Mid term analysis of safety and quality of life after the laparoscopic repair of paraesophageal hiatal hernia

Background Initial experience with the laparoscopic repair of paraesophageal and type III mixed hiatal hernias showed that it is safe and feasible, with excellent immediate and short-term results. However, after a longer follow-up, a recurrence rate of 40% has been demonstrated. Data related to the outcome of paraesophageal hernia repair and the recurrence rate are still lacking. Quality-of-life scores may offer a better means of assessing the impact of surgical treatment on the overall health status of patients. Therefore, we performed prospective evaluation of anatomic and/or symptomatic recurrences after paraesophageal or large hiatal hernia repair. In addition, we investigated the correlation between recurrence and the patients quality of life.Methods All patients after who had undergone repair of paraesophageal of mixed hiatal hernia were identified prospectively from a database consisting of all patients who had had laparoscopic operations for gastroesophageal pathology at our hospital between February 1998 and December 2002. The preoperative symptoms were taken from patients clinical files. In March 2003, all patients with 6 months of follow-up had a barium swallow and were examined for radiological and clinical signs of recurrence. Thereafter, the patients quality of life after surgery was evaluated using three standard questionnaires (Short Form 36 [SF-36], Glasgow Dyspepsia Severity Score [GDSS], and Gastrointestinal Quality of Life Index [GIQLI].Result During the study period, 46 patients had been operated on. The mean age was 63 years (range, 28–93). Thirty seven of them had a follow-up of 6 months. Eight patients (21%) had postoperative gastrointestinal symptoms. Barium swallow was performed in 30 patients (81%) and showed a recurrence in six of them (20%). According to SF-36 and GDSS, the patients postoperative quality of life reached normal values and did not differ significantly from the standard values for the Spanish population of similar age and with similar comorbidities. Successfully operated patients reached a GIQLI value comparable to the standard population. However, symptomatic patients had significantly lower GIQLI scores than the asymptomatic or the Rx-recurrent group.Conclusion The laparoscopic treatment of large paraesophageal and mixed hiatal hernias is not only feasible and safe but also offers a good quality of life on a midterm basis. However, the anatomic and functional recurrence rate is high. The next step is to identify the subset of patients who are at risk of failure and to establish technical alternatives that would ensure the durability of the repair.Presented in foster format at the 2003 scientific meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, CA, USA, March 2003, and as a free paper at the 10th congress of the European Association for Endoscopic Surgery (EASES), Glasgow, Scotland, United Kingdom, June 2003     

腹腔镜食道裂孔疝修补联合胆囊切除术的临床应用探讨

目的探讨腹腔镜下食道裂孔疝修补联合胆囊切除手术的临床应用。方法回顾性分析24例腹腔镜食道裂孔疝修补联合胆囊切除术患者的临床资料。结果 24例均获成功,无并发症发生及中转开腹,术后4～7d痊愈出院。结论腹腔镜下食道裂孔疝修补联合胆囊切除术能安全有效的处理腹部多发病变,在掌握好手术适应证的条件下是安全可行的。     

Use of absorbable meshes in laparoscopic paraesophageal hernia repair

Paraesophageal hernia(PEH) repair is one of the most challenging upper gastrointestinal operations. Its high rate of recurrence is due mostly to the low quality of the crura and size of the hiatal defect. In an attempt to diminish the recurrence rates, some clinical investigators have begun performing meshreinforced cruroplasty with nonabsorbable meshes like polypropylene or polytetrafluoroethylene. The main problem with these materials is the occurrence, in some patients, of serious mesh-related morbidities, such as erosions into the stomach and the esophagus, some of which necessitate subsequent esophagectomy or gastrectomy. Absorbable meshes can be synthetic or biological and were introduced in recent years for PEH repair with the intent of diminishing the recurrence rates observed after primary repair alone but,theoretically, without the risks of morbidities presented by the nonabsorbable meshes. The current role of absorbable meshes in PEH repair is still under debate,since there are few data regarding their long-term efficacy, particularly in terms of recurrence rates, morbidity, need for revision, and quality of life. In this opinion review, we analyze all the presently available evidence of reinforced cruroplasty for PEH repair using nonabsorbable meshes(synthetic or biological),focusing particularly on recurrence rates, mesh-related morbidity, and long-term quality of life.     

腹腔镜食管裂孔疝修补术并发症的预防

目的探讨使用腹腔镜行食管裂孔疝修补术的疗效和安全性。减少手术并发症,随访腹腔镜治疗食道裂孔疝的效果。方法对280例食管裂孔疝患者使用腹腔镜行食管裂孔疝修补术,其中132例做胃底270°部分折叠术（Toupet术）,148例做胃底360°折叠术（Nissen术）。36例应用补片修补疝缺口,剩余患者采用直接缝合。结果 280例腹腔镜食管裂孔疝修补术全部获得成功。手术时间30～190min,平均手术时间110min,失血10～50ml;术后24～48h进流质饮食,无术后并发症;术后平均住院5.7d。结论腹腔镜食道裂孔疝修补术具有疗效确定、安全和创伤小的优点。并发症率极低。     

Emergency laparoscopic repair of a paraesophageal hernia

A 63-year-old male with a previously documented paraesophageal hernia presented with acute severe epigastric pain and bloating. He was taken urgently to the operating room for laparoscopic exploration. The hernia sac was reduced with difficulty owing to extensive adhesions and the incarcerated portion of the stomach was mottled and blue. After 10 min of observation the stomach began to resume a normal appearance. The anterior crura were approximated and an anterior gastropexy was performed. The patient was discharged on the 3rd postoperative day and has been asymptomatic since. Paraesophageal hernias with evidence of impending gastric necrosis can be approached laparoscopically as long as basic principles are observed.     

Laparoscopic repair of large paraesophageal hernia is associated with a low incidence of recurrence and reoperation

Background: Laparoscopic repair of paraesophageal hernia (LRPEH) is a feasible and effective technique. There have been some recent concerns regarding possible high recurrence rates following laparoscopic repair. Methods: We reviewed our experience with LRPEH from 5/1996 to 8/2002. Large paraesophageal hernia (PEH) was defined by the presence of more than one-third of the stomach in the thoracic cavity. Principles of repair included reduction of the hernia, excision of the sac, approximation of the crura, and fundoplication. Pre- and postoperative symptoms were evaluated utilizing visual analogue scores (VAS) on a scale ranging from 0 to 10. Patients were followed with VAS and barium esophagram studies. Statistical analysis was performed using two-tailed Students t-test. Results: A total of 166 patients with a mean age of 68 years underwent LRPEH. PEH were type II (n = 43), type III (n = 104), and type IV (n = 19). Mean operative time was 160 min. Fundoplications were Nissen (127), Toupet (23), Dor (1), and Nissen-Collis (1). Fourteen patients underwent a gastropexy. One patient required early reoperation to repair an esophageal leak. Mean hospital stay was 3.9 days. At 24 months postoperatively there was statistically significant improvement in the mean symptom scores: heartburn from 6.8 to 0.5, regurgitation from 5.9 to 0.3, dysphagia from 4.0 to 0.5, chest pain from 3.7 to 0.3. Radiographic surveillance was obtained in 120 patients (72%) at a mean of 15 months postoperatively. Six patients (5%) had radiographic evidence of a recurrent paraesophageal hernia (two required surgery), 24 patients (20%) had a sliding hernia (two required surgery), and four patients (3.3%) had wrap failure (all four required surgery). Reoperation was required in 10 patients (6%); two for symptomatic recurrent PEH (1.2%), four for recurrent reflux symptoms (2.4%), and four for dysphagia (2.4%). Patients with abnormal postoperative barium esophagram studies who did not require reoperation have remained asymptomatic at a mean follow up of 14 months. Conclusion: LPEHR is a safe and effective treatment for PEH. Postoperative radiographic abnormalities, such as a small sliding hernia, are often seen. The clinical importance of these findings is questionable, since only a small percentage of patients require reoperation. True PEH recurrences are uncommon and frequently asymptomatic. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, CA, USA, March 2003     

Histologic results 1 year after bioprosthetic repair of paraesophageal hernia in a canine model

Background The use of prosthetic materials for the repair of paraesophageal hiatal hernia (PEH) may lead to esophageal stricture and perforation. High recurrence rates after primary repair have led surgeons to explore other options, including various bioprostheses. However, the long-term effects of these newer materials when placed at the esophageal hiatus are unknown. This study assessed the anatomic and histologic characteristics 1 year after PEH repair using a U-shaped configuration of commercially available small intestinal submucosa (SIS) mesh in a canine model. Methods Six dogs underwent laparoscopic PEH repair with SIS mesh 4 weeks after thoracoscopic creation of PEH. When the six dogs were sacrificed 12 months later, endoscopy and barium x-ray were performed, and biopsies of the esophagus and crura were obtained. Results The mean weight of the dogs 1 year after surgery was identical to their entry weight. No dog had gross dysphagia, evidence of esophageal stricture, or reherniation. At sacrifice, the biomaterial was not identifiable grossly. Biopsies of the hiatal region showed fibrosis as well as muscle fiber proliferation and regeneration. No dog had erosion of the mesh into the esophagus. Conclusions This reproducible canine model of PEH formation and repair did not result in erosion of SIS mesh into the esophagus or in stricture formation. Native muscle ingrowth was noted 1 year after placement of the biomaterial. According to the findings, SIS may provide a scaffold for ingrowth of crural muscle and a durable repair of PEH over the long term. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Denver, Colorado, 3 April 2004     

Clinical and radiologic assessment of laparoscopic paraesophageal hernia repair

Background: Unlike sliding hiatal hernias, paraesophageal hiatal hernias (PEH) present a risk of catastrophic complications and should be repaired. To assess laparoscopic repair of PEH, we prospectively evaluated the outcome of 38 consecutive patients with type II (20 patients) or III (18 patients) PEH treated laparoscopically. Methods: With the use of 5 or 6 ports, laparoscopic PEH reduction and repair was attempted. One patient (3%) was converted to an open procedure. In the first 12 patients, the hiatus was closed using varying techniques including the placement of prothestic mesh in 6 patients, and the hernia sac was not routinely excised. In the next 25 patients, the hernia sac always was excised and the hiatus routinely sutured posteriorly to the esophagus. Twenty-nine patients also underwent either a Nissen (n= 27) or Toupet (n= 2) fundoplication, which is now performed routinely. Sutured anterior gastropexy was performed selectively in 10 of the first 20 patients, then routinely, using T-fasteners in the last 17 patients. Barium swallow studies were performed on all patients at 3 to 5 months postoperatively. Results: Mean ± standard error of the mean (SEM) age was 67 ± 2 year (range, 39–92 years; 11 men, 27 women), and the American Society of Anesthesia (ASA) score was 2.5 ± 0.1. The operating time was 195 ± 10 min: 244 ± 15 min in the first 12 patients and 170 ± 11 min in the last 25 patients (p < 0.001). There were three (8%) intraoperation complications, which were treated without sequelae, and four (11%) grade II postoperation morbidities. Median discharge was 3 days, and return to full activity was 14 days. Two patients (5%) died of cardiovascular disease after discharge. Barium swallow revealed 2/35 (6%) PEH recurrences (1 reoperated), 3 (9%) intrathoracic wraps, and 3 (9%) small sliding hiatal hernias. At follow-up of 1 year or more, 6/28 (21%) patients noted mild symptoms of reflux or bloating, but only 1 patient (4%) required medication for these symptoms. Conclusions: Laparoscopic PEH repair offers a reasonable alternative to traditional surgery, especially for high-risk patients. Rapid recovery is achieved with acceptable morbidity and early outcome. Barium x-rays revealed hiatal abnormalities in a significant fraction of patients, many of whom were asymptomatic. Longer follow-up will be required to determine the ideal strategy for management of these patients. Received: 4 April 1998/Accepted: 9 December 1998     

Towards a near-zero recurrence rate in laparoscopic inguinal hernia repair for pediatric patients of all ages

Background/Purpose

The recurrence rate in laparoscopic inguinal hernia (LIH) repair remains high. The aim of this study was to assess whether the introduction of technical improvements, including (1) decreasing tension on the purse-string knot when closing the internal hernia opening by injecting normal saline extraperitoneally, (2) using an airtight knot, and (3) stress-testing the airtightness of the knot by increasing intraperitoneal gas pressure, could eliminate recurrence in LIH repair in pediatric patients of all ages.

Methods

A retrospective review was performed of the prospectively collected data of 451 LIH repairs in 314 children of various ages in our institution from September 2002 to September 2006. The technical improvements mentioned above to prevent recurrence were introduced in the second half of the series of operations (tensionless repair [TL]). The data on both groups of operations were then compared.

Results

A total of 225 hernias were repaired in the first group (164 patients), compared with 226 in the TL group (150 patients). The differences between the ratio of boys to girls (129:35 vs 112:38) and the mean ages (50.84 ± 48.15 vs 45.59 ± 47.95 m) in the 2 groups were not statistically significant. The recurrence rate in the TL group was much lower than in the first group (0.4% vs 4.88%, P = .003). There was no postoperative testicular atrophy in either group of patients.

Conclusion

It is possible to achieve a near-zero recurrence rate in laparoscopic hernia repair in pediatric patients of all ages.     

Laparoscopic paraesophageal hernia repair with acellular dermal matrix cruroplasty

Background:

Laparoscopic paraesophageal hernia repair (LPEHR) has been shown to be both safe and efficacious. Compulsory operative steps include reduction of the stomach from the mediastinum, resection of the mediastinal hernia sac, ensuring an appropriate intraabdominal esophageal length, and crural closure. The use of mesh materials in the repair of hiatal hernias remains controversial. Synthetic mesh may reduce hernia recurrences, but may increase postoperative dysphagia and result in esophageal erosion. Human acellular dermal matrix (HADM) may reduce the incidence of hernia recurrence with reduced complications compared with synthetic mesh.

Methods:

A retrospective review of all cases of laparoscopic hiatal hernia repair using HADM from December 2008 through March 2010 at a single institution was performed evaluating demographic information, BMI, operative times, length of stay, and complications.

Discussion:

Forty-six LPEHRs with HADM were identified. The mean age of patients was 60.3 years (±13.9); BMI 30.3 (±5.3); operative time 182 minutes (±56); and length of stay 2.6 days (±1.9). Nine of 46 (19.6%) patients experienced perioperative complications, including subcutaneous emphysema without pneumothorax (n=2), urinary retention (n=1), COPD exacerbation (n=2), early dysphagia resolving before discharge (n=1), esophageal perforation (n=1), delayed gastric perforation occurring 30 days postoperatively associated with gas bloat syndrome (n=1), and PEG site abscess (n=1). There were 2 clinically recurrent hernias (4.3%). Radiographic recurrences occurred in 2 of 26 patients (7.7%). Six of 46 (13%) patients reported persistent dysphagia.

Conclusion:

LPEHR with HADM crural reinforcement is an effective method of repairing symptomatic paraesophageal hernias with low perioperative morbidity. Recurrences occur infrequently with this technique. No mesh-related complications were seen in this series.     

Long-term outcome of laparoscopic repair of paraesophageal hernia

Background

It has been reported that the laparoscopic repair of paraesophageal hernias is associated with higher complication and recurrence rates than the open methods of repair.

Methods

We identified 136 consecutive patients who underwent laparoscopic repair of a paraesophageal hernia between 1993 and 1999. Patient demographics and symptom scores for regurgitation, heartburn, chest pain, and dysphagia at presentation and at last follow-up were recorded (0=none, 1=mild, 2=moderate, 3=severe). The operative records were reviewed, and early and late complications were noted. Only patients with a follow-up of 1 were included in the analysis.

Results

The median age was 64 years, and there was a female preponderance (1.8∶1). Most patients had some medical comorbidity; the American Society of Anesthesiologists (ASA) scores were <2 in eight patients and ≥2 in 117 patients. Three laparoscopic operations were converted to open procedures. There were nine intraoperative complications, five early complications, and three related deaths (morbidity and mortality rates of 10.2% and 2.2%, respectively). Follow-up data were available for 83 patients (66%), and the mean follow-up time was 40 months (range, 12–82). The percentage of patients experiencing chest pain, dysphagia, heartburn, and regurgitation in the moderate to severe range dropped from a range of 34–47% to 5–7% (p<0.05). Three patients underwent repeat laparoscopic repair for symptomatic recurrence.

Conclusion

The laparoscopic repair of paraesophageal hernias provides excellent long-term symptomatic relief in the majority of patients and has a low rate of symptomatic recurrence. The complication and death rates may be related in part to the higher incidence of comorbidities in this somewhat elderly patient population.     

Laparoscopic repair of paraesophageal hernia

Large paraesophageal hernias are generally repaired by reduction of the stomach into the abdomen, sac excision, crural closure, and gastropexy or fundoplication. After gaining experience performing laparoscopic repair of sliding hiatal hernias and Nissen fundoplication we combined laparoscopic access with traditional surgical technique in treating patients with complex paraesophageal hernias.Ten adults, six males and four females, with type III paraesophageal hernias underwent laparoscopic repair between February 1993 and April 1994. The average age of the patients was 60.4 years (range 38–81). Using five ports (three 10 mm and two 5 mm), the stomach was reduced into the abdomen, the hernia sac was resected, and the defect was closed with pledgeted horizontal mattress sutures. In addition, nine patients had a Nissen fundoplication performed and one patient had a diaphragmatic gastropexy.The procedure was completed laparoscopically in all ten cases and the median operating time was 282 min (range 165–430). Two complications occurred, an intraoperative gastric laceration, and a postoperative mediastinal seroma. All patients were discharged on the 2nd or 3rd postoperative day. Eight of nine patients were asymptomatic at last follow-up (mean 8.9 months postop). One patient has mild dysphagia and heartburn from partial migration of the fundoplication into the chest. One patient died 3 months postoperatively of unrelated causes. Paraesophageal hernia can be reduced and repaired safely with laparoscopic access using standard surgical techniques.Presented at the annual meeting of the Society of American Gastro-intestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994     

腹腔镜胃间质瘤切除联合食道裂孔疝修补术的临床体会

目的探讨腹腔镜下胃间质瘤切除联合食道裂孔疝修补术的临床体会。方法回顾性分析8例腹腔镜胃间质瘤切除联合食道裂孔疝修补术的临床资料。结果 8例均获成功,无并发症发生及中转开腹,术后7～9d痊愈出院。结论腹腔镜下胃间质瘤切除联合食道裂孔疝修补术能安全有效的处理胃食道多发病变,在掌握好手术适应症的条件下是安全可行的。     

Transthoracic Collis-Nissen repair for massive type IV paraesophageal hernia

An 80-year-old woman presented with type IV massive hiatal hernia with intrathoracic upside-down stomach and transverse colon. She was dyspneic and vomited upon consuming food or water. Consequently, she developed aspiration pneumonia. Both esophagoscopy and upper gastrointestinal series demonstrated significant cephalad displacement of the gastroesophageal junction. A Collis-Nissen hernial repair by muscle-sparing mini-thoracotomy was performed successfully. To date, 3 years after surgery, the patient is enjoying normal oral intake, has an excellent activities of daily living level, and there is no hernia recurrence. Cases of massive paraesophageal hernia are frequently associated with esophageal shortening that causes tension on the repairs and late failure. Advantages of the transthoracic approach in such cases include feasibility of direct esophageal mobilization, accurate assessment of esophageal tension, and facilitation of Collis gastroplasty. The true indication for transthoracic Collis-Nissen repair among cases of paraesophageal hiatal hernia with a short esophagus should be acknowledged more in the era of laparoscopy.     

腹腔镜治疗食管裂孔疝的麻醉

目的探讨腹腔镜行食管裂孔疝修补术对全身麻醉患者血流动力学、呼吸及动脉血气的影响。方法选择了62例（ASAI—II）食管裂孔疝患者使用腹腔镜行食管裂孔疝修补术,监测气腹前,气腹后30min血压（BP）、心率（HR）、心电图（ECG）、脉搏、氧饱和度（SPO2）及动脉血气、气道压力的变化。结果62例腹腔镜食管裂孔疝修补术全部获得成功。气腹前、后患者的血流动力学变化不明显（P〉0．05）,气道压力,动脉血气发生显著改变,出现高碳酸血症（P〈0．05）。结论腹腔镜行食管裂孔疝修补术CO2气腹对全身麻醉患者呼吸及血气产生一定的影响,术中应加强麻醉的管理及监测。     

Short-term outcome of laparoscopic paraesophageal hernia repair

Background: The purpose of this study is to determine the morbidity, mortality, and short-term outcomes associated with laparoscopic paraesophageal hernia repair (LPHR). Methods: A series of 58 consecutive LPHRs performed by the author were reviewed with an average 1-year follow-up. Morbidity and mortality rates were compared with historical series of open repairs. Anatomy and technical considerations pertinent to LPHR were reviewed. Results: There were no procedure-related or perioperative deaths in this series of patients undergoing LPHR. Four major complications occurred (7%), two of which required reoperation, all in urgently repaired patients. One patient required conversion to laparotomy (1.7%). Based on symptoms, there were no reherniations. No patients had long-term dysphagia worse than preoperatively. Preoperative symptoms of chest pain, esophageal obstruction, hemorrhage, and reflux were resolved in all patients. Conclusions: LPHR is safe, effective, and compares favorably to historical series of open paraesophageal hernia repair. Received: 24 July 1996/Accepted: 20 November 1996     

Octogenarians exhibit quality of life improvement but increased morbidity after paraesophageal hernia repair

BackgroundThe benefit of elective laparoscopic paraesophageal hernia repair (eLPEHR) in the elderly is unclear. This study compared quality of life and symptom resolution and morbidity after eLPEHR between octogenarians and younger patients.MethodsA retrospective review was conducted comparing octogenarians (n = 23) to younger patients (n = 162) undergoing eLPEHR. Primary outcomes were pre and post-operative disease-specific quality of life (GERD-HRQL) and symptom scales (GERSS) and post-operative morbidity and length of stay (LOS).ResultsOctogenarians presented with higher ASA and lower preoperative BMI. Compared to controls, octogenarians exhibited higher overall morbidity (34.8% vs 16.1%, p = 0.03), including cardiac events (8.7% vs 0.6%) and mortality (8.7% vs 0%), and longer LOS (3 vs 2 days, p < 0.005). Post-operative reduction in GERD-HRQL/GERSS scores was comparable between groups.ConclusionOctogenarians who undergo eLPEHR exhibit significant improvement in quality of life and symptom burden but may experience increased morbidity, suggesting a role for watchful waiting in this population.SummarySymptom burden, quality of life, and immediate post-operative morbidity was compared between octogenarians and younger patients undergoing elective laparoscopic paraesophageal hernia repair at a single institution. While exhibiting comparable post-operative improvement in symptom burden and quality of life, octogenarians experience higher post-operative morbidity. This may suggest a role for watchful waiting in the elderly population.     

Laparoscopic repair of incarcerated paraesophageal hernias

Paraesophageal hernias comprise only 2–5% of all hiatal hernias, yet unlike the more common sliding hiatal hernia, paraesophageal hernias are prone to undergo volvulus, with obstruction, ischemia, and gangrenous perforation. Due to their propensity toward calamitous complications, they must be recognized and repaired as expeditiously as possible. Traditionally these hernias have been repaired by either an open transabdominal or an open transthoracic approach. Laparoscopic repair with Nissen fundoplication has already been successfully applied to the repair of the more common sliding hiatal hernia. Described here is the laparoscopic repair of two paraesophageal hernias. The merit of an anti-reflux procedure as part of this repair is discussed.     

Recurrent paraesophageal hernia due to diaphragm rupture: a case report

A 58-year-old male patient was operated for complaints of dysphagia, anemia and retrosternal discomfort due to a type II hiatal hernia. A complete hernia sac excision and posterior crural repair was performed laparoscopically with support of the da Vinci™ robotic system. An antireflux procedure was not performed because of the absence of gastroesophageal reflux disease. Nine months after surgery the patient presented with recurrent complaints of dysphagia and retrosternal pain. Barium esophagram series revealed a recurrent paraesophageal hernia which was confirmed on esophagogastroscopy. A robot-assisted re-laparoscopy was performed. Left to the still intact hiatoplasty of the original operation a tear in the diaphragm, through which part of the stomach covered with peritoneum had herniated, was encountered. The hernia sac was excised, the diaphragmatic defect closed and reinforced with an expanded polytetrafluoroethylene strip of 5×8 cm. After surgery the patient recovered quickly, oral intake was resumed on the first postoperative day and the hospital stay was 3 days. The use of prosthetic mesh to reinforce the hiatoplasty and the addition of an antireflux procedure after hiatal hernia repair are ongoing controversial aspects of hiatal hernia repair. Reports on laparoscopic redo surgery for recurrent diaphragmatic hernia are limited and will be addressed in this case report, in perspective of the aforementioned controversial components.     

Comparison of patient-centered outcomes after laparoscopic Nissen fundoplication for gastroesophageal reflux disease or paraesophageal hernia

Background Patients undergoing laparoscopic Nissen fundoplication (LNF) with paraesophageal hernias (PEH) are not only older and less healthy than those with gastroesophageal reflux disease (GERD), but in addition the repair is more complicated. We evaluated whether outcomes relating to GERD symptoms and quality of life (QOL) were impacted by the presence of PEH. Methods Prospectively entered data from 149 patients (109 GERD and 40 PEH) were evaluated prior to and one year after LNF with standardized and validated symptoms scores. Scores for heartburn, dysphagia, disease-specific QOL (GERD-HRQL), and general health-related QOL (SF-12 physical and mental component scores) were compared between patients undergoing LNF for PEH or for GERD alone, at baseline and one year after surgery. p < 0.05 was considered statistically significant. Results Preoperative data for GERD-HRQL, heartburn, and dysphagia were available for 134 patients, with 96% one-year follow-up. SF-12 data were collected for 98 patients with 100% follow-up. PEH patients were older and had greater comorbidity. Preoperative GERD-HRQL and heartburn were significantly worse in the GERD group. One year after surgery, both GERD and PEH patients showed significant improvement in GERD-HRQL, heartburn and dysphagia scores, with no difference in any of these disease or symptom measures between the two study groups. Postoperative PCS and MCS scores showed improvement in GERD patients, while PEH patient scores remained at or below the population mean. Conclusions LNF is equally effective as an antireflux procedure in both GERD and PEH patients, prevents symptoms of reflux in PEH patients that have none preoperatively, and does not increase dysphagia in either group. Despite the increased complexity of the procedure, LNF provides an effective control of reflux symptoms in patients undergoing PEH repair. Supported by an unrestricted educational grant from Tyco Healthcare Canada