Laparoscopic Paraesophageal Hernia (PEH) Repair, a Challenging Operation: Medium Term Outcome of 116 Patients
Abstracts
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Purpose: As the optimal technique for PEH repair is controversial, we analyzed our experience with laparoscopic repair of these challenging problems. Methods: Laparoscopic PEH repairs done in 116 patients between 1992 and 2001 were prospectively analyzed. Perioperative outcomes were assessed and follow up was performed under protocol including symptomatic assessment and barium esophagram. Results: There were 85 female and 31 male patients, with mean ± S.D. age of 65 ±13 years. Among 119 patients, 116 were completed laparoscopically (97%). All but two patients underwent an antireflux procedure with 108 Nissen and 6 Toupet fundoplications. Gastropexy was performed in 48 patients, an esophageal lengthening procedure in 6, and prosthetic closure of hiatus in 6 patients. Mean operating time was 169 ±52 minutes and median postoperative hospital stay was 2 days (1-18 d.). Significant complications occurred in 7 patients (6%) with two postoperative deaths (1.7%) occurring after discharge due to myocardial infarction. Mean follow up was 30 ±25 months; five patients were lost to follow up, seven patients have died of unrelated causes and 96 patients (83%) have been followed for >6 mos. Among these patients, 73 (76%) are asymptomatic, 11 (11%) complain of mild symptoms, and 12 (13%) are taking antacid medications. Barium esophagrams were done in 69% of patients at a mean postoperative interval of 29 months. Recurrence of hiatal hernia was documented in 21 patients (22%). In 13 of these, disruption of the fundoplication was found along with 7 PEH and 6 sliding hernias; in the remaining 8 patients an intact wrap migrated to the thorax. The size of the recurrent hernias was 1-3 cm in 12 patients (57%) and 4-7 cm in 9 (43%). Only 3 patients have required reoperation for symptomatic recurrence. There was no significant difference in recurrence rates when mesh repair or gastropexy was performed. When only the patients with recurrent hiatal hernias are considered, 13 (62%) are symptomatic but only 6 (28%) require medications for symptoms. Conclusions: Laparoscopic repair of PEH is safe and feasible in most patients. This study confirms a relatively high incidence of recurrent hiatal abnormalities after PEH repair. However, most recurrent hiatal hernias are small and have required no therapy over medium-term follow up. Protocol esophagram detects recurrences that are minimally symptomatic. New techniques are needed to improve the outcome of laparoscopic PEH repair. |
