Long Term Outcomes of Radiologic Recurrence After Paraesophageal Hernia Repair with Mesh

Rachel A Jones, MD, Anton Simorov, MD, Carl J Tadaki, MD, Dmitry Oleynikov, MD. University of Nebraska Medical Center, Department of General Surgery.

Introduction: Paraesophageal hernia repair has historically had a high radiologic recurrence rate in the literature, even with the use of biologic mesh as a prosthetic buttress to reinforce the primary crural repair. This review was done to evaluate outcomes at our institution after paraesophageal hernia with mesh.

Methods: A retrospective analysis was done of all patients who underwent paraesophageal hernia repair with mesh at our institution between December 2004 and March 2013. Patients were reviewed for evidence of recurrence, defined as stomach extending vertically at least 2 cm above the diaphragm on upper gastroinstestinal studies (UGI). Time specific, mesh specific, and size specific recurrence was analyzed as well as pre- and postoperative symptom scores.

Results: A total of 209 patients underwent paraesophageal hernia repair with mesh. The mean follow up for patients with mesh was 21 months (range 0-101). In all cases an absorbable mesh was used (159 Alloderm, 35 BioA, 15 Strattice). 156 (75%) were 5cm or larger. Of the patients repaired with mesh 160 (77%) had UGIs available to review for radiologic recurrence. Total recurrence was 21% (n=33). No mesh erosions were seen and only 1 patient required reoperation for early hernia recurrence. Recurrence rates increased over time: 22% after 1 year (n=28), 31% after 2 years (n=16), 33% after 3 years (n=14), 37% after 4 years (n=11), and 42% after 5 year follow up (n=8). Recurrence rates were higher for large hernias (23 vs 16%) with 50% recurrence rate at 5 years for hernias 5cm or larger. The median size of the recurrence was 3.8cm (range 2-7cm) and consisted of posterior gastric migration above the diaphragm with gastroesophageal junction and the wrap below the diaphragm. Overall, patients showed significant improvement in their symptom scores. Heartburn had 83% reduction (CI 78.2-87.7; p<0.05), regurgitation had 81.1% reduction (CI 76.1-86.1; p<0.05) and belching had 63% reduction (CI 56.7-69.3; p<0.05) and there was no significant difference in postoperative symptom scores between patients with or without radiologic recurrence.

Conclusions: In this study, paraesophageal hernia repair with mesh was safe and effective at controlling symptoms over the long term. Radiologic recurrence rate increased over time and was highest in patients with hiatal hernias greater than 5cm. No patients were symptomatic if the gastroesophageal junction remained below the diaphragm. Therefore, in our experience, paraesophageal hernia repair with mesh is a safe therapy and though radiologic recurrence does increase with time, symptom resolution is maintained.

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