Acute Emergent Reoperation After Laparoscopic Paraesophageal Hernia Repair: 15 Year Experience at a Single Institution

Carmen L Mueller, MD, Pepa Kaneva, MSc, Melina Vassiliou, MD, Lorenzo E Ferri, MD, Liane S Feldman, MD, Gerald M Fried, MD

Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, Canada

Introduction:
Laparoscopic paraesophageal hernia repair (LPEHR) remains a technically challenging operation requiring specialized expertise. The overall recurrence rate is known to be high, but repeat repair is generally not recommended in asymptomatic patients. The most feared complication of PEH is acute strangulation or obstruction. The objective of this study was to estimate the incidence of emergency reoperation for complicated recurrent PEH after laparoscopic repair.

Methods:
A prospectively collected database of patients undergoing LPEHR at a single tertiary-care institution from 1997 – 2012 was retrospectively reviewed. Repair included hiatal closure with selective use of mesh and fundoplication. Measures included disease specific quality-of-life questionnaires (GERD-HRQL) at baseline, 1.5 months, 3 months, 6 months, and annually. Medical records were reviewed for cases requiring emergency reoperation after LPEHR for acute recurrence, gastric strangulation, ischemia and/or volvulus.

Results:
LPEHR was performed in 153 patients; mean age 69 (42 – 96), 66% female, average BMI 27kg/m2 (19 – 37). Nine patients had previous hiatal surgery (5.9%) and 12 were emergency operations for obstruction or strangulation (7.8%). Laparoscopic repair was completed in 147 cases (96%), and 6 cases (4.0 %) required conversion to open. Mesh was employed in 22 patients (15%), the majority of which were biologic (18/22). The median length of stay was 2 days (range: 1-146 days), and 30-day mortality was zero.

After a mean follow up of 45 months, nine patients required emergent reoperation for post-PEH repair complications. Of these, four were immediate post-operative complications occurring during the initial hospitalization. The remaining five presented after discharge and required emergency reoperation for recurrent PEH. The median time to reoperation was 119 days (range: 72 – 576 days), with 4/5 presenting within 4 months of initial repair. No patient reported significant PEH-related symptoms on routine serial follow up questionnaires prior to requiring emergent operation. Three reoperations required an open approach while two were completed laparoscopically. Resection of ischemic stomach was required for 3/5 patients and two patients underwent revision of hiatal closure alone. Median length of stay after reoperation was 21 days (range: 3 – 33 days).

Conclusions:
Acute recurrences requiring emergency reoperation for gastric obstruction/ischemia after LPEH repair occurred with greatest frequency during the first several months after initial repair, and often required gastric resection. Further study is needed to determine the optimal follow up of patients in the early post-operative period to potentially identify these cases before acute presentation.

Session: Poster Presentation

Program Number: P207