Minimally invasive management of paraesophageal herniation in the high-risk surgical patient

Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper

BACKGROUND

Diaphragmatic hernia (DH) presenting acutely can be a potentially life-threatening condition. Its management continues to be debatable.

METHODS

A bibliographic search using major databases was performed using the terms "emergency surgery" "diaphragmatic hernia," "traumatic diaphragmatic rupture" and "congenital diaphragmatic hernia." GRADE methodology was used to evaluate the evidence and give recommendations.

RESULTS

CT scan of the chest and abdomen is the diagnostic gold standard to evaluate complicated DH. Appropriate preoperative assessment and prompt surgical intervention are important for a clinical success. Complicated DH repair is best performed via the use of biological and bioabsorbable meshes which have proven to reduce recurrence. The laparoscopic approach is the preferred technique in hemodynamically stable patients without significant comorbidities because it facilitates early diagnosis of small diaphragmatic injuries from traumatic wounds in the thoraco-abdominal area and reduces postoperative complications. Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable. Damage Control Surgery is an option in the management of critical and unstable patients.

CONCLUSIONS

Complicated diaphragmatic hernia is a rare life-threatening condition. CT scan of the chest and abdomen is the gold standard for diagnosing the diaphragmatic hernia. Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias. Open repair is considered necessary in majority of unstable patients in whom Damage Control Surgery can be life-saving.

Gastric Volvulus: Diagnosis and Successful Endoscopic De-rotation Towards Conservative Management in a Patient With Multiple Comorbidities

Gastric volvulus is a condition that is not frequently seen in clinical practice and can present with a myriad of symptoms, meaning it can be challenging to diagnose. We present an 82-year-old female attending the emergency department with epigastric pain and coffee ground vomiting on a background of rectosigmoid cancer and a large, complex hiatus hernia. On investigation there was no drop in haemoglobin. However, the chest X-ray showed air-fluid levels and raised the suspicion of gastric volvulus, particularly given her past medical history. The timely organisation of a computed tomogram (CT) scan allowed for prompt decision-making with involvement of surgical colleagues. The patient proceeded to successful conservative management with upper gastroduodenal endoscopy and a de-rotation technique. This case highlights the importance of considering gastric volvulus as a differential diagnosis in those presenting with epigastric pain and vomiting particularly in patients over 50 with a history of large hiatus hernia. This allows for prompt diagnosis and management and avoidance of major complications like gastric mucosal ischaemia.

Treatment strategy for laparoscopic hiatal hernia repair

INTRODUCTION

According to the anatomy-function-pathology classification, the recurrence rates of A2 and A3 hiatal hernia (HH) after laparoscopic fundoplication are higher than the rate of A1 HH. Therefore, we introduced mesh reinforcement for A2 and A3 cases. In addition, gastropexy was added to A3 cases. We present the strategy for HH repair.

METHODS

In all, 537 patients (mean age 55.4 ± 16.7 years, 219 women) who underwent primary laparoscopic fundoplication for HH from January 1995 to October 2019 were included. They were divided into three groups by A factor (A1:A2:A3 = 296:156:85). Their clinical data were collected in a prospective fashion and retrospectively reviewed.

RESULTS

The median age (years) of the patients in each group was A1:A2:A3 = 46:63:74 years, and age was directly proportional to the size of HH (P < 0.0001). The proportion of females was significantly higher in A3 than in other classes (P < 0.0001). Preoperative reflux esophagitis was severe in A2 (P < 0.0001) and operation time (min) was directly proportional to HH size (A1:A2:A3 = 135:167:193, P < 0.0001). The recurrence rate of conventional laparoscopic fundoplication was 15% (46/304), and it was higher for A2 and A3 than for A1 (P = 0.027). However, with reinforcement of the hiatus using a mesh and gastropexy, the recurrence rates decreased.

CONCLUSION

Combining mesh reinforcement and gastropexy may reduce the recurrence rate of para- and mixed-type HH.

Buried bumper syndrome: a case report of an early PEG gastropexy-associated complication in a patient with gastric volvulus

Buried bumper syndrome (BBS) is a rare complication associated with percutaneous endoscopic gastrostomy (PEG) tubes. It develops when the internal bumper migrates through the gastric wall, lodging anywhere along the gastrostomy tract leading to overgrowth of gastric mucosa thereby encasing the tube. BBS can lead to bleeding, perforation, peritonitis and intra-abdominal sepsis. Our case is a 71-year-old female presenting with tenderness, erythema and purulent discharge at the PEG tube site 2-weeks post-insertion. Computer tomography scan demonstrated the PEG had dislodged with the internal bumper in the subcutaneous tissue and the distal tip lying within the tract beyond the stomach wall. The PEG was removed by simple external traction. The patient clinically improved and discharged home on day three.

Although BBS usually occurs late post-PEG insertion, it can also occur acutely. Preventative measures should be adopted at ward-level and emphasized with appropriate PEG tube care information provided to patients to avoid and recognize such complication.

Elective paraesophageal hernia repair in elderly patients: an analysis of ACS-NSQIP database for contemporary morbidity and mortality

BACKGROUND

Elective paraesophageal hernia (PEH) repair in asymptomatic or minimally symptomatic patients ≥ 65 years of age remains controversial. The widely cited Markov Monte Carlo decision analytic model recommends watchful waiting in this group, unless the mortality rate for elective repair was to reach ≤ 0.5%; at which point, surgery would become the optimal treatment. We hypothesized that with advances in minimally invasive surgery, perioperative care, and practice specialization, that mortality threshold has been reached in the contemporary era. However, the safety net would decrease as age increases, particularly in octogenarians.

METHODS

We identified 12,422 patients from the 2015-2017 ACS-NSQIP database, who underwent elective minimally invasive PEH repair, of whom 5476 (44.1%) were with age ≥ 65. Primary outcome was 30-day mortality. Secondary outcomes were length of stay (LOS), operative time, pneumonia, pulmonary embolism, unplanned intubation, sepsis, bleeding requiring transfusion, readmission, and return to OR.

RESULTS

Patients age ≥ 65 had a higher 30-day mortality (0.5% vs 0.2%; p < 0.001). Subset analysis of patients age 65-80 and > 80 showed a 30-day mortality of 0.4% vs. 1.8%, respectively (p < 0.001). Independent predictors of mortality in patients ≥ 65 years were age > 80 (OR 5.23, p < 0.001) and COPD (OR 2.59, p = 0.04). Patients ≥ 65 had a slightly higher incidence of pneumonia (2% vs 1.2%; p < 0.001), unplanned intubation (0.8% vs 0.5%; p < 0.05), pulmonary embolism (0.7% vs 0.3%; p = 0.001), bleeding requiring transfusion (1% vs 0.5%; p < 0.05), and LOS (2.38 vs 1.86 days, p < 0.001) with no difference in sepsis, return to OR or readmission.

CONCLUSION

This is the largest series evaluating elective PEH repair in the recent era. While morbidity and mortality do increase with age, the mortality remains below 0.5% until age 80. Our results support consideration for a paradigm shift in the management of patients < 80 years toward elective repair of PEH.

A Safe and Effective Technique of Paraesophageal Hernia Reduction Using Combined Laparoscopy and Nonsutured PEG Gastropexy in High-Risk Patients

BACKGROUND

Paraesophageal hernias (PHs) can cause significant morbidity and even mortality in untreated patients. While formal surgical repair remains the ideal treatment option, patients who are elderly and/or frail and who have with multiple comorbidities may be unsuitable candidates for a surgical repair. We present a case series of 5 patients treated with a combined laparoscopic reduction of PH and 2-point percutaneous endoscopic gastropexy (PEG).

METHODS

Data on the 5 patients were collated, and a review of the literature was performed to determine similar cases and outcomes.

RESULTS

Five elderly patients (mean age 80 y, range 71-89 y) with significant existing comorbidities (average ASA 3) presented acutely with large PH at our institution. All had abdominal pain, nausea/vomiting, symptoms of gastric outlet obstruction, and an element of hypoxia. Computed tomography examination results confirmed the diagnosis. Because the patients were elderly and frail, a formal surgical repair of the PHs was not feasible. A combined laparoscopy/PEG gastropexy was undertaken to reduce the PH, and a 2-point PEG fixation was performed. Four of the 5 patients returned to normal oral intake before discharge. A fifth patient was successfully fed via the PEG. There were no complications, and all were discharged to their usual place of residence.

CONCLUSION

A combination of laparoscopic reduction and nonsutured PEG gastropexy is a safe and effective alternative treatment for high-risk patients (with significant morbidity and mortality) with symptomatic PHs. Most patients (80%) returned to normal oral intake postprocedure and were discharged home within 3 d.

Who gets a PEG? An analysis of simultaneous PEG placement during elective laparoscopic paraesophageal hernia repair

INTRODUCTION

Percutaneous Endoscopic Gastrostomy (PEG) is an infrequent adjunct in elective paraesophageal hernia repair (PEHR). Guidelines denote that PEG "may facilitate postoperative care in selected patients." Though there is sparse literature defining which patients may benefit. The purpose of this study is to determine factors associated with simultaneous PEG placement during PEHR and their subsequent outcomes.

METHODS

The NSQIP database was queried from 2011 to 2016 for patients undergoing elective laparoscopic PEHR. Cases were excluded if PEHR or fundoplasty was not the primary procedure, a concomitant bariatric procedure was performed, or if the primary surgeon was not a general or cardiothoracic surgeon. Groups were Propensity Score Matched for age, BMI, and ASA Class.

RESULTS

15700 patients were identified, 371 who underwent simultaneous PEG placement (2.4%). Non-PEG patients were matched at a 5:1 ratio, producing 1855 controls. PEG patients had higher rates of pre-operative dyspnea (OR 1.45, p = 0.0110), pre-operative weight loss (OR 2.87, p = 0.0001), and lower pre-operative albumin (3.92 vs. 4.01, p = 0.0129). PEG patients had more intra-operative contamination (mean Wound Classification 1.54 vs. 1.38, p < 0.0001) and longer case durations (170 vs. 148 min, p < 0.0001). PEG patients had longer lengths of stay (3.4 vs. 2.5 days, p = 0.0001), rates of superficial SSI (OR 5.82, p = 0.0012), peri-operative transfusions (OR 2.68, p = 0.0197), and pulmonary emboli (OR 3.61, p = 0.0359).

CONCLUSION

Patients undergoing simultaneous PEG during PEHR are more likely to have respiratory symptoms, markers of malnutrition, and intra-operative factors indicative of more technically challenging cases. These patients have longer hospitalizations, higher rates of superficial SSI, and more pulmonary emboli.

Routine use of mesh during hiatal closure is safe with no increase in adverse sequelae

BACKGROUND

Primary laparoscopic hiatal repair with fundoplication is associated with a high recurrence rate. We wanted to evaluate the potential risks posed by routine use of onlay-mesh during hiatal closure, when compared to primary repair.

METHODS

Utilizing single-institutional database, we identified patients who underwent primary laparoscopic hiatal repair from January 2005 through December 2014. Retrospective chart review was performed to determine perioperative morbidity and mortality. Long-term results were assessed by sending out a questionnaire. Results were tabulated and patients were divided into 2 groups: fundoplication with hiatal closure + absorbable or non-absorbable mesh and fundoplication with hiatal closure alone.

RESULTS

A total of 505 patients underwent primary laparoscopic fundoplication. Mesh reinforcement was used in 270 patients (53.5%). There was no significant difference in the 30-day perioperative outcomes between the 2 groups. No clinically apparent erosions were noted and no mesh required removal. Standard questionnaire was sent to 475 patients; 174 (36.6%) patients responded with a median follow-up of 4.29 years. Once again, no difference was noted between the 2 groups in terms of dysphagia, heartburn, long-term antacid use, or patient satisfaction. Of these, 15 patients (16.9%, 15/89) in the 'Mesh' cohort had symptomatic recurrence as compared to 19 patients (22.4%, 19/85) in the 'No Mesh' cohort (p = 0.362). A reoperation was necessary in 6 patients (6.7%) in the 'Mesh' cohort as compared to 3 patients (3.5%) in the 'No Mesh' cohort (p = 0.543).

CONCLUSIONS

Onlay-mesh use in laparoscopic hiatal repair with fundoplication is safe and has similar short and long-term results as primary repair.

Laparoscopic gastropexy relieves symptoms of obstructed gastric volvulus in highoperative risk patients

BACKGROUND

Operative repair of obstructive gastric volvulus is challenging. In high-operative risk patients with obstructive gastric volvulus, we perform laparoscopic reduction of gastric volvulus and anterior abdominal wall sutured gastropexy. This case series reports our experience with this operation.

METHODS

We reviewed the charts of all patients who presented with obstructive gastric volvulus and underwent laparoscopic gastropexy between 2007 and 2013.

RESULTS

Eleven patients underwent laparoscopic gastropexy. Median age was 83 years (50 to 92). Six patients presented with chronic obstruction; 5 presented with acute obstruction. Median postoperative hospitalization was 2 days (1 to 39). Two patients required reoperation for displaced gastrostomy tubes. At median follow-up of 3 months (2 weeks to 57 months), all patients remained free of gastric obstructive symptoms and recurrent episodes of volvulus. Only 1 patient received nutrition via gastrostomy tube.

CONCLUSIONS

Laparoscopic gastropexy can treat obstructed gastric volvulus in highoperative risk patients. Because of associated morbidity, gastrostomy tubes should be placed selectively.

Laparoscopic paraesophageal hernia repair: advanced age is associated with minor but not major morbidity or mortality

BACKGROUND

Large studies have documented the safety of laparoscopic paraesophageal hernia (PEH) repair in the general population. Even though this condition affects primarily the elderly, data on the short-term outcomes of this procedure on the oldest-old are lacking.

STUDY DESIGN

The NSQIP database was analyzed for all patients undergoing laparoscopic PEH repair in 2010 and 2011. Chi-square, Fisher's exact, and 2-tailed Student's t-test were used to compare baseline characteristics, morbidity, and mortality. Binary logistic regression was used to control for confounding variables. Odds ratios (OR) with 95% confidence intervals (CI) were reported when applicable.

RESULTS

A total of 2,681 patients undergoing laparoscopic PEH repair were identified. The mean (±SD) age of the cohort was 63 ± 14 years. We identified 313 patients (11.7%) aged 80 years and older. Using regression analysis, advanced age (OR 1.7, 95% CI 1.1 to 2.7, p = 0.009), American Society of Anesthesiologists class 3 or 4 (OR 1.4, 95% CI 1.0 to 2.1, p = 0.045), gastrostomy placement (OR 2.4, 95% CI 1.3 to 4.7, p = 0.007), and significant recent weight loss (OR 2.1, 95% CI 1.1 to 4.1, p = 0.037) were independently associated with development of overall morbidity. Mortality (1% vs 0.4%, p = 0.16) and serious morbidity (5.8% vs 3.7%, p = 0.083) were not significantly different between the older and younger groups. Minor morbidity was higher in the older group (8.3% vs 3.5%, OR 2.5, 95% CI 1.6 to 3.9, p < 0.001).

CONCLUSIONS

In an assessment of modern nationwide practice, laparoscopic PEH repair is performed with minimal morbidity and mortality. Elective repair in patients aged 80 years or older is not associated with significant differences in mortality or major morbidity compared with younger patients.

PEG fixation of an upside-down stomach using a flexible endoscope: case report and review of the literature

INTRODUCTION

Upside-down stomach usually is asymptomatic in adults, but sometimes it can cause regurgitation, vomiting, and weight loss. This condition has an incidence increasing with age thus increasing the risk of surgical intervention.

CASE REPORT

A 90-year-old man was admitted with dysphagia, postprandial regurgitation, and an 18 kg weight loss in the past year. Gastroscopy revealed a significantly dilated, cranky esophagus and an upside-down stomach. The diagnosis was confirmed by a barium swallow and computed tomography. The stomach was repositioned with a gastroscope using insufflation and an α-loop maneuver under fluoroscopic guidance. A percutaneous endoscopic gastrostomy tube was then inserted to fix the stomach. The patient was discharged on the first postinterventional day. He gained 6 kg in the next 2 months.

DISCUSSION

High-risk patients with upside-down stomach can be managed by endoscopic repositioning of the stomach and percutaneous endoscopic gastrostomy fixation. This is a useful alternative therapeutic intervention. There have been 14 similar cases being reported in the literature.

Open versus laparoscopic hiatal hernia repair

Laparoscopic repair of paraesophageal hiatal hernia where only a portion of the stomach is in the chest, is associated with a lower mortality rate than open repair.

Background:

The literature reports the efficacy of the laparoscopic approach to paraesophageal hiatal hernia repair. However, its adoption as the preferred surgical approach and the risks associated with paraesophageal hiatal hernia repair have not been reviewed in a large database.

Method:

The Nationwide Inpatient Sample dataset was queried from 1998 to 2005 for patients who underwent repair of a complicated (the entire stomach moves into the chest cavity) versus uncomplicated (only the upper part of the stomach protrudes into the chest) paraesophageal hiatal hernia via the laparoscopic, open abdominal, or open thoracic approach. A multivariate analysis was performed controlling for demographics and comorbidities while looking for independent risk factors for mortality.

Results:

In total, 23,514 patients met the inclusion criteria. By surgical approach, 55% of patients underwent open abdominal, 35% laparoscopic, and 10% open thoracic repairs. Length of stay was significantly reduced for all patients after laparoscopic repair (P < .001). Age ≥60 years and nonwhite ethnicity were associated with significantly higher odds of death. Laparoscopic repair and obesity were associated with lower odds of death in the uncomplicated group.

Conclusion:

Laparoscopic repair of paraesophageal hiatal hernia is associated with a lower mortality in the uncomplicated group. However, older age and Hispanic ethnicity increased the odds of death.

Paraoesophageal herniation: a review

BACKGROUND

Paraoesophageal hiatus herniae repair can represent a formidable challenge. Afflicted patients tend to be elderly with multiple infirmities often with cardio-pulmonary dysfunction. They may present acutely with protracted vomiting and concurrent biochemical imbalances and it is a technically demanding procedure. There are several debated issues regarding operative technique. This paper will attempt to explain the nature of paraoesophageal hiatus herniae and reviews the recommended pre-operative investigations and operative strategies available.

METHODS

A literature search was performed from Pubmed and suitable clinical papers were selected for review. When attempting to address whether meshes should be included routinely, electronic searches were performed in PubMed, Embase and the Cochrane library. A systematic search was done with the following medical subject heading (MeSH) terms: 'paraoesophageal hernia repair' AND 'mesh'. In PubMed and Embase the search was carried out with the limits 'humans', 'English language', 'all adult: 19+ years' and 'published between 1990 and 2010'. A manual cross-reference search of the bibliographies of included papers was carried out to identify additional potentially relevant studies.

RESULTS

Firm conclusions are difficult to draw due to the diverse nature of both the disorder and the presentation however principals of management can be suggested. Similarly, there is no conclusive proof of the most effective operative technique and therefore the options are described.

CONCLUSION

Due to the relative lack of cases encountered at smaller institutions, there is a good argument for centralisation of these cases into regional centres to allow research and facilitate improvements in care.

Inpatient mortality analysis of paraesophageal hernia repair in octogenarians

INTRODUCTION

Paraesophageal hernia repair is often performed in an elderly population. Few studies have evaluated perioperative mortality in this group. We identified predictors of inpatient mortality using a nationally representative sample.

METHODS

Patients >/=80 years old undergoing transabdominal paraesophageal hernia repair were identified in the 2005 Nationwide Inpatient Sample. Congenital diaphragmatic defects and traumatic injuries were excluded.

RESULTS

One thousand five discharges (73% female) with mean age 84.7 met inclusion criteria. Mean length of stay was 10.1 days (95% confidence interval 8.9-11.3) with a mortality of 8.2%. Non-elective repair was performed in 43%. For these patients, mortality and mean length of stay (16%; 14.3 days) were increased compared to elective repair (2.5%; 7.0 days, p < 0.05). Non-elective repair was the sole predictor of inpatient mortality in adjusted analyses (odds ratio 7.1, 95% confidence interval 1.9-26.3, p < 0.05).

CONCLUSION

Non-elective repair was associated with a six to sevenfold increase in mortality and longer length of stay. Earlier elective repair of paraesophageal hernia may reduce mortality.

Laparoscopic hiatal hernia repair with human acellular dermal matrix patch: our initial experience

BACKGROUND

The laparoscopic repair of large hiatal hernia followed by an antireflux procedure is currently the gold standard therapy for gastroesophgeal reflux disease. However, it is recognized that recurrent hiatal herniation and wrap migration are major sources of operative failures in these patients. Some have described a reduction of such events with the placement of nonbiodegradable prosthetic patches over the primary cruroplasty. This prosthetic material may be associated with transesophageal and gastric erosions and a higher rate of postoperative dysphagia and chest pain when compared with simple suture cruroplasty alone. The aim of this study is to compare hiatal closure with a biodegradable patch (acellular dermal matrix) and simple suture curaplasty in patients undergoing laparoscopic antireflux surgery.

METHODS

A total of 44 patients were prospectively enrolled in this study. Twenty-two consecutive patients undergoing large hiatal hernia repair (>5 cm) and fundoplication with primary suture cruroplasty only (group 1) were compared with 22 consecutive patients undergoing the same procedure with suture cruroplasty reinforced with an onlay acellular dermal matrix patch (group 2). The 2 groups were compared with regards to demographics, size of the hiatal hernia, pre- and postoperative symptom scores, pH studies, operative times, and hiatal hernia recurrence.

RESULTS

Patients in both groups were well matched by age, weight, height, and size of hiatal hernia. There were similar preoperative values in esophageal manometry, 24-hour pH monitoring, and symptom scoring in both groups. Average operative time was 108 minutes in group 1 and 121 minutes in group 2. There were no major complications in either group. The median period of hospitalization was 1 day in both groups. Postoperative pH studies and symptoms score data were significantly improved in both groups. There was no significant difference in postoperative symptoms scores for dysphagia between the 2 groups. Two patients (one in each group) underwent esophageal dilatation for mild dysphagia postoperatively. In group 1, 2 patients (9%) had Nissen failure with hiatal hernia recurrences 6 months after surgery. There were no recurrences for the follow-up period in group 2.

CONCLUSIONS

Our early results suggest that hiatal hernia repair reinforced with an acellular dermal matrix patch may reduce the incidence of recurrent herniation and wrap migration. In addition, the increase in postoperative dysphagia, chest pain, and esophageal erosions associated with nondegradable mesh has not been observed in those with an acellular dermal matrix patch to this point in our follow up. However, future investigation of the material for this particular application as well as longer follow-up is necessary.

Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial

OBJECTIVE

Laparoscopic paraesophageal hernia repair (LPEHR) is associated with a high recurrence rate. Repair with synthetic mesh lowers recurrence but can cause dysphagia and visceral erosions. This trial was designed to study the value of a biologic prosthesis, small intestinal submucosa (SIS), in LPEHR.

METHODS

Patients undergoing LPEHR (n = 108) at 4 institutions were randomized to primary repair -1 degrees (n = 57) or primary repair buttressed with SIS (n = 51) using a standardized technique. The primary outcome measure was evidence of recurrent hernia (> or =2 cm) on UGI, read by a study radiologist blinded to the randomization status, 6 months after operation.

RESULTS

At 6 months, 99 (93%) patients completed clinical symptomatic follow-up and 95 (90%) patients had an UGI. The groups had similar clinical presentations (symptom profile, quality of life, type and size of hernia, esophageal length, and BMI). Operative times (SIS 202 minutes vs. 1 degrees 183 minutes, P = 0.15) and perioperative complications did not differ. There were no operations for recurrent hernia nor mesh-related complications. At 6 months, 4 patients (9%) developed a recurrent hernia >2 cm in the SIS group and 12 patients (24%) in the 1 degrees group (P = 0.04). Both groups experienced a significant reduction in all measured symptoms (heartburn, regurgitation, dysphagia, chest pain, early satiety, and postprandial pain) and improved QOL (SF-36) after operation. There was no difference between groups in either pre or postoperative symptom severity. Patients with a recurrent hernia had more chest pain (2.7 vs. 1.0, P = 0.03) and early satiety (2.8 vs. 1.3, P = 0.02) and worse physical functioning (63 vs. 72, P = 0.03 per SF-36).

CONCLUSIONS

Adding a biologic prosthesis during LPEHR reduces the likelihood of recurrence at 6 months, without mesh-related complications or side effects.

Outcomes of laparoscopic paraesophageal hernia repair in elderly and high-risk patients

BACKGROUND

This study examines the impact of age and comorbidities on complications and outcomes of laparoscopic (Lap) paraesophageal hernia (PEH) repair.

METHODS

Data were collected prospectively on all patients who underwent Lap PEH repair from January 1995 through June 2005. Pre- and postoperative variables including complications were analyzed. Patients were stratified by age (Group [Gr.] 1, <65 years; Gr. 2, 65 to 74 years; Gr. 3, >/=75 years) and American Society of Anesthesiology (ASA) class (1 and 2 vs 3 and 4). Statistical analysis was performed using 1-way ANOVA, chi-square, and Fisher exact test.

RESULTS

Overall, 171 patients underwent Lap PEH repair. Mean patient age was 65 +/- 15 years, mean ASA class 2.4 +/- 0.5, gender 72% female, and mean operating time 173 +/- 49 min. Patients in Gr. 3 had a significantly higher ASA class (Gr. 1, 2.3 +/- 0.6; Gr. 2, 2.5 +/- 0.5; Gr. 3, 2.6 +/- 0.5) and longer postoperative length of stay (LOS) compared with Gr. 1 (P < 0.05). Esophageal lengthening was required in 10.4% of patients in Gr. 3 versus 2.6% in Gr. 1 and 2.1% in Gr. 2 (P = 0.079). Total complication rates were 17.1% in Gr. 1, 22.4% in Gr. 2, and 27.7% in Gr. 3 (P = not significant [NS]). Most complications were minor; grade 2 or higher complications occurred in 10.5% of patients in Gr. 1, 8.3% in Gr. 2, and 8.5% in Gr. 3 (P = NS). There was 1 death (Gr. 2) on postoperative day 18 due to a myocardial infarction (mortality rate = 0.6%). Mean follow-up was 25.3 +/- 20.6 months. Postoperative symptoms of heartburn and regurgitation were similar between groups as was antisecretory medication use. Anatomic failure of the repair occurred in 23.7% of patients with adequate follow-up: 26.7% in Gr. 1, 15.4% in Gr. 2, and 27.8% in Gr. 3 (P = NS). Reoperation was performed in 1 of 32 (3.1%) failures.

CONCLUSIONS

Lap PEH repair is safe in elderly and properly selected high-risk patients, although complication rates are higher than in younger patients. Most patients have a good symptomatic outcome irrespective of their age, but the anatomic recurrence rates remain a concern for all age groups.

Laparoscopic repair of paraesophageal hernia

Laparoscopic repair of paraesophageal hernias is rapidly replacing the traditional open approach. Regardless of the approach, certain aspects of repairing paraesophageal hernias have proven to be beneficial and others remain controversial. This article addresses the effectiveness of the laparoscopic approach, the accepted and controversial technical aspects of repair, and which patients should undergo surgical correction of the hernia.

Laparoscopic repair of large paraesophageal hernia is associated with a low incidence of recurrence and reoperation

BACKGROUND

Laparoscopic repair of paraesophageal hernia (LRPEH) is a feasible and effective technique. There have been some recent concerns regarding possible high recurrence rates following laparoscopic repair.

METHODS

We reviewed our experience with LRPEH from 5/1996 to 8/2002. Large paraesophageal hernia (PEH) was defined by the presence of more than one-third of the stomach in the thoracic cavity. Principles of repair included reduction of the hernia, excision of the sac, approximation of the crura, and fundoplication. Pre- and postoperative symptoms were evaluated utilizing visual analogue scores (VAS) on a scale ranging from 0 to 10. Patients were followed with VAS and barium esophagram studies. Statistical analysis was performed using two-tailed Student's t-test.

RESULTS

A total of 166 patients with a mean age of 68 years underwent LRPEH. PEH were type II ( n = 43), type III ( n = 104), and type IV ( n = 19). Mean operative time was 160 min. Fundoplications were Nissen (127), Toupet (23), Dor (1), and Nissen-Collis (1). Fourteen patients underwent a gastropexy. One patient required early reoperation to repair an esophageal leak. Mean hospital stay was 3.9 days. At 24 months postoperatively there was statistically significant improvement in the mean symptom scores: heartburn from 6.8 to 0.5, regurgitation from 5.9 to 0.3, dysphagia from 4.0 to 0.5, chest pain from 3.7 to 0.3. Radiographic surveillance was obtained in 120 patients (72%) at a mean of 15 months postoperatively. Six patients (5%) had radiographic evidence of a recurrent paraesophageal hernia (two required surgery), 24 patients (20%) had a sliding hernia (two required surgery), and four patients (3.3%) had wrap failure (all four required surgery). Reoperation was required in 10 patients (6%); two for symptomatic recurrent PEH (1.2%), four for recurrent reflux symptoms (2.4%), and four for dysphagia (2.4%). Patients with abnormal postoperative barium esophagram studies who did not require reoperation have remained asymptomatic at a mean follow up of 14 months.

CONCLUSION

LPEHR is a safe and effective treatment for PEH. Postoperative radiographic abnormalities, such as a small sliding hernia, are often seen. The clinical importance of these findings is questionable, since only a small percentage of patients require reoperation. True PEH recurrences are uncommon and frequently asymptomatic.

The use of small intestine submucosa in the repair of paraesophageal hernias: initial observations of a new technique

BACKGROUND

Recent reports suggest that when laparoscopy is used to repair paraesophageal hernias recurrence rates reach 20% to 40%. Tension-free hernia closure with synthetic mesh reduces recurrence but occasionally results in esophageal injury. We hypothesized that reinforcement of the hiatal closure with small intestine submucosa (SIS) mesh, in some unusually large hernias, might reduce recurrence rates without causing injury to the esophagus.

METHODS

From January 2001 to March 2002 we treated 18 large paraesophageal hernias via a laparoscopic approach. In 9 of the largest hernias (one type II and 8 type III, of which 1 was recurrent) the repair was reinforced with SIS mesh (Surgisis, Cook Surgical) and represent the subjects of this study. Nissen fundoplication with gastropexy was performed in all patients. Clinical follow-up ranged from 3 to 16 months (median 8). Every patient was evaluated with barium esophagram or endoscopy or both 1 to 8 months (median 2) postoperatively.

RESULTS

The presenting symptoms were postprandial pain/fullness (9 of 9), heartburn (4 of 9), anemia (4 of 9), dysphagia (3 of 9), regurgitation (3 of 9), and chest pain (3 of 9). One patient died of a hemorrhagic stroke within 30 days of the operation. Postoperatively, presenting symptoms resolved (83%) or improved (17%) in each of the remaining 8 patients. One patient required endoscopic dilation for mild dysphagia. Seven of 8 patients had a normal barium esophagram without evidence of hernia. One morbidly obese (body mass index = 47) patient had a small (2 cm) sliding hiatal hernia postoperatively. There were no other complications, and specifically no perforations or mesh erosions.

CONCLUSIONS

These observations suggest that the use of SIS in the repair of paraesophageal hernias is safe and may reduce recurrence. Longer follow-up and a randomized study are needed to validate these results.

Anterior gastropexy may reduce the recurrence rate after laparoscopic paraesophageal hernia repair

BACKGROUND

Although laparoscopic repair of type 3 paraesophageal hernias is safe and results in symptomatic relief, recent data have questioned the anatomic integrity of the laparoscopic approach. The reports document an asymptomatic recurrence rate as high as 42% with radiologic follow-up evaluation for type 3 paraesophageal hernias repaired laparoscopically. This disturbingly high recurrence rate has prompted the addition of an anterior gastropexy to our standard laparoscopic paraesophageal hernia repair.

METHODS

A prospective series of 28 patients underwent laparoscopic repair of large type 3 hiatal hernias between July 2000 and January 2002 at the Cleveland Clinic Foundation by one surgeon. All the patients underwent reduction of the hernia, sac excision, crural repair, antireflux procedure, and anterior gastropexy. They all had a video esophagram 24 h after surgery, then at 3-, 6-, and 12-month follow-up visits and annually thereafter. Symptomatic outcomes were assessed with a standard questionnaire at each follow-up visit.

RESULTS

In this study, 21 women and 7 men with a mean age of 67 years (range, 35-82 years) underwent successful laparoscopic paraesophageal hernia repair. The mean operative time was 146 min (range, 101-186 min), and the average blood loss was 71 ml (range, 10-200 ml). One intraoperative complication occurred: A small esophageal mucosal tear occurred during esophageal dissection and was repaired laparoscopically. At 24 h, upper gastrointestinal examination identified no leaks. At this writing, all the patients have undergone video esophagram at a 3-month follow-up visit. All were asymptomatic and all examinations were normal. Of the 28 patients, 27 have undergone follow-up assessment at 6 months. At this writing, all the patients have undergone video esophagram at 3, 6, and 12 months follow up visits. All were asymptomatic and all examinations were normal. Ten patients have completed 2 year follow up barium swallows with no recurrences.

CONCLUSIONS

With up to 2 years of follow-up evaluation, the addition of an anterior gastropexy to the laparoscopic repair of type 3 hiatal hernias resulted in no recurrences. These encouraging results necessitate further follow-up evaluation to document the long-term effects of anterior gastropexy in reducing postoperative recurrence after laparoscopic repair of paraesophageal hernias.