Lauren McCormack, MD, Carl Westcott, MD. Wake Forest
Introduction: Fundoplication at the time of giant paraesophageal hernia repair is controversial. The proposed advantages are better reflux control and lower recurrence. Disadvantages include fundoplication specific complications, might be unnecessary and may not decrease recurrence. We retrospectively reviewed giant paraesophageal hernia repairs (PEH) with two point gastropexy in the fundus and body, and no antireflux procedure. Data collected is postoperative GERD symptoms, postoperative Proton Pump inhibitors (PPIs) therapy and recurrence.
Methods: A retrospective review of patients who underwent repair of giant PEH from 2012 to December of 2016. Giant was defined as a hernia with 50% or more of the stomach above the diaphragm. Follow up consisted of upper GI (UGI) study one year postoperatively and reflux symptom questionnaire. Patients were followed every 4 months in the surgery clinic and a PPI wean was initiated at the second postoperative visit. The primary outcome we evaluated was discontinuation of PPIs. In addition, we utilized a standardized reflux scale and recurrence rates collected. Chi-Squared was used for statistical analysis.
Results: 69 patients underwent giant PEH repair as described, 13 (18.8%) were previously repaired. Average age was 68 years, and 54 of the patients were female. 58 patients (84%) reported preoperative PPI usage and 86% (59) of patients reported preoperative GERD symptoms. Seven patients were lost to follow up before the third postoperative visit. 42 (61%) patients received a one year UGI follow up and average follow up is 344 days post-operatively. The recurrence rate was 15.9% (11 patients), 3 (4.3%) required repeat repair.
25 of 58 patients were off PPI therapy postoperatively (chi 20.16, p<001). 33 patients continued single dosage PPI postoperatively. 20 patients reported full symptom relief on single dosage PPI. Total of 44 of 61 patients reported improvement in symptoms postoperatively regardless of PPI use (Chi 33.13, p <0.001). 9 of 59 patients had continued to report some GERD symptoms despite PPI therapy. No patients reported worsening GERD symptoms. The most common postoperative complaint was dysphagia, occurring in 17 (24%) patients.
Conclusion: Antireflux procedure in the setting of giant PEH repair proved extraneous in most these patients (44 of 69). Its possible that 9 of 69 would benefit from a fundoplication because of GERD despite medication after operation. The conundrum is beneficiaries cannot be identified preoperatively and exposing all giant PEH patients to the risk of dysphagia (11% to 15%), gas bloat (40%) and fundoplication failure (30%) seems unwarranted.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87108
Program Number: P407
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster
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