Reoperative Laparoscopic Paraesophageal Herniorraphy Can Produce Excellent Outcomes

Introduction: Patients undergoing laparoscopic paraesophageal herniorraphy, either initial or recurrent, present with a myriad of esophageal and extra-esophageal symptoms. Given an overall recurrence rate of approximately 8%, reoperative paraesophageal herniorraphy is necessary on a significant number of patients. The goal of this study is to determine whether patients proceeding with laparoscopic reoperative paraesophageal herniorraphy experienced symptom resolution equal to or better than patients undergoing a first-time repair.

Methods: A comprehensive, symptom frequency based clinical tool consisting of 24 esophageal and extra-esophageal reflux symptoms was developed and administered to patients undergoing an initial or reoperative paraesophageal herniorraphy between February 2002 and September 2009. This was administered pre-operatively and post-operatively. From individual symptom scores, a composite score for esophageal reflux and extra-esophageal reflux was calculated. A retrospective analysis of patient records including history and physical examination, laboratory investigations, operative and post-operative follow-up progress notes was reviewed. Data on age, gender, twenty-four symptom frequencies, manometry results, pH testing results was collected and analyzed using appropriate statistical tests.

Results: Patients included in the study had a mean age of 53.6 years and 57.4% of patients were female. Analysis of composite symptom scores of 195 patients demonstrated that paraesophageal herniorraphy results in a significant resolution of both esophageal (16.1 ± 8.5 pre-op vs. 3.5 ± 5.0 at 6 months post-op; p<0.001) and extra-esophageal (8.6 ± 7.5 pre-op vs. 2.2 ± 5.1 at 6 months post-op; p<0.001). Patients showed significant resolution of all individual symptom scores following surgery (p<0.05). Additionally, both composite and individual six-month follow-up scores were not significantly different from the twelve-month scores. Patients undergoing first-timerepairdemonstrated significant differences in pre-operative symptoms, when compared to patients undergoing revision surgery. Pre-operatively, the reoperative patients demonstrated a trend towards higher composite esophageal scores (18.0 ± 8.8 revision vs. 15.8 ± 8.4 initial; NS) and significantly higher individual symptom scores such as dysphagia and abdominal discomfort. Post-operative, the reoperative patients also had significantly lower composite (6.1 ± 7.2 revision vs. 9.1 ± 7.5 initial; p<0.05) and individual scores for extra-esophageal symptoms such as throat clearing, laryngitis and hoarseness. At six- and twelve-months post-operatively, patients after reoperativeparaesophageal herniorraphyhad significantly less frequent esophageal and extra-esophageal symptoms than those who underwent a first-time paraesophageal herniorraphy (p<0.05). However, the composite scores between the two groups were not different.

Conclusions: It is believed that patients undergoing reoperative paraesophageal herniorraphy have poor symptom resolution. However, our data demonstrates that in a center with expertise in performing laparoscopic reoperative paraesophageal herniorraphy, reoperative patients have symptom resolution equal to or better than first-time patients.

Session: Podium Presentation

Program Number: S082