Long-term Outcomes of Laparoscopic Paraesophageal Hernia Repair – Primary Repair vs. Mesh Buttress Repair: a Retrospective Chart Review

Blaire Anderson, MD, Rani Al-Sairafi, MD, Clifford Sample, MD. University of Alberta

Objective: Paraesophageal hernia occurs due to weakness in the physiologic sphincter of the diaphragmatic crura. Laparoscopic surgical repair is universally accepted as the standard of care for treatment. Technique and fixation approach remain controversial with both primary tissue repairs and buttressed mesh repairs currently utilized. High rates of anatomic recurrence have been reported; however symptomatic recurrence is less common. Recurrence rates for primary repair range from 20% to 42%, while those for mesh repair are < 10%. This being said, mesh repair has been associated with dysphagia secondary to reactive fibrosis as well as occasional esophageal erosion, ulceration, and stricture. A previously published abstract from this center reported a statistically significant difference in anatomic recurrence rates with comparable operative time, favoring mesh repair. Recently long-term follow-up studies have revealed equivalent symptom recurrence and rate of complications between groups. Therefore, the goal of this study is to investigate the durability of different methods of paraesophageal hernia repair with longer term follow-up.

Methods: The charts of 176 adults who underwent paraesophageal hernia repair by a single surgeon with either primary repair (PR) or buttressed mesh repair (BMR) between July 2004 and July 2014 were reviewed retrospectively. Operative time, incidence of postoperative complications, symptom questionnaire scores, and anatomic recurrence as determined by post-operative radiologic or endoscopic studies were evaluated. Operative characteristics and postoperative outcomes were compared using the chi-square test for nominal variables and Student’s t-test for continuous variables.

Results: The mean patient age was 56.0 + 14.5 years and female percentage was 57.1%. Buttressed mesh repair was implemented in 52.8% of patients, 81.7% of mesh was biologic prosthesis (small intestinal submucosa). Operative time (PR 122 + 42 min; BMR 120 + 42 min, P = 0.21) and post-operative complications (PR 20.5%; BMR 24.7%, P = 0.39) were comparable. At median follow-up of 12 weeks postoperatively (range 0 to 204 weeks) 137 patients (77.4%) completed a reflux symptom questionnaire. In the BMR group 38.9% of patients reported symptoms including heartburn, regurgitation, pain, fullness, dysphagia, and cough; compared to only 8.4% in the PR group (P<0.0001). Radiologic or endoscopic recurrence rate was 15.7% in the PR group and 15.1% in the BMR group (P=0.91).

Conclusion: Primary tissue repair alone appears to result in comparable operative time, complication rate, and anatomic recurrence when compared to BMR. Superior results were found for PR when symptom recurrence was analyzed. Buttressed mesh repairs may not be justifiable given the increased cost of this additional step.

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