LAPAROSCOPIC GASTROPEXY FOR LARGE PARAESOPHAGEAL HERNIA IN THE ELDERLY
Andrew D. Newton*, Julie Clanahan, David A. Herbst, Daniel T. Dempsey
Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
Introduction: The optimal technique for laparoscopic repair of large (>50% stomach above the diaphragm) symptomatic paraesophageal hernia (PEH) is unknown. Most of these patients are elderly and have mechanical symptoms (postprandial pain, dysphagia, shortness of breath, anemia, etc.) rather than severe gastroesophageal reflux. For the past several years we have performed laparoscopic gastropexy (LG) alone (no hernia sac removal, crural repair or fundoplication) in older patients with large PEH and predominately non-reflux mechanical symptoms. The purpose of this study was to examine patient outcomes and patient satisfaction with this approach.
Methods: We retrospectively reviewed all LGs performed by a single surgeon from August 2011-March 2018. Postoperative morbidity and postoperative upper gastrointestinal (UGI) radiograph findings were analyzed. Subjective patient outcomes and satisfaction were assessed by phone survey. The association of patient symptoms and satisfaction with residual hernia size and GE reflux on postop UGI was assessed by logistic regression.
Results: Laparoscopic gastropexy was performed in 117 patients (81.8% female, median age 71.5, IQR 64.0-78.8 years). Median preoperative percentage intrathoracic stomach was 90% (IQR 66-90%). Median postop LOS was 1 day (IQR 1-3 days). There was one postop 90-day mortality (0.8%) and two serious morbidities (pneumonia requiring mechanical ventilation and gastric perforation requiring reoperation). Among 77 survey respondents (median follow-up 22 months, IQR 8-38 months), 86%, 92%, 96%, 97%, and 90% were never or rarely bothered by heartburn, regurgitation, chest pain, abdominal pain, and dysphagia, respectively, and 91% were satisfied or very satisfied with their results. Of these patients, 77% were on daily acid suppression (proton pump inhibitor or H2 antagonist), and 27/31 (87%) with preoperative shortness of breath felt significantly improved. Postoperative UGI demonstrated residual hiatal hernia containing >10% of the stomach in 49% of the patients, and gastroesophageal reflux in 62% of the patients. Neither of these radiologic findings was associated with postoperative heartburn, regurgitation, chest pain, dysphagia, PPI use, or overall satisfaction.
Conclusions: Laparoscopic gastropexy alone for large PEH has low morbidity and high patient satisfaction. LG alone should be considered the procedure of choice in older patients with mechanical symptoms from large PEH. Postoperative upper GI findings do not correlate with postoperative clinical outcomes or patient satisfaction.
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