Skip to main content

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

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.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3

References

  1. Collet D, Luc G, Chiche L (2013) Management of large para-esophageal hiatal hernias. J Visc Surg 150(6):395–402

    CAS  Article  PubMed  Google Scholar 

  2. Skinner DB, Belsey RH (1967) Surgical management of esophageal reflux and hiatus hernia. Long-term results with 1,030 patients. J Thorac Cardiovasc Surg 53(1):33–54

    CAS  PubMed  Google Scholar 

  3. DE Maziak, Todd TR, Pearson FG (1998) Massive hiatus hernia: evaluation and surgical management. J Thorac Cardiovasc Surg 115(1):53–60 (discussion 61-2)

    CAS  Article  PubMed  Google Scholar 

  4. Stylopoulos N, Gazelle GS, Rattner DW (2002) Paraesophageal hernias: operation or observation? Ann Surg 236(4):492–500 (Discussion 500-1)

    Article  PubMed  PubMed Central  Google Scholar 

  5. Patti MG, Fisichella PM (2009) Laparoscopic paraesophageal hernia repair. How I do it. J Gastrointest Surg 13(9):1728–1732

    Article  PubMed  Google Scholar 

  6. Nguyen NT, Christie C, Masoomi H, Matin T, Laugenour K, Hohmann S (2011) Utilization and outcomes of laparoscopic versus open paraesophageal hernia repair. Am Surg 77(10):1353–1357

    PubMed  Google Scholar 

  7. Karmali S, McFadden S, Mitchell P, Graham A, Debru E, Gelfand G, Graham J, Martin S, Tiruta C, Grondin S (2008) Primary laparoscopic and open repair of paraesophageal hernias: a comparison of short-term outcomes. Dis Esophagus 21(1):63–68

    CAS  Article  PubMed  Google Scholar 

  8. Hashemi M, Peters JH, DeMeester TR, Huprich JE, Quek M, Hagen JA, Crookes PF, Theisen J, DeMeester SR, Sillin LF, Bremner CG (2000) Laparoscopic repair of large type III hiatal hernia: objective followup reveals high recurrence rate. J Am Coll Surg 190(5):553–560 (discussion 560-1)

    CAS  Article  PubMed  Google Scholar 

  9. Dallemagne B, Kohnen L, Perretta S, Weerts J, Markiewicz S, Jehaes C (2011) Laparoscopic repair of paraesophageal hernia. Long-term follow-up reveals good clinical outcome despite high radiological recurrence rate. Ann Surg 253(2):291–296

    Article  PubMed  Google Scholar 

  10. Oelschlager BK, Pellegrini CA, Hunter J, Soper N, Brunt M, Sheppard B, Jobe B, Polissar N, Mitsumori L, Nelson J, Swanstrom L (2006) Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial. Ann Surg 244(4):481–490

    PubMed  PubMed Central  Google Scholar 

  11. Oelschlager BK, Pellegrini CA, Hunter JG, Brunt ML, Soper NJ, Sheppard BC, Polissar NL, Neradilek MB, Mitsumori LM, Rohrmann CA, Swanstrom LL (2011) Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair: long-term follow-up from a multicenter, prospective, randomized trial. J Am Coll Surg 213(4):461–468

    Article  PubMed  Google Scholar 

  12. Terry ML, Vernon A, Hunter JG (2004) Stapled-wedge Collis gastroplasty for the shortened esophagus. Am J Surg 188(2):195–199

    Article  PubMed  Google Scholar 

  13. Ponsky JL, Gauderer MW (1981) Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gastrointest Endosc 27(1):9–11

    CAS  Article  PubMed  Google Scholar 

  14. Hinder RA, Klingler PJ, Perdikis G, Smith SL (1997) Management of the failed antireflux operation. Surg Clin N Am 77(5):1083–1098

    CAS  Article  PubMed  Google Scholar 

  15. Ponsky J, Rosen M, Fanning A, Malm J (2003) Anterior gastropexy may reduce the recurrence rate after laparoscopic paraesophageal hernia repair. Surg Endosc 17(7):1036–1041

    CAS  Article  PubMed  Google Scholar 

  16. Frantzides CT, Madan AK, Carlson MA, Stavropoulos GP (2002) A prospective, randomized trial of laparoscopic polytetrafluoroethylene (PTFE) patch repair vs simple cruroplasty for large hiatal hernia. Arch Surg 137(6):649–652

    Article  PubMed  Google Scholar 

  17. Granderath FA, Schweiger UM, Kamolz T, Asche KU, Pointner R (2005) Laparoscopic Nissen fundoplication with prosthetic hiatal closure reduces postoperative intrathoracic wrap herniation: preliminary results of a prospective randomized functional and clinical study. Arch Surg 140(1):40–48

    Article  PubMed  Google Scholar 

  18. Stadlhuber RJ, Sherif AE, Mittal SK, Fitzgibbons RJ Jr, Michael Brunt L, Hunter JG, Demeester TR, Swanstrom LL, Daniel Smith C, Filipi CJ (2009) Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series. Surg Endosc 23(6):1219–1226

    Article  PubMed  Google Scholar 

  19. Alicuben ET, Worrell SG, DeMeester SR (2014) Impact of crural relaxing incisions, Collis gastroplasty, and non-cross-linked human dermal mesh crural reinforcement on early hiatal hernia recurrence rates. J Am Coll Surg 219(5):988–992

    Article  PubMed  Google Scholar 

  20. Wouters MW, Wijnhoven BP, Karim-Kos HE, Blaauwgeers HG, Stassen LP, Steup WH, Tilanus HW, Tollenaar RA (2008) High-volume versus low-volume for esophageal resections for cancer: the essential role of case-mix adjustments based on clinical data. Ann Surg Oncol 15(1):80–87

    Article  PubMed  Google Scholar 

  21. Köckerling F, Bittner R, Kraft B, Hukauf M, Kuthe A, Schug-Pass C (2017) Does surgeon volume matter in the outcome of endoscopic inguinal hernia repair? Surg Endosc 31(2):573–585

    Article  PubMed  Google Scholar 

  22. Aquina CT, Probst CP, Kelly KN, Iannuzzi JC, Noyes K, Fleming FJ, Monson JR (2015) The pitfalls of inguinal herniorrhaphy: surgeon volume matters. Surgery 158(3):736–746

    Article  PubMed  Google Scholar 

  23. Aquina CT, Kelly KN, Probst CP, Iannuzzi JC, Noyes K, Langstein HN, Monson JR, Fleming FJ (2015) Surgeon volume plays a significant role in outcomes and cost following open incisional hernia repair. J Gastrointest Surg 19(1):100–110 (discussion 110)

    Article  PubMed  Google Scholar 

  24. Pfluke JM, Parker M, Bowers SP, Asbun HJ, Daniel Smith C (2012) Use of mesh for hiatal hernia repair: a survey of SAGES members. Surg Endosc 26(7):1843–1848

    Article  PubMed  Google Scholar 

  25. Perdikis G, Hinder RA, Filipi CJ, Walenz T, McBride PJ, Smith SL, Katada N, Klingler PJ (1997) Laparoscopic paraesophageal hernia repair. Arch Surg 132(6):586–589

    CAS  Article  PubMed  Google Scholar 

  26. Wu JS, Dunnegan DL, Soper NJ (1999) Clinical and radiologic assessment of laparoscopic paraesophageal hernia repair. Surg Endosc 13(5):497–502 (discussion 590-1)

    CAS  Article  PubMed  Google Scholar 

  27. Khaitan L, Houston H, Sharp K, Holzman M, Richards W (2002) Laparoscopic paraesophageal hernia repair has an acceptable recurrence rate. Am Surg 68(6):546–551 (discussion 551-2)

    PubMed  Google Scholar 

  28. Jobe BA, Aye RW, Deveney CW, Domreis JS, Hill LD (2002) Laparoscopic management of giant type III hiatal hernia and short esophagus. Objective follow-up at 3 years. J Gastrointest Surg 6(2):181–188 (discussion 188)

    Article  PubMed  Google Scholar 

  29. Mattar SG, Bowers SP, Galloway KD, Hunter JG, Smith CD (2002) Long-term outcome of laparoscopic repair of paraesophageal hernia. Surg Endosc 16(5):745–749 (Epub 2002 Feb 8)

    CAS  Article  PubMed  Google Scholar 

  30. Diaz S, Brunt LM, Klingensmith ME, Frisella PM, Soper NJ (2003) Laparoscopic paraesophageal hernia repair, a challenging operation: medium-term outcome of 116 patients. J Gastrointest Surg 7(1):59–66 (discussion 66-7)

    Article  PubMed  Google Scholar 

  31. Lubezky N, Sagie B, Keidar A, Szold A (2007) Prosthetic mesh repair of large and recurrent diaphragmatic hernias. Surg Endosc 21(5):737–741 Epub 2007 Feb 16

    Article  PubMed  Google Scholar 

  32. Nason KS, Luketich JD, Qureshi I, Keeley S, Trainor S, Awais O, Shende M, Landreneau RJ, Jobe BA, Pennathur A (2008) Laparoscopic repair of giant paraesophageal hernia results in long-term patient satisfaction and a durable repair. J Gastrointest Surg 12(12):2066–2075 (discussion 2075-7)

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

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

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Steven P. Bowers.

Ethics declarations

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.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

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

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

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

Keywords

  • Paraesophageal hernia repair
  • Laparoscopy
  • Recurrence
  • Outcomes