Abstract
Introduction
Giant paraesophageal hernias (PEH) involve herniation ofstomach and/or other viscera into the mediastinum. These are usually symptomatic and commonly occur in the elderly. The benefits and risks of operating on elderly patients with giant PEH have not been clearly elucidated.
Materials and Methods
We performed a retrospective chart review of consecutive patients aged 70 or greater with giant PEHs undergoing repair.Quality of life data were gathered using QOLRAD, GERD-HRQL and adysphagia severity score.
Results
Fifty-eight patients (34 females), median 78 years old, presented for repair. Nine patients presented urgently. There was no 30-day mortality. Major morbidity was 15.5%. At mean follow-up of 1.3 years, 81% were symptom free compared to baseline (p < 0.0001). Both short-term (p < 0.001) and long term QOLRAD (p < 0.001) scores improved significantly, as did GERD HRQL scores (p < 0.001). Dysphagia scores worsened in the short term but returned to baseline at long term follow up.
Conclusions
Symptomatic giant PEH in this elderly population can be repaired with symptomatic improvement, minimal morbidity and mortality in both the elective and urgent setting. The decision to operate should be made by a physician experienced in managing this complex patient population.
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Discussant
Dr. Piero Marco Fisichella (Maywood, IL): You show that with an operation of this high-risk group of patients that can be treated, can achieve good results in terms of quality of life.
However, based on your results, one may think that the operation is still safe. Still, you had a 10% recurrence rate and two perforations. Moreover, the overall complication rate was 24% if you combine minor and major complications. That means that more or less one patient out of four will have some sort of complication.
I have three questions.
First, I am interested in the surgical technique. Based on your experience, what are the technical elements that can allow you to achieve good results?
You briefly mention in the paper the dissection of the sac, the posterior mediastinal dissection. You also mentioned lengthening procedures. Although, you did not use any lengthening procedures, in the discussion, you say that you used these selectively. In addition, you also said that you used three different techniques.
In summary, could you tell us what is the right approach that you would use for these patients?
Second. When did recurrence occur? Is there a specific time that you saw the recurrence coming? Basically, is there a threshold in the follow-up beyond which patients may be safe from recurrence?
Third. Do you know if mesh plays a role in the recurrence or not?
Last question. You had roughly 25 to 35 patients with short-term quality of life data, results before and after surgery. And you have 68% of patients with long-term results. Do you have any idea what is the complication rate in these patients?
Closing discussant
Dr. Brian E. Louie: To address your first question around our technique or what we think is important, I think we are like most laparoscopic surgeons, we prefer entire sac reduction. We believe bringing the sac down is important and detaching it circumferentially around the esophageal hiatus. We spend a considerable amount of time in the operation, probably two thirds of the time mobilizing the intrathoracic esophagus. And our general goal has been to reestablish at least 2 to 3 cm of intra-abdominal esophagus once we’re satisfied about tension.
And if that means taking the dissection up above the inferior pulmonary veins, that generally means doing so. So we spend an inordinate amount of time doing that. And I think that esophageal mobilization is probably the key to the whole operation. And I think, regardless of which anti-reflux procedure you add on to mobilization of the esophagus, at least in our series, it doesn’t seem to make much difference whether we used a Nissen, a Hill, or a hybrid procedure; I think mobilization is key.
To answer your third question about the complications and the quality of life and recurrences, the recurrences for us, when we follow these patients, they are generally studied at 6 months and 12 months with the barium swallow and/or other tests, so the recurrences generally occur between that 6‑ and 12‑month interval. We have seen a couple out later than that, but I don’t have a definite time frame for that.
In terms of quality of life for that group, we didn’t pull that specifically out for the paper, but the patients that did have the perforations or did get readmission, their general quality of life in this group is generally very good and very similar to the elective group.
And then your other question was recurrence of mesh. So early in the series, we used no mesh until the report by Dr. Oeschlager and colleagues saying that mesh reduced the hernia rate, then we began to use mesh much more liberally. I’m not sure.
We looked at the data one way and said, you know, we probably should be using mesh because of the six recurrences, three didn’t have mesh. But the other way to look at it is 60% of our patients didn’t have mesh and we still had the same recurrence rates. And I know Dr. Luketich’s group said the need for mesh is not as great as everybody thinks it is. I think that is very controversial. For now, I think we are going to continue to use mesh.
Discussant
Dr. Nathaniel Soper (Chicago, IL): This is something that we all struggle with. What do you do with the old patient who has a paraesophageal hernia, because there is a significant morbidity and mortality?
First of all, you state all of these patients had symptoms, so you do not operate on asymptomatic patients who have paraesophageal hernias; is that correct?
Dr. Brian E. Louie: That would not be quite correct because I would think we have operated on them. They might not have been over 70, but in this group they were all symptomatic that were—in the consecutive series, that they all happened to have symptoms.
Discussant
Dr. Nathaniel Soper (Chicago, IL): You said you did not include the emergency operations that were done for strangulation. Just to give us a perspective, in this same period of time, how many of those were there in your medical center?
Closing Discussant
Dr. Brian E. Louie: In the medical center, we had about a dozen over the five-year period that the two senior surgeons have counted that came in for strangulation and went to the operating room the same night for endoscopic findings of strangulation, so 12.
Discussant
Dr. Nathaniel Soper (Chicago, IL): And so it’s so hard to know what the denominator is total in any of this series.
Last but not least, you had a 10% recurrence rate, but your mean follow-up was only about 1.3 years. Do you routinely perform anatomical tests to really assess what your true recurrence rate is, or were these symptomatic patients who happened to get studied?
Closing discussant
Dr. Brian E. Louie: Our follow-up protocol is generally to get a barium swallow at about a year. And then if the patients are willing, we will undergo full foregut evaluation with endoscopy, pH analysis, and manometry. We did not include that in this series because we have not gotten some of the patients out that far yet. But if we follow them long enough, I think we’ll continue to have objective data on recurrences down the road.
But it is our protocol generally to get some imaging study, whether it’s upper GI esophagogram or an endoscopy.
Presented at Digestive Disease Week and SSAT, New Orleans, LA May 3, 2010
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Louie, B.E., Blitz, M., Farivar, A.S. et al. Repair of Symptomatic Giant Paraesophageal Hernias in Elderly (>70 Years) Patients Results in Improved Quality of Life. J Gastrointest Surg 15, 389–396 (2011). https://doi.org/10.1007/s11605-010-1324-6
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DOI: https://doi.org/10.1007/s11605-010-1324-6