FUNDOPEXY, AN ALTERNATIVE TO TOUPET FUNDOPLICATION IN SELECTED PATIENTS, WITH HIGHER SYMPTOMATIC RELIEF AND LOWER RATE OF REOPERATION FOR SYMPTOMATIC RECURRENT HIATAL HERNIA
Clarissa Hoffman*3, Megan Mai2, Mary Dyson3, Andre Miller4, Farzaneh Banki1
1Cardiothoracic and Vascular Surgery, University of Texas Health Science Center, Memorial Hermann Southeast Esophageal Disease Center, Houston, TX; 2Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; 3The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, TX; 4Memorial Hermann Southeast Hospital, Houston, TX
Introduction Laparoscopic hiatal hernia repair with Toupet fundoplication results in good outcomes. Prevention of recurrent hiatal hernia remains a challenge. Toupet fundoplication was replaced by fundopexy in selected patients with the aim to minimize recurrent hiatal hernia. Methods A retrospective review of hiatal hernia repairs with Toupet fundoplication vs. fundopexy was conducted. Outcomes were assessed by phone questionnaire and rate of reoperation for symptomatic recurrent hiatal hernia. Tension-free intra-abdominal esophageal length and crural closure were obtained in all. Toupet was replaced with fundopexy in patients Age ? 60/hiatal hernia type III/IV/esophageal dysmotility/chief complaint of dysphagia. Fundopexy was performed by placing interrupted stitches below the gastroesophageal junction, at the level of divided short gastric vessels, between the entire fundus and the left upper-lateral abdominal wall, with the aim to maintain maximum intra-abdominal esophageal length and prevent recurrence. Values are median (IQR). Results Out of 256 primary repairs, Toupet was performed in 133/256 (52.0%) and Fundopexy in 123/256 (48.0%). There was no difference in sex/BMI. Toupet vs. Fundopexy, Age: 63 (54-69) vs. 69 (58-76), p<0.001, ASA: III (II-III) vs. III (III-III), p=0.001, hernia type: III (I-IV) vs. III (III-IV), p=0.001. Hernia size: 5(4-8) vs. 6 (4-8), p=0.441. Operative time: 104 min (91-121) vs. 109 min (91-128), p=0.199. LOS: 0 (0-1) vs. 0 (0-2), p=0.117. Post-op dysphagia requiring dilation: 22/133 (16.5%) vs. 17/123 (13.8%), p=0.545. At 34.8 months (27.6-40.2) vs.11.6 months (6.0-15.4), p<0.001, reoperation for symptomatic recurrent hiatal hernia: 15/133 (11.3%) vs. 0/123 (0%), p<0.001. Duration to reoperation: 17.8 months (12.2-24.3). A phone questionnaire was obtained at 26.6 months (16.9-32.3) vs.10.4 months (5.1-13.5), p<0.001, in 102/133 (76.7%) vs. 102/123 (82.9%) patients, p=0.215. Patients free of preoperative symptoms, 69/102 (67.6%) vs. 88/102 (86.3%), p=0.002. Free of heartburn: 80/102 (78.4%) vs. 92/102 (90.2%), p=0.021. Free of regurgitation: 78/102 (76.5%) vs. 94/102 (92.2%), p=0.002. Free of dysphagia: 78/102 (76.5%) vs. 91/102 (89.2%), p=0.016. Free of bloating: 86/102 (84.3%) vs. 95/102 (93.1%), p=0.046. Off PPI: 76/102 (74.5%) vs. 92/102 (90.2%), p=0.003. Satisfied with operation: 79/102 (77.5%) vs. 95/102 (93.1%), p=0.002.
Conclusion: Fundopexy is an alternative to Toupet fundoplication in selected patients, with a better symptomatic outcome, higher patient satisfaction, less use of PPI, and less need for reoperation for recurrent hiatal hernia in short-term. Better short-term outcomes can be achieved with fundopexy in older patients with higher ASA and with more complex hernias. Longer follow-up and larger population with objective diagnostic studies are needed to confirm long-term advantages of fundopexy.
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