Hitoshi Idani, MD, FACS1, Kent Mishima, MD1, Kanyu Nakano, MD1, Tetsushi Kubota, MD1, Masao Harano, MD1, Shinya Asami, MD2, Norihisa Takakura, MD2. 1Department of Surgery, Hiroshima City Hiroshima Citizens Hospital, 2Department of Surgery, Fukuyama City Hospital
Background: Tailored fundoplication according to the esophageal motility is not indicated in recent guideline during laparoscopic hiatal hernia repair, however, dysphagia after surgery is still a crucial matter which might cause aspiration pneumonia especially in elderly patients. We have introduced laparoscopic hiatal hernia repair with anterior or lateral fundoplication for elderly patients with hiatal hernia to minimize dysphagia and evaluated the outcome.
Surgical technique: After the crus was approximated posteriorly +/- anteriorly, anterior 90-180 degree fundoplication or lateral fundoplication was performed according to the age and the symptom of the patient. Onlay mesh was used only for patients with vulnerable hiatus.
Patients and methods: From May 1997 to August 2017, a total of 182 patients with GERD and/or hiatal hernia underwent laparoscopic repair in our hospitals. Preoperative work up included esophagogastrogram, endoscopy, CT, 24h pH and impedance and manometry (selected patients). Nissen or Toupet was indicated for patients aged < 75 and/or with severe to moderate reflux symptom. Anterior fundoplication was indicated for patients aged 70 to 85 years with mild reflux and /or dysphagia. Lateral fundoplication was indicated for patients aged over 80 with dysphagia and/or had a history of aspiration pneumonia. Symptom score and clinical outcome were evaluated.
Results: The type of fundoplication was as follows; Nissen:70, Toupet:69, Anterior:28, lateral:15. Operation time was 141+/-44.3min and hospital stay was 9.1 days. There was no mortality. Conversion to open surgery was required on one patient. Symprom scores of heart burn, dysphagia and regurgitation were significantly improved both after anterior and lateral fundoplication. LES pressure (from 1.0 to 14.8mmHg, p=0.0032), LES length (from 1.1 to 2.9, p=0.0021) and DeMeester score (from 27.2 to 2.4, p=0.0018) were significantly increase or improved after anterior fundoplicastion. In 88 patients with paraesophageal hernia, dysphagia (2/40 vs 6/48, p=0.283), esophagitis (4/48 vs 2/40, p=0.448), hernia recurrence (5/48 vs 4/40, p=1.00) and reoperation (6/40, vs 1/40, p=0.121) after anterior or lateral fundoplication were comparable to those after Nissen or Toupet fundoplication. There was no pneumonia after surgery. Anterior fundoplication showed excellent antireflux effect in 24 h pH and impedance monitoring although the number of patients was small.
Conclusion: Laparoscopic hiatal hernia repair with anterior or lateral fundoplication has feasible outcome and can be a option of fundoplicstion for elderly patients with dysphagia.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87238
Program Number: P446
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster
sages_adbutler_leaderboard