Paraesophageal Hernia Repair in the Obese

Aaron J Wille, BS¹, Kevin M Reavis, MD¹, Christy M Dunst, MD¹, Valerie J Halpin, MD², Lee L Swanstrom, MD¹. ¹The Oregon Clinic, ²Legacy Health and Services

Introduction:

Laparoscopic paraesophageal hernia (PEH) repair is a complex foregut procedure with a notoriously high recurrence rate. Fortunately, despite high radiographic recurrence rates, symptom recurrence remains low. PEH repair in the obese is controversial with concerns for decreased durability. The aim of this study is to evaluate outcomes of PEH repair in obese patients.

Methods:

A prospectively collected advanced foregut surgery database was queried for primary laparoscopic PEH repair between January 2006 and May 2010. Patients with prior foregut surgery, emergent presentations, and procedures including gastroplasty were excluded. Demographics and perioperative outcomes were recorded. Patients were stratified by body mass index (BMI). Pre- and post-operative subjective symptom scores were collected on a 5-point scale (0,1,2,3,4) ranging from “never” to “continuous”. All patients had a standardized laparoscopic PEH repair with implantation of biologic mesh reinforcement to the diaphragmatic closure and a fundoplication as previously described. Hernia recurrence was defined on standard post-operative radiographic contrast studies and/or endoscopy at two years.

Results:

Of 196 patients, 126 (87 F, 39M) met criteria for analysis. The BMI less than 35 group included 99 patients and there were 27 in the BMI greater than 35 group. Overall, the study patients showed symptom improvements in heartburn, reflux, and chest pain (p<0.05) at follow-up. Patients in both groups demonstrated similar levels of symptom improvements (p>0.05). Radiographic (59) and/or endoscopic (98) follow-up was performed at a median of 25 (IQR 16-33) months. Objective recurrence rates were 33% in the BMI<35 group vs 40% in the BMI>35 group (p=0.533).

Conclusion:

Clinical outcomes of PEH repair are similar regardless of BMI. Recurrence rate is not negatively influenced by obesity. Symptoms are improved similarly in all BMI groups. Overall, concerns about outcomes including durability should not be reason to deny obese patients PEH repair.