Yves Borbely, MD, Andrew Wright, MD, Brant K Oelschlager, MD, Carlos Pellegrini, MD. Department of Surgery, University of Washington
Paraesophageal Hernia (PEH) repair is technically challenging. Recurrence is common although most recurrences do not require re-operation. There are little published data on indications for redo PEH repair, or on outcomes of re-operation.
All patients who underwent operation for recurrent PEH at a single, high-volume tertiary care center between 01/2005 and 12/2013 were analyzed. Data were obtained from a prospectively maintained database and systematic patient questionnaires.
Forty-six patients had surgery for recurrent PEH. Median time from initial repair was 65.2 months (range 2.7-234.5). Multiple prior attempts at repair were seen in 14 patients. Median age was 58.9 years (30.6 – 87.5) with a median BMI of 28.4 kg/m2 (21.3 – 50.3); 29 patients (63%) were ASA ≥3, 24 patients (52%) had a Charlson Comorbidity Index >3. The main presenting symptom was dysphagia in 59%, pain in 17%, heartburn in 22% and respiratory in 2%. Anemia was present in 5 patients; 8 (20%) had Cameron’s ulcers.
At reoperation, the most common abnormality found was large (>10cm) hiatus (34 patients), followed by previously unresected sac (17), wrap created using the gastric body rather than fundus (21 patients[CP1] ), disrupted wrap (9), redundant fundus (8), slipped wrap (4), twisted wrap (3), 2 or more fundoplications (3), and too-tight hiatal closure (1). Closure was deemed difficult in 20 patients.
Four patients underwent gastropexy to relieve volvulus only, 40 underwent repair of PEH with redo fundoplication, and in 2 a gastrectomy was performed. All operations started laparoscopically, 2 were converted to open. Three operations were emergent (2 PEH repair, 1 reduction of volvulus). No mesh was used in 10 patients, biologic mesh in 35, and Gore-Tex mesh was used in 1. Relaxing incisions in the diaphragm were needed in 4 patients and 5 had an esophageal lengthening procedure (vagotomy). Mean OR time was 227±112min.
Median length of stay was 2d (range 2-88d). Perioperative (<30d) morbidity consisted of 9 Clavien grade I complications (19.6%), [CP2] 10 grade II (21.7%), 3 grade III (6.5%), and 4 grade IV (8.7%). There were 2 deaths (4.3%). Readmission rate was 10.8% (dysphagia in 4 patients, pain in 1).
Follow-up ≥3 months (median 11 months, range 3-91) was available for 38 (83%) patients. Dysphagia improved in 87%, heartburn in 79%, pain in 61% and respiratory symptoms in 70%. One patient developed new onset dysphagia post-op. Diarrhea improved in 2 patients, was persistent in 2, and was a new symptoms in 8, while bloating improved in 8 patients, persisted in 3, and was new in 5. Radiologic follow-up (n=22) revealed 9 recurrences <2cm (41%), [CP3] none of which required re-operation. One patient recurred with herniation of small bowel through a relaxing incision, which required re-operation. Two patients developed incisional hernias requiring repair.
Re-operation after PEH repair is a complex operation in medically compromised patients. The indications and findings are varied. Most patients have a good outcome, but substantial morbidity and mortality can occur even in a high volume center.