Impact of surgical repair on type IV paraesophageal hernias (PEHs)

Impact of laparoscopic repair on type III/IV giant paraesophageal hernias: a single-center experience

PURPOSE

Giant paraesophageal hernia (GPEH) is a challenging problem for surgeons because of its high recurrence rate. This study was conducted to compare the outcomes in type IV vs. type III GPEHs after laparoscopic repair. Other outcomes included peri-operative morbidity and long-term quality of life.

METHODS

A retrospective analysis of 130 GPEH patients in a period between 2010 and 2019 underwent a tailored laparoscopic repair in our tertiary center with a minimum follow-up of 48 months. Operative steps included hernial sac excision, crural repair, relaxing incisions, and mesh cruroplasty with special indications.

RESULTS

The study enrolled 90 patients with type III and 40 patients with type IV GPEH. Type IV GPEH patients were older, more fragile, and scored worse on ASA classification, aside from having a more challenging surgical technique (wider crura, weaker muscles, increased need for release incisions, and mesh cruroplasty).Type IV GPEHs had a prolonged operative durations, and a higher conversion rate. Additionally, the same group showed increased morbidity, mortality, and re-operation rates. With a mean follow-up of 65 months (range 48-150 months), the incidence of recurrence was 20.7%, with an increased incidence in type IV GPEH (37.5% vs. 13.33% in type III GPEH). Type IV GPEH, low pre-operative albumin, larger crural defect, and low surgeon experience were significant risk factors for recurrence after laparoscopic repair of GPEH.

CONCLUSION

Type IV GPEH has a higher peri-operative morbidity and recurrence rate; so, a more tailored laparoscopic repair with a high surgeon experience is needed.

Patient-tailored algorithm for laparoscopic cruroplasty standardization: comparison with hiatal surface area and medium-term outcomes

BACKGROUND

Different methods have been described for laparoscopic hiatoplasty and hiatus hernia (HH) repair. All techniques are not standardized and the choice to reinforce or not the hiatus with a mesh is left to the operating surgeon's preference. Hiatal surface area (HSA) has been described as an attempt at standardization; in case the area is > 4 cm², a mesh is used to reinforce the repair.

OBJECTIVE

The aim of this study was to describe a new patient-tailored algorithm (PTA), compare its performance in predicting crura mesh buttressing to HSA, and analyze outcomes.

METHODS

Retrospective, single-center, descriptive study (September 2018-September 2021). Adult patients (≥ 18 years old) who underwent laparoscopic HH repair. Outcomes and quality of life measured with the disease-specific gastroesophageal reflux disease health-related quality of life (GERD-HRQL) and reflux symptom index (RSI) were analyzed.

RESULTS

Fifty patients that underwent laparoscopic hiatoplasty and Toupet fundoplication were included. The median age was 61 years (range 32-83) and the median BMI was 26.7 (range 17-36). According to the PTA, 27 patients (54%) underwent simple suture repair while crural mesh buttressing with Phasix-ST® was used in 23 (46%). According to the HSA, the median hiatus area was 4.7 cm² while 26 patients had an HSA greater than 4 cm². The overall concordance rate between PTA and HSA was 94% (47/50). The median hospital stay was 1.9 days (range 1-8) and the 90-day complication rate was 4%. The median follow-up was 18.6 months (range 1-35). Hernia recurrence was diagnosed in 6%. Postoperative dysphagia occurred in one patient (2%). The GERD-HRQL (p < 0.001) and RSI (p = 0.001) were significantly improved.

CONCLUSIONS

The application of PTA for cruroplasty standardization in the setting of HH repair seems effective. While concordance with HSA is high, the PTA seems easier and promptly available in the operative theater with a potential increase in procedure standardization, reproducibility, and teaching.

Paraesophageal hernia repair with laparoscopic Toupet fundoplication: impact on pulmonary function, respiratory symptoms and quality of life

BACKGROUND

Paraesophageal hiatal hernia (PEH) is characterized by protrusion of intra-abdominal organs into the posterior mediastinum. Respiratory symptoms and reduced pulmonary function have been described as possibly related to lung compression.

OBJECTIVE

To assess the effect of laparoscopic Toupet fundoplication (LTF) for PEH repair on pulmonary function, measured with pulmonary function tests (PFTs), and respiratory symptoms.

METHODS

Retrospective, single-center, cohort study (November 2015-2020). All patients that completed pre- and postoperative (12 months) PFTs assessment were included. The gastroesophageal reflux disease health-related quality of life (GERD-HRQL), reflux symptom index (RSI) and short form-36 (SF-36) were used.

RESULTS

Overall, 71 patients were included. The median age was 67.1 years and the majority were females (78.8%). Baseline PFTs were within normal limits in 91% of patients. At 12 month follow-up, total lung capacity (TLC) (4.77 vs. 5.07 L; p = 0.0251), vital capacity (VC) (2.97 vs. 3.31 L; p = 0.0065), forced expiratory volume in one second (FEV1) (2.07 vs. 2.44 L; p < 0.001) and forced vital capacity (FVC) (2.78 vs. 3.19 L; p < 0.001) were significantly improved. No significant differences were found for diffusing capacity of lung for carbon monoxide (DLCO) (17.09 vs. 17.24; p = 0.734), and FEV1/FVC (0.77 vs. 0.77; p = 0.967). Interestingly, improvements were more pronounced in patients with large PEH (type IIIb and IV). At 12 month follow-up, both gastrointestinal and respiratory symptoms were significantly improved and 94% of patients were satisfied with the operation. The GERD-HRQL (18.1 ± 7.9 vs. 4.01 ± 2.4; p = 0.001), RSI (37.8 ± 9.7 vs. 10.6 ± 8.9; p < 0.001) and all SF-36 items were improved.

CONCLUSIONS

LTF for the treatment of PEH is safe and seems to be effective up to 12 month follow-up with improved lung volumes, spirometry values, quality of life, gastrointestinal and respiratory symptoms.