Nathaniel Stoikes, MD, Mary Quasebarth, RN, Brent Matthews, MD, Margaret Frisella, RN, L. Michael Brunt, MD. Section of Minimally Invasive Surgery, Washington University School of Medicine, St. Louis, MO
Introduction: Anatomic failure after laparoscopic paraesophageal hernia (PEH) repair ranges from 20-40%. However, the clinical significance of these recurrences has not been clearly delineated. We reviewed the course of known recurrences, and the need for medical management and surgical intervention.
Methods: The records of patients who underwent laparoscopic PEH repair from 1996-2009 were reviewed for anatomic failure. Thirty-seven patients were identified with anatomic failures, who had follow-up information for review. Recurrences were identified by routine barium swallow at 6-12 months postoperatively. Pre-operative variables and operative details were analyzed. Follow-up consisted of symptom scores, use of acid suppression, anatomic or symptomatic progression, and need for reoperation.
Results: Of the 37 patients with anatomic failures, six (16%) had early failures (at < 12 days) that were repaired acutely and were excluded from further analysis. Of the remaining 31 patients (mean age 67 yrs), types of PEH originally repaired were: type II (7%), type III (90%), and type IV (3%). Average hiatal defect size was 5.1 x 3.2 cm and 22 of 31 patients (71%) had either a biologic (n=20) or synthetic mesh (n=2) placed at the hiatus. Esophageal lengthening was performed in 7 patients (23%) and a complete Nissen fundoplication in 94%. Recurrences were type I in 93% (average 3.3 cm above the diaphragm) with only 2 recurrent PEH. Two patients had a disrupted wrap without a hiatal recurrence. Mean time to detection of anatomic failure was 15 months (5-60 months). Four patients had subsequent barium swallow studies 1-3 years after the initial diagnosis of recurrence that showed stable size hernias. Symptom scores were collected in 74% of patients. At a mean follow-up of 27 months (5-96 months), 43% of patients were completely asymptomatic. Prevalence of symptoms at last follow-up were: heartburn in 22%, regurgitation in 13%, solid food dysphagia in 26%, dysphagia to liquids in 9%; and chest pain in 22%. While 68% of patients were on acid suppression pre-operatively, only 32% required medical treatment for their recurrence. One patient required endoscopic dilatation two years post-operatively for symptomatic dysphagia. No patients required reoperation for symptoms.
Conclusions: Most anatomic failures after PEH repair are small type I hiatal recurrences that occur around the first year post-operatively and require no medical intervention. Reoperation is rare over medium term follow-up.
Program Number: S111