Rafik Sorial, Sofia Valanci, Pepa Kaneva, Julio F. Fiore Jr, Gerald M Fried, Liane S Feldman, Lorenzo E Ferri, Lawrence Lee, Carmen L Mueller. McGill University
Introduction: Laparoscopic repair of giant paraesophageal hernia (LPEHR) has historically been associated with significant morbidity and mortality, such that elective repair is only recommended for symptomatic patients. Since LPEHR was initially reported in the 1990s, technological improvements, specialization in surgical training and regionalization of care have occurred such that recent reports suggest modern era outcomes of LPEHR have improved. Elective repair may now be safer than previously thought, yet historical data continue to inform patient selection for surgery and informed consent discussions.
The objective of this study is to systematically review modern era surgical outcomes for elective laparoscopic giant paraesophageal hernia repair (LPEHR) performed at high volume center.
Methods: A systematic review was conducted according to PRISMA guidelines to identify all studies published between 01/2013-08/2018 reporting outcomes after elective repair of giant (>50% herniated stomach) paraesophageal hernia. High volume centers were defined as those reporting >15 cases/year over the study period. Review articles, those including >10% Type I PEH or revision surgeries, any co-surgeries other than cholecystectomy, pediatric series and those not reporting primary data were excluded. The MINORS instrument was used to assess quality of observational studies. Data heterogeneity precluded meta-analysis.
Results: Eleven identified articles were included, of which ten were observational studies and one was an RCT. The mean MINORS score for observational studies was 14.0 (SD: 3.6; range: 9-18). A total of 1,926 patients underwent primary repair of type II-IV PEHs (63-78% female; mean age range 57-71 years). PEHs were classified by type in 8 studies (1146 patients) and were mostly Type IIIs (mean incidence MI=88%). Procedures were begun laparoscopically in all studies except one (61% open approach) with conversion to open reported in 7/1707 cases (MI=0.2%). Collis gastroplasty was reported in 5 studies (MI=2.7%) and crural mesh reinforcement in 8 studies (MI=64%). Median length of stay ranged from 2-4 days. Complications within 30 days of surgery were reported in 10 studies (MI=11%), with 30/1809 cases severe (Clavien-Dindo grade ≥3; MI=2.5%). Peri-operative death was reported in 1 case (MI=0.1%). Nine studies reported anatomical recurrences (MI=21%) of which revision was performed in 30 cases (MI=4.4%). Post-operative quality of life scores were reported in 6 (54.5%) studies, with all reporting statistically significant improvement over pre-operative values.
Conclusion: Modern-era morbidity and mortality after elective primary LPEHR in high volume centers is low. Patient selection for surgery and pre-operative consent discussions should reflect modern and institutional-specific outcomes data.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95425
Program Number: P557
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster