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2006 Abstracts: Predictors of Anatomic Recurrence After Paraesophageal Hernia Repair: The Importance of the Learning Curve
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Predictors of Anatomic Recurrence After Paraesophageal Hernia Repair: The Importance of the Learning Curve
Allan Okrainec, Lorenzo S. Ferri, Liane S. Feldman, Gerald F. Fried; Steinberg-Bernstein Centre for Minimally Invasive Surgery, Mcgill University, Montreal, QC, Canada

Introduction: There are numerous reports in the literature documenting high recurrence rates after laparoscopic paraesophageal hernia repair (LPEHR). The purpose of this study was to identify factors predictive of recurrence in patients undergoing LPEHR. Methods: 44 consecutive patients (14M:30F) with paraesophageal hernia were evaluated prospectively before and after LPEHR performed by a single sugeon between 1997 and 2005. (All repairs were done without prosthetic mesh or esophageal lengthening). UGI was performed 3 mo post-op to look for recurrence, defined as any fundus above the diaphragm. Clinical, operative, and post-operative data were analyzed for predictors of recurrence. T-test or chi-square determined significance (p<0.05). Results: Post-op UGI was available in 42 patients (93%). Anatomic recurrence occurred in 8 patients (19%). Age, gender, symptoms, BMI, ASA, type of PEH, operative time, blood loss, or length of stay were not predictive of recurrence. When patients were stratified based on early (first 20 cases) vs late experience, there was a significantly higher recurrence rate during the first 20 cases (33% vs 8%, p=.04). The cumulutive sum (CUSUM) method was used to analyze the learning curve (Fig). CUSUM analysis showed that the learning curve was 26 cases before we were achieving an acceptable recurrence rate,(< 20%) with 95% probability. Conclusions: Surgeon experience is the most significant predictor of recurrence after LPEHR. CUSUM analysis revealed that the recurrence rate diminishes after 20 cases (point A) and reaches an acceptable rate after 26 cases (point B).


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