Surgical Management of Large Hiatal Hernia After a Failed Anti-Reflux Surgery

Arpad Juhasz, MD PhD, Abhishek Sundaram, MBBS MPH, Masato Hoshino, MD, Tommy H Lee, MD, Sumeet K Mittal, MD. Department of Surgery, Creighton University Medical Center, Omaha, NE, USA

Background: The objective of this study was to evaluate outcomes for patients who underwent re-operative intervention after a failed anti-reflux surgery and had a large recurrent hiatal hernia (>5cm).
Methods: A retrospective review of a prospectively maintained database was performed to identify patients who during re-operation and were found to have a large recurrent hiatal hernia (>5cm on pre-operative work up) between 12/1/2003 and 8/31/2009. Operative reports, barium swallow and endoscopic examinations were evaluated. Pre-operative and post-operative symptoms were graded on a scale of 0 to 3. These scores were summarized for a total symptom score. Pre-operative chief complaint and total symptom scores were compared to the corresponding post-operative scores. Post-operative symptom scores in patients undergoing different re-operative interventions were compared. Wilcoxon-test was used to compare symptom scores.
Results: Out of 203 patients who underwent re-operation following an anti-reflux procedure during the study period, 26 satisfied the study criteria. Of these, 20 were females and 6 were males. The mean age for the study population was 59.9 years. The distribution of chief complaints was as follows – heartburn (23%), dysphagia (23%), epigastric pain (19.2%), chest pain (15.5%), regurgitation (15.5%) and fullness (3.8%). Barium swallow revealed a type I hiatal hernia in 53.8%, type II in 26.9%, type III in 11.5% and a type IV in 7.7% of the study population. Endoscopic evaluation prior to re-operation revealed an intact fundoplication in 10 (38.5%) patients, slipped fundoplication in 1 (3.8%) patient, disrupted fundoplication in 7 (26.9%) patients, intrathoracic fundoplication in 2 (7.7%) patients, twisted fundoplication in 5 (19.2%) patients and mesh erosion in 1 (3.8%) patient. Re-operation consisted of redo-fundoplication in 16 patients (61.6%, laparoscopic – 6, open – 10, 6 Collis gastroplasty) and RNY in 10 patients (38.46%, laparoscopic – 6, open – 4). Intra-operative complications occurred in 11 (42.3%) patients (bleeding – 3, perforation – 8). Post-operative complications occurred in 16 patients (61.53%) and consisted of wound infections, atrial fibrillation, pneumonia, pleural effusion, pulmonary embolism and leaks. All three leaks were successfully managed with drainage. Five patients (19.23%) need early re-operation for the following: bleeding, intra-abdominal abscess, pyloric dysfunction, acute herniation of gastric pouch and intestinal obstruction. RNY’s were associated with a higher (p = 0.034) peri-operative complication (major and minor) rate (90%) than redo-fundoplications (75%). At 1 year, 4 patients were lost to follow up. Among the remaining 22 patients, the post-operative chief complaint (p<0.001) and total symptom scores (p=0.002) were significantly lower than the corresponding pre-operative scores. Patients in the RNY group had significantly lower symptom scores (p = 0.002) than the redo-fundoplication group.
Conclusion: Repair of a large hiatal hernia after a failed anti-reflux surgery is a technically challenging procedure with significant peri-operative morbidity, however there is high degree of symptom resolution and patient satisfaction. While the RNY was associated with higher peri-operative morbidity than the redo-fundoplication, it provided a more significant alleviation of symptoms.

Session: SS04
Program Number: S013

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