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Laparoscopic repair of giant paraesophageal hernia: are there factors associated with anatomic recurrence?

Surgical Endoscopy volume 32, pages 945–954 (2018)Cite this article

Abstract

Background

Repair of giant paraesophageal hernia (PEH) is associated with a favorably high rate of symptom improvement; however, rates of recurrence by objective measures remain high. Herein we analyze our experience with laparoscopic giant PEH repair to determine what factors if any can predict anatomic recurrence.

Methods

We prospectively collected data on PEH characteristics, variations in operative techniques, and surgeon factors for 595 patients undergoing laparoscopic PEH repair from 2008 to 2015. Upper GI study was performed at 6 months postoperatively and selectively thereafter—any supra-diaphragmatic stomach was considered hiatal hernia recurrence. Exclusion criteria included revisional operation (22.4%), size <5 cm (17.6%), inadequate follow-up (17.8%), and confounding concurrent operations (6.9%). Inclusion criteria were met by 202 patients (31% male, median age 71 years, and median BMI 28.7).

Results

At a median follow-up of 6 months (IQR 6–12), overall anatomic recurrence rate was 34.2%. Symptom recurrence rate was 9.9% and revisional operation was required in ten patients (4.9%). Neither patient demographics nor PEH characteristics (size, presence of Cameron erosions, esophagitis, or Barrett’s) correlated with anatomic recurrence. Technical factors at operation (mobilized intra-abdominal length of esophagus, Collis gastroplasty, number of anterior/posterior stitches, use of crural buttress, use of pledgeted or mattress sutures, or gastrostomy) were also not correlated with recurrence. Regarding surgeon factors, annual volume of fewer than ten cases per year was associated with increased risk of anatomic failure (54 vs 33%, P = 0.02). Multivariate analysis identified surgeon experience (<10 cases per year) as an independent factor associated with early hiatal hernia recurrence (OR 3.7, 95% CI 1.34–10.9).

Conclusions

Laparoscopic repair of giant PEH is associated with high anatomic recurrence rate but excellent symptom control. PEH characteristics and technical operative variables do not appear to significantly affect rates of recurrence. In contrast, surgeon volume does appear to contribute significantly to durability of repair.

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Acknowledgements

The authors thank Mauricia Buchanan, RN for assistance with database management.

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Authors and Affiliations

  1. Department of Surgery, Mayo Clinic in Florida, Davis 3 North, 4500 San Pablo Road, Jacksonville, FL, 32224, USA

    Michael Antiporda, Chloe Jackson, Pujan Kandel & Steven P. Bowers

  2. Department of Surgery, Rush University Medical Center, Chicago, IL, USA

    Benjamin Veenstra

  3. Piedmont Hospital, Atlanta, GA, USA

    C. Daniel Smith

Authors
  1. Michael Antiporda
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  2. Benjamin Veenstra
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  5. C. Daniel Smith
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Correspondence to Steven P. Bowers.

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Disclosures

Dr. Smith is a member of the advisory committee for Torax Medical and ValenTx. Drs. Antiporda, Veenstra, Kandel, Bowers, and Ms. Jackson have no conflicts of interest or financial ties to disclose.

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Antiporda, M., Veenstra, B., Jackson, C. et al. Laparoscopic repair of giant paraesophageal hernia: are there factors associated with anatomic recurrence?. Surg Endosc 32, 945–954 (2018). https://doi.org/10.1007/s00464-017-5770-z

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  • DOI: https://doi.org/10.1007/s00464-017-5770-z

Keywords

  • Paraesophageal hernia repair
  • Laparoscopy
  • Recurrence
  • Outcomes