Partial Fundoplication Results in Excellent Outcomes and Better Dysphagia Control Than Total Fundoplication After Laparoscopic Paraesophageal Hernia Repair

Vladan N Obradovic, MD, Girish Luthra, MD, Aamir Akmal, MD, Dancea C Horatiu, MD, Wai M Yeung, MD, Mohanbabu Alaparti, MD, Mathew E Plank, PAC, Andrea L Plank, Jon D Gabrielsen, MD FACS, Anthony T Petrick, MD FACS. Geisinger Medical Center, Danville Pennsylvania

Background: The objective of this study was to identify whether partial fundoplication leads to better dysphagia outcomes in patients undergoing laparoscopic paraesophageal hernia (LPEHR). LPEHR is now recognized as safe and effective when done in experienced centers. Controversy remains as to the optimal surgical approach; but, as experience increases approaches can be more specifically tailored to patient needs.
Methods: Our study was a retrospective EMR review of 341 patients who underwent LPEHR at our institution from October 2001 through July 2010. 26 patients were excluded who underwent no fundoplication. In the study group (n=315), 86 patients had partial fundoplication (PF) and 229 had total fundoplication (TF). Patients in both groups were compared for dysphagia symptoms pre- and post-operatively. The groups were studied for demographic and peri-operative differences as well as morbidity, mortality, LOS and hernia recurrence. GI symptom, antacid use, and QOLRAD scores were also analyzed. Differences were calculated for significance using the unpaired T-test and Fisher’s exact test.
Results: Average age was significantly higher in PF vs the TF group (70 vs. 63; p<0.0001) with more PF female patients (84% vs 67%; p=0.005). BMI was not significantly different between the groups nor were the presenting symptoms of dysphagia (67% vs 72%) or reflux (77% vs 73%). The PF group had a significantly larger % of intra-thoracic stomach (64% vs. 54%; p=0.003) and were more likely to have mesh cruroplasty (93% vs 59%; p<0.0001). LOS, complications and mortality were not significantly different. Overall 30-day mortality rate for all 315 patients was 0.95%. Both procedures effectively reduced pre-operative dysphagia (PF 50% vs TF 38 % reduction); however, significantly fewer patients in the PF group experienced dysphagia after fundoplication (17% vs 33%; p=.008). The reduction in pre-operative reflux symptoms was also significant for both groups (PF 71%; p<0.001 and TF 66%; p<0.001) with comparable incidence of post-operative reflux between the groups (PF 5.8% vs TF 7.9%; p=0.63). GI symptom, antacid use, and QOLRAD scores were significantly improved post-operatively in both groups with no significant difference between the PF and TF groups. There was no significant difference in PEH recurrences between the groups with an overall rate of 6.35% for all 315 patients.
Conclusion: Many groups, including our own, have demonstrated the safety and efficacy of LPEHR in experienced centers. Our PF patients were older with larger PEH’s and more likely to have crural mesh. The two groups had similar incidence of dysphagia and reflux symptoms pre-operatively, yet the PF patients had significantly better reduction of dysphagia and overall dysphagia incidence post-operatively. The groups also had equivalent control of GERD symptoms, reduction in antacid use and QOLRAD improvement. This improvement was accomplished with very low PEH recurrence rates. While conclusions are limited by the retrospective design, we believe PF leads to superior dysphagia outcomes after LPEHR and should be strongly considered in those patients presenting with dysphagia as their primary symptom.