The Natural History of Anatomic Failure After Laparoscopic Paraesophageal Hernia Repair

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.

Session: Resident/Fellow
Program Number: S111

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