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How high is too high? Extensive mediastinal dissection in patients with hiatal hernia repair

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Abstract

Background

Approximately 10% of patients receiving anti-reflux procedures present with shortened esophagus. Collis gastroplasty (CG) is the current gold standard for esophageal lengthening, but mediastinal esophageal mobilization without gastroplasty may be an alternative approach. This study assesses preoperative and intraoperative hernia characteristics and mediastinal dissection impact in patients with large hiatal hernia repair (HHR).

Methods

A single-institution, prospectively collected database was reviewed for adults who underwent laparoscopic HHR with mesh and anti-reflux surgery between 2005 and 2016, hernia ≥ 5 cm. Preoperative hernia and follow-up were assessed using upper endoscopy and barium swallow. Intraoperative hernia characteristics were collected from the operative note. Esophageal symptom scores were collected pre- and postoperatively. Analyses were conducted using SPSS v26.0.

Results

Among 662 patients who had anti-reflux surgery in this period, a total of 205 patients who underwent HHR with mesh met the inclusion criteria and were included in study. Mean age was 61.7 ± 13.6 years, and majority of patients were female and Caucasian. Mean BMI was 29.9 ± 6.0 kg/m2. Median hernia size was 6.5 cm [5.0–12.0 cm], and intra-thoracic stomach had a prevalence of 21.9%. Analysis of preoperative barium swallow revealed an average of elevated gastroesophageal junction above the diaphragm of 4.10 ± 1.67 cm. Radiographically, average hernia size was 6.34 ± 1.93 cm and 6.38 ± 1.92 cm in the anterior–posterior and obliquus view, respectively. Median follow-up time was 2.7 years [1–9 years]. Esophageal symptoms improved in all patients (p < 0.05). 45% of patients had radiographic recurrence, but only four presented symptomatic or were on PPI.

Conclusions

CG has been the standard for ensuring adequate esophageal length prior to anti-reflux surgery. Our results support that CG is unnecessary in the majority of cases, and extensive mediastinal dissection was successfully used instead of CG with durable, long-term outcomes. Extended mediastinal dissection may mitigate CG risks in patients requiring additional intra-abdominal esophagus.

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Funding

Funding for this study was provided by the Center for Advanced Surgical Technology at the University of Nebraska Medical Center.

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Authors and Affiliations

  1. Center for Advanced Surgical Technology, 986246 Nebraska Medical Center, University of Nebraska Medical Center, Omaha, NE, 68198-6246, USA

    Laura E. Flores, Priscila R. Armijo, Dietric Hennings, Crystal Krause & Dmitry Oleynikov

  2. College of Medicine, 98 Nebraska Medical Center, University of Nebraska Medical Center, Omaha, NE, 68198, USA

    Laura E. Flores, Tailong Xu & Michael Otten

  3. Department of Surgery, 986245 Nebraska Medical Center, University of Nebraska Medical Center, Omaha, NE, 68198-6245, USA

    Priscila R. Armijo, Dietric Hennings & Dmitry Oleynikov

Authors
  1. Laura E. Flores
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  2. Priscila R. Armijo
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  3. Tailong Xu
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  4. Michael Otten
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  5. Dietric Hennings
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  6. Crystal Krause
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  7. Dmitry Oleynikov
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Corresponding author

Correspondence to Priscila R. Armijo.

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Disclosures

The address for Dr. Dmitry Oleynikov and Dr. Dietric Hennings reflects their address at the time the study was performed. Dr. Dmitry Oleynikov declares to be stock holder at Virtual Incision Corporation. Laura Flores, Dr. Priscila Rodrigues Armijo, Tailong Xu, Michael Otten, Dr. Dietric Hennings, and Dr. Crystal Krause have no conflicts of interest or financial ties to disclose.

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Flores, L.E., Armijo, P.R., Xu, T. et al. How high is too high? Extensive mediastinal dissection in patients with hiatal hernia repair. Surg Endosc 35, 2332–2338 (2021). https://doi.org/10.1007/s00464-020-07647-9

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  • DOI: https://doi.org/10.1007/s00464-020-07647-9

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