life index (GIQLI), was also administered.

Results

A total of 77 patients were identified: 17 men (22 %) and 60 women (78 %). The mean age at the time of fundoplication was 64 years (range 24–87 years) and at the review time 73 years (range 34–96 years). The amount of stomach contained within the PEH sac was <50 % in 39 patients (50 %), >50 % in 31 (40 %), and 100 % (intrathoracic stomach) in 7 (9.5 %). A 360º PTFe mesh was used to reinforce the repair in six cases and a polyethylene mesh in three. In May 2011, 55 of the 77 patients were available for interview (71 %), and the mean follow-up was 107 months (range 48–160 months). Altogether, 43 patients (66 %) were asymptomatic, and 12 (21 %) reported symptoms that included dysphagia in 7 patients, heartburn in 3, belching in 1, and chest pain in 1. Esophagography in 43 patients (78 %) revealed recurrence in 20 (46 %). All recurrences were small sliding hernias (<3 cm long). In all, 37 patients (67 %) answered the GIQLI questionnaire. The mean GIQLI score was 111 (range 59–137; normal 147). Patients with objective anatomic recurrence had a quality of life index of 110 (range 89–132) versus 122 in the nonrecurrent hernia group (range 77–138, p < 0.01). Mesh was used to buttress the esophageal hiatus in nine patients. One patient died during the follow-up period. Five of the remaining eight patients (62 %) developed dysphagia, a mesh-related symptom. Three patients required reoperation because of mesh-related complications. Esophagography revealed recurrence in four (50 %) of the eight patients. GIQLI scores were similar in patients with recurrence (126, range 134–119) and without it (111, range 133–186) (p > 0.05).

Conclusions

Long-term follow-up (up to 160 months) in our study showed that laparoscopic PEH repair is clinically efficacious but is associated with small anatomic recurrences in ≤50 % of patients. Further studies are needed to identify the anatomic, pathologic, and physiological factors that may impair outcome, allowing the procedure to be tailored to each patient.     

Revision of failed traditional fundoplication using EsophyX® transoral fundoplication

Background

Laparoscopic revision of failed traditional fundoplication is difficult and involves risk of gastric, esophageal, and vagal nerve injury that is higher than that of the primary fundoplication. This study assessed feasibility and clinical outcomes of the transoral approach to revision of loose Nissen.

Methods

Between November 2009 and August 2011, a total of 11 patients underwent transoral repair as opposed to 70 patients who underwent laparoscopic or open revision of a failed fundoplication. Subjective and objective outcomes were evaluated with the GERD health-related quality of life (GERD-HRQL) questionnaire and the reflux symptom index (RSI) questionnaire and ambulatory pH testing. The competency of the new antireflux barrier was evaluated by endoscopy. Wilcoxon signed-rank test was used to compare pre- and postoperative variables.

Results

All 11 patients evidenced loosening of the Nissen fundoplication without evidence of hiatal failure. Mean age was 57 years, BMI was 25.1 kg/m², and 4 of 11 (36 %) were female. Indications for operation were abnormal pH-metry off PPIs (6), impedance/pH on PPIs (3), esophagitis (1), and evidence of free reflux on barium swallow (1). One patient developed a postoperative bleed requiring transfusion. Two patients had laparoscopic revision at 6 and 8 months after the transoral procedure. At a median follow-up of 14 (range = 6–28) months, 8/10 patients reported resolution of their primary symptoms. Eight patients had pH testing off PPIs both pre- and postoperatively; median % time with pH <4 improved by dropping from 8.1 % (21–4.8 %) to 0.6 % (13.4–0.01 %) (p = 0.008). Esophageal acid exposure normalized in 5/6 patients. Mean GERD-HRQL score improved significantly by dropping from 28.6 (10.6) preoperatively to 6.7 (6.1) post-TIF (p = 0.016). Mean RSI score improved more than 50 % in 5/7 patients.

Conclusion

Transoral revision of failed traditional fundoplication without herniation is technically feasible. It results in symptomatic and objective improvement of GERD without the risks of laparoscopic dissection for a majority of patients.     

Prevalence and Resolution of Anemia with Paraesophageal Hernia Repair

Background

Paraesophageal hernias may produce a variety of clinical sequelae including anemia and esophagogastric ulcerations or erosions. We examined the prevalence of anemia in patients with paraesophageal hernias and frequency of anemia resolution with hernia repair.

Methods

Patients undergoing paraesophageal hernia repairs from July 1996 to September 2010 were included. Data gathered included age, gender, type of hernia, presence of symptomatic anemia, presence of esophagogastric ulcer/erosion, type of repair, and anemia resolution.

Results

One hundred eighty-three patients underwent paraesophageal hernia repair; of these, 68 (37?%) were anemic. Of these anemic patients, 39 (57?%) were symptomatic from their anemia or specifically referred for anemia, and 20 (29?%) had esophagogastric ulceration/erosion. Fifty-eight had documented follow-up. Overall, of these, 35 (60?%) had resolution of their anemia. Seventy percent of symptomatic patients had resolution of their anemia, compared to 48?% of asymptomatic patients (p?=?0.1). Of patients with esophagogastric ulceration/erosion, 85?% were symptomatic and 88?% had resolution of anemia, compared to 50?% of patients without ulceration/erosion (p?=?0.015).

Conclusions

Anemia was a common finding in patients with paraesophageal hernia and most patients were symptomatic because of their anemia. Those patients with esophageal or gastric ulceration/erosion were very likely to have symptomatic anemia, and, interestingly, these patients were more likely to have their anemia resolve with paraesophageal hernia repair.     

Incidence, mechanisms, and outcomes of esophageal and gastric perforation during laparoscopic foregut surgery: a retrospective review of 1,223 foregut cases

Background

Intraoperative perforation is a potentially major complication of laparoscopic (lap) foregut surgery. This study analyzed the incidence, mechanism, and outcomes of intraoperative perforations during these procedures in a large institutional experience.

Methods

All patients who underwent lap foregut surgery including laparoscopic antireflux surgery (LARS), paraesophageal hernia (PEH) repair, Heller myotomy, and reoperative hiatal hernia (redo HH) repair at the authors’ institution from August 2004 to September 2012 were reviewed retrospectively. Perforation events and postoperative outcomes were analyzed, and complications were graded by the modified Clavien system. All data are expressed as means ± standard deviations or as medians. Statistical analysis was performed using Fisher’s exact test and the Mann–Whitney U test.

Results

In this study, the repairs for 1,223 patients were analyzed (381 LARS procedures, 379 PEH repairs, 313 Heller myotomies, 150 redo HH repairs). Overall, 51 patients (4.2 %) had 56 perforations resulting from LARS (n = 4, 1 %), PEH repair (n = 7, 1.8 %), Heller myotomy (n = 18, 5.8 %), and redo HH repair (n = 22, 14.6 %). Redo HH was significantly more likely to result in perforations than LARS or PEH repair (p < 0.001). The locations of the perforations were esophageal in 13 patients (23.6 %), gastric in 40 patients (72.7 %), and indeterminate in 2 patients (3.6 %). The most common mechanisms of perforations were suture placement for LARS (75 %) and traction for PEH repair (43 %) and for Heller myotomy during the myotomy (72 %). The most redo HH perforations resulted from dissection/wrap takedown (73 %) and traction (14 %). Perforations were recognized and repaired intraoperatively in 43 cases (84 %) and postoperatively in eight cases (16 %). Perforations discovered postoperatively were more likely to require reoperation (75 vs 2 %; p < 0.001), to require more gastrointestinal and radiologic interventions (50 vs 2 %; p = 0.004), and to have higher morbidity (88 vs 26 %; p = 0.004) than perforations recognized intraoperatively.

Conclusions

In a high-volume center, intraoperative perforations are the most frequent with reoperative HH repair. If perforations are recognized and repaired intraoperatively, they require minimal postoperative intervention. Unrecognized perforations usually require reoperation and result in significantly greater morbidity.     

Laparoscopic Paraesophageal Hernia Repair

Background and Objective:

Paraesophageal hernias are uncommon yet potentially lethal conditions. Their repair has now been facilitated by laparoscopic technology. We present a series of 20 patients with paraesophageal hernias repaired laparoscopically.

Methods:

Twenty patients with paraesophageal hernias had laparoscopic repairs. Eighteen patients had primary repair of their hiatal defect. Two required mesh reinforcement. Fifteen patients had a fundoplication procedure performed concomitantly.

Results:

Long-term follow-up is available on 17 patients. There was no in-hospital morbidity or mortality. Average length of stay was 2.3 days. One patient recurred in the immediate postoperative period. There were no other recurrences. The only death in the series occurred in the oldest patient 18 days postoperatively. He had been discharged from the hospital and died of cardiac failure. No patients have had complications from a paraesophageal hernia postoperatively.

Conclusion:

Laparoscopic repair of paraesophageal hernias is possible. Preoperative work-up should include motility evaluation to assess esophageal peristalsis as the majority of these will need a concomitant anti-reflux procedure. This data helps the surgeon to determine whether or not a complete or partial wrap should be done. Repair of the diaphragmatic defect can be accomplished in the majority of patients without the use of prosthetic material with excellent results.