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HOW HIGH IS TOO HIGH: MEDIASTINAL DISSECTION IN PATIENTS WITH PARAESOPHAGEAL HERNIA REPAIR.
Michael Otten, Dietric Hennings^*, Priscila R. Armijo, Crystal Krause, Dmitry Oleynikov
University of Nebraska Medical Center, Omaha, NE
Introduction:

Shortened esophagus is observed in approximately 10% of patients that receive anti-reflux procedures. While Collis gastroplasty (CG) is considered a gold standard for esophageal lengthening in such cases, adequate mediastinal mobilization to ensure a 3 cm intraabdominal esophagus without gastroplasty may change the risk profile associated with CG. This study assesses preoperative and intraoperative hernia characteristics and its impact on mediastinal dissection in patients with paraesophageal hernia repairs.

Methods
A single-institution prospectively collected database was reviewed for adult patients who underwent laparoscopic paraesophageal hernia repair followed by anti-reflux surgery between 2004 and 2016. Patient demographics, hernia characteristics, and surgical data were collected. Preoperative hernia characteristics, including the gastro-esophageal junction (GEJ) length above the diaphragm and hernia size were assessed using upper endoscopy and barium swallow. Intraoperative hernia characteristics were collected from the operative note. Only patients who had a barium swallow performed preoperatively were included. Esophageal symptoms score were collected pre- and postoperatively. Hernia recurrence was evaluated in postoperative upper GI endoscopy or barium swallow. Analysis were conducted using SPSS v23.0.

Results
70 patients who underwent paraesophageal hernia repair were included. Mean age was 61±13.3 years, 63% were female and all were Caucasian. Mean BMI was 29.62±5.45 kg/m². Mean hernia size was 5.86cm (SD: 2.46cm), and intra-thoracic stomach had a prevalence of 52.8%. Analysis of preoperative barium swallow revealed an average of elevated gastroesophageal junction above the diaphragm of 4.10±1.67cm. Radiographically, average hernia size was 5.66±2.19cm and 5.69±2.20cm in the anterior-posterior and obliquus view, respectively. Patients had a median of 10.0cm [0-15cm] of mediastinal dissection, and a median of 3.0cm [2-5cm] of intra-abdominal dissection, which allowed us to obtain a median of 3.0cm [2-15cm] of intra-abdominal esophagus. Median follow-up time was 2.7 years [1-9years]. For all patients, preoperative esophageal symptoms improved, all p<0.05. Although 51.2% patients had radiographic hernia recurrence, only four presented reflux symptoms or were on PPI.

Conclusion
Previous literature has cited CG as a standard of ensuring adequate esophageal length prior to antireflux surgery. Our results support the conclusion that CG is not necessary in the vast majority of cases. In cases where esophageal shortening is present, the use of extensive mediastinal dissection was used successfully in place of neoesophagus creation with durable, long-term outcomes. Extended mediastinal dissection may mitigate the risks associated with a Collis gastroplasty in patients requiring additional intraabdominal esophagus.

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