Laparoscopic Paraesophageal Hernia Repair

Laparoscopic revisional antireflux and hiatal hernia surgery results in a higher rate of complications and severity at 90 days than primary surgery

OBJECTIVE

Data on graded complications and their frequency after laparoscopic revisional antireflux and hiatal hernia surgery compared with primary surgery are lacking. We describe 30- and 90-day morbidity using the Clavien-Dindo classification.

METHODS

A total of 298 patients underwent revision surgery between 2003 and 2020 and were propensity matched to primary surgeries (1:2 ratio) based on age, sex, body mass index, American Society of Anesthesiology classification, Los Angeles grade esophagitis, presence of Barrett's, and indication for surgery. Complications were graded using the Clavien-Dindo classification, with the highest grade of complication reported per patient.

RESULTS

After matching, both groups had a majority of female patients, with a median age of 60 years and a median body mass index of 29.5 kg/m2. Most were healthy, with nonerosive esophagitis and modest levels of Barrett's esophagus. A laparoscopic Nissen fundoplication was most common; however, a partial fundoplication was more common in revisions. Mesh, relaxing incisions, and Collis were more common in revisional surgery. At 30 days, total complications were similar (23.5% [70/298] vs 20.6% [123/596], P = .373) with 1 death in each group. Minor complications (less than Clavien-Dindo 3A) were comparable. Patients undergoing revisional surgery experienced Clavien-Dindo 3B complications (4.7% [14] vs 0.8% [5], P > .001) more frequently, with esophageal obstruction requiring revision and esophageal/gastric leak being most common. Grade Clavien-Dindo 4 A/B complications were comparable in both groups. At 90 days, patients undergoing revisional surgery experienced overall complications (7.1% [21] vs 2.0% [12], P = .003), and Clavien-Dindo 3B complications (1.0% [3] vs 0, P = .037) more frequently, with intra-abdominal abscess washout being the most common Clavien-Dindo 3B complication.

CONCLUSIONS

Revisional surgery results in similar total complications at 30 days, but additional complications can occur out to 90 days.

The effect of frailty and age on outcomes in elective paraesophageal hernia repair

INTRODUCTION

Paraesophageal hernia repair (PEHR) is a safe and effective operation. Previous studies have described risk factors for poor peri-operative outcomes such as emergent operations or advanced patient age, and pre-operative frailty is a known risk factor in other major surgery. The goal of this retrospective cohort study was to determine if markers of frailty were predictive of poor peri-operative outcomes in elective paraesophageal hernia repair.

METHODS

Patients who underwent elective PEHR between 1/2011 and 6/2022 at a single university-based institution were identified. Patient demographics, modified frailty index (mFI), and post-operative outcomes were recorded. A composite peri-operative morbidity outcome indicating the incidence of any of the following: prolonged length of stay (≥ 3 days), increased discharge level of care, and 30-day complications or readmissions was utilized for statistical analysis. Descriptive statistics and logistic regression were used to analyze the data.

RESULTS

Of 547 patients who underwent elective PEHR, the mean age was 66.0 ± 12.3, and 77.1% (n = 422) were female. Median length of stay was 1 [IQR 1, 2]. ASA was 3-4 in 65.8% (n = 360) of patients. The composite outcome occurred in 32.4% (n = 177) of patients. On multivariate analysis, increasing age (OR 1.021, p = 0.02), high frailty (OR 2.02, p < 0.01), ASA 3-4 (OR 1.544, p = 0.05), and redo-PEHR (OR 1.72, p = 0.02) were each independently associated with the incidence of the composite outcome. On a regression of age for the composite outcome, a cutoff point of increased risk is identified at age 72 years old (OR 2.25, p < 0.01).

CONCLUSION

High frailty and age over 72 years old each independently confer double the odds of a composite morbidity outcome that includes prolonged post-operative stay, peri-operative complications, the need for a higher level of care after elective paraesophageal hernia repair, and 30-day readmission. This provides additional information to counsel patients pre-operatively, as well as a potential opportunity for targeted pre-habilitation.

Economic evaluation of robotic and laparoscopic paraesophageal hernia repair

BACKGROUND

Robotic approach in paraesophageal hernia (PEH) repair may improve outcomes over laparoscopic approach, though at additional cost. This study aimed to compare cost-effectiveness of robotic and laparoscopic PEH repair.

METHODS

A decision tree was created analyzing cost-effectiveness of robotic and laparoscopic PEH repair. Costs were obtained from 2021 Medicare data and were accumulated within 60 months after surgery. Effectiveness was measured in quality-adjusted life-years (QALYs). Branch-point probabilities and costs of robotic surgery consumables were obtained from published literature. The primary outcome of interest was incremental cost-effectiveness ratio (ICER). One-way, two-way, and probabilistic sensitivity analyses were performed. A secondary analysis including attributable capital and maintenance costs of robotic surgery was conducted as well.

RESULTS

Laparoscopic repair yielded 3.660 QALYs at $35,843.82. Robotic repair yielded 3.661 QALYs at $36,342.57, with an ICER of $779,488.62/QALY. Robotic repair was favored when rates of open conversion and symptom recurrence were low, or with reduced cost of robotic instruments. A probabilistic sensitivity analysis favored laparoscopic repair in 100% of simulations. When accounting for costs of robotic technology, robotic approach was preferred only in unrealistic clinical scenarios.

CONCLUSIONS

Laparoscopic repair is likely more cost-effective for most institutions, though results were relatively similar. With experienced surgeons who surpass the initial learning curve, robotic surgery may improve outcomes enough to be cost-effective, but only when excluding capital and maintenance fees.

Anatomic location and mechanism of hiatal hernia recurrence: a video-based assessment

INTRODUCTION

Hiatal hernia recurrence following surgical repair is common. We sought to define the most common anatomic location and mechanism for hiatal failure to inform technical strategies to decrease recurrence rates.

METHODS

Retrospective chart review and video analysis were performed for all recurrent hiatal hernia operations performed by a single surgeon between January 2013 and April 2020. Hiatal recurrences were defined by anatomic quadrants. Recurrences on both left and right on either the anterior or posterior portion of the hiatus were simply classified as 'anterior' or 'posterior', respectively. Three or more quadrants were defined as circumferential. Mechanism of recurrence was defined as disruption of the previous repair or dilation of the hiatus.

RESULTS

There were 130 patients to meet criteria. Median time to reoperation from previous hiatal repair was 60 months (IQR19.5-132). First-time recurrent repairs accounted for 74%, second time 18%, and three or more previous repairs for 8% of analyzed procedures. Mesh had been placed at the hiatus in a previous operation in 16%. All reoperative cases were completed laparoscopically. Video analysis revealed anterior recurrences were most common (67%), followed by circumferential (29%). There were two with left-anterior recurrence (1.5%), two posterior recurrence (1.5%), and one right-sided recurrence. The mechanism of recurrence was dilation in 74% and disruption in 26%. Disruption as a mechanism was most common in circumferential hiatal failures. Neither the prior number of hiatal surgeries nor the presence of mesh at the time of reoperation correlated with anatomic recurrence location or mechanism. Reoperations in patients with hiatal disruption occurred after a shorter interval when compared to hiatal dilation.

CONCLUSION

The most common location and mechanism for hiatal hernia recurrence is anterior dilation of the hiatus. Outcomes following techniques designed to reinforce the anterior hiatus and perhaps to prevent hiatal dilation should be explored.