Thomas Wade, MD, Mary Quasebarth, Sara Baalman, L. Michael Brunt, MD. Washington University in St Louis
Introduction. The use of biologic mesh repair during laparoscopic paraesophageal hernia (PEH) repair has been associated with lower recurrence rate at 6 months but an increased recurrence rate up to 5 years after surgery. Few studies have correlated symptomatic outcomes and radiographic recurrences at or beyond one year follow-up. The purpose of this study was to evaluate patient centered outcomes and the rate of recurrent hiatal hernia ≥1 year after PEH repair with biologic mesh.
Methods and Procedures. A retrospective review of all primary PEH repairs with biologic mesh by one surgeon from 2003 to August 2013 was performed. All PEH repairs were performed with primary sutured cruroplasty with a biologic mesh buttress. Esophageal lengthening using a wedge fundectomy was performed selectively for short esophagus. Standardized symptom score sheets were completed pre-operatively and at follow-up visits for 5 GERD-related symptoms (dysphagia liquids, dysphagia solids, heartburn, chest pain, regurgitation); scoring used a composite of frequency and severity of symptoms on a 5 point Likert scale (maximum score 80). Barium esophagram was performed in all patients at one year and subsequently as clinically indicated. Data are mean ±SD and statistical analysis is by non-paired students t test.
Results. Primary PEH repairs with biologic mesh were performed in 138 patients; esophageal lengthening was performed in 50 of these cases (48%). One year barium swallow was completed in 104 patients (75.4%) Fourteen of 104 patients (13%) had evidence of recurrent hernia on barium swallow within the first year. An additional 16/104 (15%) patients had a recurrent hernia on barium swallow at 2-5 years post operation. Symptom score sheets were completed at 1 year or more after the operation in 74/104 (71%) patients. The average symptom score preoperatively was 8.5; at one year postoperatively it was 3.6± 9.8 for patients without radiologic recurrence and 1.0± 1.3 for those with a radiologic recurrence (p=0.91). Patients who developed a recurrent hernia at 2-5 years had a mean symptom score at 1 year of 7.3±17.1 compared to 2.0±5.5 in patients who did not develop recurrence (p<0.11). Most recurrent hernias were small (2cm) and only 4 patients (3.8%) required reoperation over a mean follow-up period of 24 months.
Conclusions. Recurrent hiatal hernia is common after PEH repair but most do not require reoperation. Symptom scores did not correlate with radiologic recurrence of PEH at one year. However, patients with increased symptom scores at 1 year follow up may be more likely develop a recurrent hernia at 2-5 years. These patients may benefit from more frequent follow-up and imaging.