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Laparoscopic Repair of Giant Paraesophageal Hernia Results in Long-Term Patient Satisfaction and a Durable Repair

  • 2008 ssat plenary presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Laparoscopic repair of giant paraesophageal hernia (LRGPEH) is routinely performed in many centers, but high recurrence rates have led to concerns regarding this approach. We evaluate long-term recurrence rates, symptom improvement and correlation with radiographic recurrence, and risk factors for recurrence in our cohort of patients.

Methods

A cohort of consecutive patients with a minimum of 5 years potential follow-up (1997–2003) post-LRGPEH was identified from a prospective database. Clinical outcomes, barium esophagram (BE), and quality-of-life (QoL) measures were obtained.

Results

Laparoscopic repair was successful in 185/187 patients. Routine clinical follow-up (median 77 months) was available for all patients. Detailed questionnaires and BE were obtained in 65% and 82% of patients. Gastroesophageal Reflux Disease Health-Related QoL (GERD-HRQoL) scores were excellent to good in 86.7%. BE (median 51 months) demonstrated radiographic hernia recurrence in 15% of patients, but without consistent symptom association. There was a trend toward increased risk of radiographic recurrence in patients with a history of pulmonary disease (p = 0.08). Seven reoperations (4.4%) were performed for symptomatic recurrence (median 44 months postoperative).

Conclusions

LRGPEH performed in our minimally invasive center of excellence resulted in a durable repair with a high degree of satisfaction and preservation of GERD-related QoL at a median follow-up of over 6 years.

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Author information

Authors and Affiliations

  1. Division of Thoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA

    Katie S. Nason, James D. Luketich, Irfan Qureshi, Samuel Keeley, Shannon Trainor, Omar Awais, Manisha Shende, Rodney J. Landreneau, Blair A. Jobe & Arjun Pennathur

  2. Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh, Shadyside Medical Building, 5200 Centre Ave., Suite 706, Pittsburgh, PA, 15232, USA

    Katie S. Nason

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  1. Katie S. Nason
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Discussion

Laparoscopic Repair of Giant Paraesophageal Hernia Results in Long-Term Patient Satisfaction and a Durable Repair

Carlos A. Pellegrini, M.D., (Seattle, WA): I think this paper, with its abundant data and long follow-up, provides a benchmark against which to compare anyone’s results. As it becomes widely quoted and a true landmark, I am afraid it may also lead to an unintended consequence and that is, that the average physician will take the conclusions to mean that this is a safe operation, this is an operation that I can do, and this operation leads to a recurrence rate of 15% with a need for reoperation of only 4%. I think these results are achieved by your group in part as a reflection of the large volume of patients you do that in itself a reflection of the dedicated way esophageal surgery is handled in your center. With that in mind, perhaps the most important thing you may want to consider is to provide the ingredients that you think are needed to achieve these results. What is it that you do that you think impacts most in your results? How can you have such a low rate of recurrence and in particular or reoperations?

On the other hand, 15% is still higher than the 8% that we found with Drs. Hunter, Jobe, and others in the prospective randomized multicenter trial that we reported with the use of mesh, and we had it at 24% when we did not use mesh. So my next question is, why not use mesh more frequently since you still have a 15% recurrence rate.

The last two questions that I have are related to the symptoms, and I am surprised that, in the paper, at least, you make very clear emphasis that the presence of a radiographic recurrence did not seem to make any difference in the symptoms. So, patients got better whether they recurred or they did not recur. I think that that is probably right, because the recurrences were relatively small, and, therefore, it is not the same thing as having that floppy sac in the mediastinum. But it makes me question why did you reoperate on some of those patients? Were those the larger hernias? Or what is your indication (a) for operation and (b) for reoperation? The second question stems from the observation that you made on the issue of aspiration. Patients with pulmonary disease or bronchiectasis are the ones that probably are aspirating and need this repair the most. So, since they tend to do the worse, what is your advice for those patients? In our study, we found that chest pain, early satiety, and physical function on the SF-36 were three clear characteristics of those who recurred, but you did not find that.

Katie S. Nason, M.D. (Pittsburgh, PA): Thank you, Dr. Pellegrini. I will try to get through these in the order that they were asked.

First, to elaborate on the procedure that we perform, we do an extensive mobilization of the esophagus circumferentially all the way to the level of the carina, beginning first with the reduction of the sac. We actually go into the mediastinum, grasp the sac, and completely ignore the stomach that is within the mediastinum. Doing that allows us to bring the stomach back into the abdomen with the sac rather than trying to pull the stomach back down into the abdomen. This minimizes trauma to the stomach. After you are done dissecting the mediastinum, when you pull back and look with the camera, you see a stomach lying nicely within the abdomen and no portion back up into the mediastinum. If we do not see that, we know that our mediastinal dissection is not complete.

Having circumferentially mobilized the esophagus to the level of the carina or higher if possible, we then evaluate the location of the GE junction. In order to do this, we actually mobilize both the anterior and the posterior fat pad and clearly visualize the gastroesophageal junction both endoscopically and laparoscopically to determine the length of esophagus that is within the abdomen. We try to keep our insufflation pressures as low as possible, usually in the range of 10 to 12 mm of pressure, in order to minimize the cephalad distraction of the diaphragm and truly determine what the length of intra-abdominal esophagus is.

After assessing esophageal length, we then decide whether or not to proceed with the Collis lengthening procedure in order to ensure that we have at least 3 to 4 cm of intra-abdominal esophagus upon which to perform our wrap.

Your second question had to do with symptoms and the indication for operation. In a subset of our patients, the indication for operation was anemia. They did not have any symptomatic complaints that you could relate to a paraesophageal hernia. Another subset of our patients actually had what you describe as significant pulmonary dysfunction related to aspiration, and several patients had multiple hospitalizations for recurrent pneumonia, many patients had adult-onset asthma and that was often an indication for repair in our population. The final indication are the classic complaints of gastroesophageal reflux, chest pain, regurgitation/vomiting, and dysphagia.

Finally, the indications for reoperation really have to do with symptoms, including recurrent anemia as well as symptomatic complaints. The seven patients that had reoperation, six of them were reoperated in our center, and all of them had recurrent significant complaints that were relieved by reoperation. The two patients with the large recurrences who do not want reoperation are currently only minimally to asymptomatic and really do not want to go through another operation because it just does not really impact on their quality of life.

Finally, to address the use of mesh, the follow-up in the paper you describe with the randomized trial, you see mesh versus no mesh with an 8% recurrence rate at 6 months. The recurrence rate on our radiographic follow-up is 51 months in this setting. So, it is hard to know how to compare those two papers one to the other.

We do a very extensive mobilization. Bringing the sac down into the abdomen and fully mobilizing the stomach off the crura is an important part of the operation, and taking the phrenoesophageal ligaments all the way down and completely freeing up the crura has allowed us to re-approximate many of these crura without tension and without the need for mesh reinforcement. However, with a recurrence rate of 15%, there is obviously more to do to reduce the rate of recurrence over time. More liberal use of mesh, particularly in patients with pulmonary dysfunction, may be an interesting way of reducing the risk of recurrence over time. At least in our paper, those patients are at higher risk of recurrence, and it may be that we can study that more completely to make a better determination in the future.

David W. Rattner, M.D. (Boston, MA): One question and one comment. My first question is, if I read the slide correctly, it looked like 85% of patients had esophageal lengthening procedures, which is really very high compared to my practice and many others. I wonder if you think that contributed to the high rate of postoperative heartburn, because if I read that slide correctly, about 40% of your patients had heartburn postoperatively.

My other comment is that you used a paper that we wrote sort of as a straw man for your argument, and I just want to clarify that the message in that paper was the mere presence of a paraesophageal hernia is not an indication for surgery, at least not in our hands, and I do not think you can make any conclusion based on a retrospective data set of your own personal series as to whether or not asymptomatic patients should be operated on or not. So I think you need to temper your conclusions a little bit, unless you have data that you have not shown us.

Dr. Nason: You are absolutely correct as far as not offering patients who are asymptomatic an operation that has the possibility of making them symptomatic, and certainly doing any kind of antireflux procedure can often lead to symptoms that the patient does not really want, such as excessive flatulence and dumping syndrome. We have found, however, that if you carefully talk to these patients that very few of them are truly asymptomatic. If you present them with a symptom assessment that is standardized, very often you will be able to dissect out problems that they are having and changes in their lifestyle that they have made in order to accommodate for the finding of paraesophageal hernia. Certainly, there are patients who are not currently being referred for surgery being treated with serial dilations for dysphagia who may benefit from the operation.

I think we have to be careful in both directions of saying that once we have carefully assessed for symptoms, if the patient is truly asymptomatic, then operating on them is probably not going to be in their favor, but it requires a careful symptom assessment, looking for symptoms of anemia, looking for symptoms of pulmonary dysfunction, and looking for atypical symptoms of reflux before you say that they are truly not symptomatic.

Steven R. DeMeester, M.D. (Los Angeles, CA): Congratulations, great series. You have had the opportunity to see 5- and, some probably, 10-year barium studies in these patients because of the length of the series. Are you able to provide any indication of the timing of recurrence? Did any of the patients have earlier barium studies where you can tell us whether the risk of recurrence levels off at some point and we do not need to worry about it?

Dr. Nason: We unfortunately do not have time series analysis on these patients and that is actually one thing that we have addressed in the last year and a half or so, and we have actually instituted a clinical pathway where patients come back every one to 2 years to get a surveillance barium esophagram, because we found that the patients that we sent out, many of them actually had symptomatic complaints that we could help them with, particularly symptoms of dysphagia that would respond to dilatation, not in the setting of a recurrent hernia but just a slightly tight wrap or some other process that is causing them to have dysphasia. Following those patients over time actually allows us to intervene and maintain some degree of a better quality of life than if they were just left on their own. So, we hope to have some data to report on that in the not too distant future.

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Nason, K.S., Luketich, J.D., Qureshi, I. et al. Laparoscopic Repair of Giant Paraesophageal Hernia Results in Long-Term Patient Satisfaction and a Durable Repair. J Gastrointest Surg 12, 2066–2077 (2008). https://doi.org/10.1007/s11605-008-0712-7

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