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A Combined Nissen Plus Hill Repair Reduces Recurrences for Paraesophageal Hernia Compared to Laparoscopic Nissen Alone
Gal Levy*, Ralph W. Aye, Alexander S. Farivar, Brian E. Louie
Thoracic And Esophageal Surgery, Swedish Medical Center, Seattle, WA
Intro
It has been shown that laparoscopic Nissen fundoplication (LNF) for paraseophageal hernia (PEH) improves both short and long-term quality of life with low morbidity and mortality, but with high long-term anatomic recurrence rates in excess of 50%. Multiple strategies have been employed to reduce recurrence including esophageal lengthening, relaxing incisions, and biologic or permanent mesh. The laparoscopic Nissen-Hill hybrid repair [HYB] combines Hill sutures, which fix the GE junction intra-abdominally with a full Nissen wrap to maintain circumferential integrity, and has been shown to be feasible for paraesophageal hernia repairs with encouraging short-term results. The purpose of this study is to compare clinical and objective post-operative outcomes of LNF to HYB for repair of PEH for patients without short esophagus.
Methods
Single institution retrospective chart review of prospectively collected data for consecutive patients undergoing PEH repair from 2006-2015 with at least 6 month follow up. Paraesophageal hernia was defined as herniation of the gastric fundus (type II-IV) above the gastroesophageal junction (GEJ) on upper GI (UGI). The type of repair was chosen by the surgeon. Patients were excluded for <18 yrs of age, history of previous antireflux surgery, presence of short esophagus assessed intra-operatively, use of Collis gastroplasty, active malignancy or medical contraindications to surgery. Quality of life metrics (QOLRAD, HRQL, and dysphagia), manometry, radiographic imaging and pH testing were administered pre and post operatively. Recurrence was defined as > 2 cm of herniated fundus on UGI or EGD.
Results
There were 255 repairs with available follow up data (LNF=136, HYB =119). The two groups were comparable in age (LNF 62.11 vs HYB 64.28, p=0.11) and male gender (35% LNF vs 33% HYB, p=0.67). HYB had higher BMI (LNF 28.9 vs HYB 30.9, p<0.05) and larger average hernia size (LNF 6.3cm vs HYB 7.2cm, p<0.05).
Median follow up was 1.75 years for HYB and 2.75 years for LNF. There were no significant differences in post-operative DeMeester scores (13.6 vs 10.9, p=0.25), Lower esophageal sphincter pressure (LESP) (22.47 vs 22.37, p=0.48), residual Lower esophageal sphincter pressure (rLESP) (10.9 vs 12.4, p=0.14), QOLRAD (6.23 v 6.49, p=0.057), or dysphagia scores (38.8 vs 40.3, p=0.18).GERD-HRQL was slightly better for LNF (LNF 6.2 vs HYB 6.5 p=0.03). However, anatomic recurrences (LNF 28% (n=12/50) vs HYB 2.9% (n=3/100), p<0.05) and reoperation rates (LNF = 5 vs HYB = 1) favored HYB.
Conclusion
In this comparative study of PEH repairs both operations controlled GERD, restored quality of life and restored lower esophageal pressures. However, the Nissen-Hill Hybrid repair appears to result in a significantly lower rate of anatomic recurrence and reoperation for failure compared to Nissen fundoplication alone.
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