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Primary vs. Redo Paraesophageal Hiatal Hernia repair: A Comparative Analysis of Operative and Quality of Life Outcomes
Hamid R. Zahiri*1, Kamran Mohiuddin1, Steven D. Leydorf2, Adam S. Weltz2, George T. Fantry2, Adrian Park1
1General Surgery, Anne Arundel Medical Center, Annapolis, MD; 2General Surgery, University of Maryland School of Medicine, Baltimore, MD
Introduction: The first attempt at Paraesophageal Hiatal Hernia (PEH) repair is the best opportunity for the surgeon to achieve a durable repair. Redo -PEH -repair is challenging due to adhesions, obscured planes and attenuated tissues. The purpose of this study was to compare operative and QOL outcomes in patients undergoing initial vs. redo PEH repair at a high volume specialty center.
Methods: Prospectively accrued outcome data was analyzed in patients following initial vs. redo PEH repair between 01/01/2004 and 11/10/2015. Demographic, perioperative, and pre/post-operative QOL data were assessed using validated surveys: reflux symptom index (RSI), gastroesophageal reflux disease health-related QOL (GERD-HRQL), laryngopharyngeal reflux health-related QOL (LPR-HRQL), and swallowing QOL (SWAL-QL).
Results: 540 patients (490 primary and 50 redo) underwent elective PEH repair. Groups were comparable with respect to mean age (58.1 vs. 59.2 p=0.65), BMI (30.9 vs. 29.6 p=0.56) and ASA (2.5 vs. 2.4 p=0.74). Preoperative studies also revealed comparable anatomic, functional and disease characteristics among both groups as indicated by mean lower esophageal sphincter pressures (21.2 vs. 22.9 p=0.67), mean liquid transit (83.8 vs. 74.2 p=0.14) and viscous transit percentiles (71.3 vs. 64 p=0.31), as well as, mean DeMeester scores (30.8 vs. 35 p= 0.65). All patients underwent laparoscopic surgical repair. Analysis of mean operative time (115.4 vs. 136 min p=<0.05), blood loss (45.5 vs. 55.7 ml p=0.49) and length of hospital stay (LOS) (2.3 vs. 3.7 days p=<0.05) indicated redo PEH patients underwent more complex surgery. Postoperative followup was, on average, 12 months. Twelve percent of patients undergoing redo PEH had complications compared to 6% in the initial PEH repair group. OQL analysis revealed equivalent symptomatic improvement after surgery for patients in both groups as shown by augmented QOL scores on RSI (46.8% vs. 53.5%, p =0.69), GERD-HRQL (71.4% vs. 77.4% p =0.67), LPR-HRQL (43.9% vs. 27.7% p=0.52) and SWAL-QL (46.3% vs. 26.9% p=0.26) surveys.
Conclusions: Patients who underwent redo PEH experienced longer surgeries with higher complication rates than those who underwent initial PEH repair. Nevertheless, at one year of followup, both groups benefited similarly from their operative intervention with comparable QOL outcomes
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