Partial Fundoplication Results in Excellent Outcomes After Laparoscopic Paraesophageal Hernia Repair

Ryan D Horsley, DO, Jarrod M Buzalewski, DO, Matthew E Plank, PAC, Jon D Gabrielsen, MD, David M Parker, MD, Anthony T Petrick, MD. Geisinger Medical Center

INTRODUCTION: The objective of this study was to review the outcomes of patients undergoing laparoscopic paraesophageal hernia repair (LPEHR) with a partial fundoplication. The best operation for paraesophageal (PEH) repair remains controversial. While reflux is not the most common symptom in PEH patients, there is consensus that fundoplication is indicated. While the Nissen is most common, the optimal type of fundoplication is not well defined.  Few studies have evaluated partial fundoplication in patients presenting with paraesophageal hernias.

METHODS AND PROCEDURES: A retrospective review of patients who underwent elective primary LPEHR from May 2012 through June 2014 was performed (n=149). 84 patients were identified in the study group. All underwent LPEHR with a 270 degree anterior Dor fundoplication. All patients in the study group underwent reinforcement of the crural repair with biologic mesh.

RESULTS: The mean age of study group was 69 years old. 84% were female. The mean age- adjusted Charleson score was 4.24.  Mean operative time and intraoperative blood loss were 169 minutes and 32.5ml respectively. Collis Gastroplasty was performed in 19% of patients. One patient (1.2%) required an ICU stay and the overall mean length of stay was 2.0 days.  Of the 84 patients, 13 (15.5%) had a complication within the 30 day postoperative period. Morbidities were classified as major (Clavien score > 3) or minor (Clavien score < 3). There were 2 major complications and 11 minor complications. There were no mortalities at 90 days. The mean length of follow up was 17.9 months. 8 (12.5%) patients had diagnostic evidence of a recurrent hiatal hernia. Only 3 patients (3.6%) had a symptomatic recurrence with one patient requiring a revision LPEHR. Preoperative dysphagia was present in 49 patients (58.3%), of which, 43 (87.8%) reported improvement post operatively. Of the entire study group, 17 (20.2%) reported postoperative dysphagia, 8 patients reported dysphagia occurring less than once per week.  There was significant improvement in Reflux Symptom Scores (RSI) (17.4 to 3.09; p<0.05) and Health Related Quality of Life Scores (HRQL) (18.24 to 3.16; p<0.05) at the mean follow up of 17.9 months.

CONCLUSION: This study confirms previous reports that LPEHR is safe and effective with low mortality, morbidity and recurrence rates. RSI, HQRL scores and dysphagia were significantly improved postoperatively. Dor Fundoplication appears to be a good option when tailoring the operative approach for patients with PEH. Further comparison to Nissen fundoplication is warranted.

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