Does composite repair of giant paraoesophageal hernia improve patient outcomes?

Recurrence in Paraesophageal Hernia: Patient Factors and Composite Surgical Repair in 862 Cases

BACKGROUND

Repair of giant paraesophageal hernia (PEH) is associated with a considerable hernia recurrence rate by objective measures. This study analyzed a large series of laparoscopic giant PEH repair to determine factors associated with anatomical recurrence.

METHOD

Data was extracted from a single-surgeon prospective database of laparoscopic repair of giant PEH from 1991 to 2021. Upper endoscopy was performed within 12 months postoperatively and selectively thereafter. Any supra-diaphragmatic stomach was defined as anatomical recurrence. Patient and hernia characteristics and technical operative factors, including "composite repair" (360° fundoplication with esophagopexy and cardiopexy to right crus), were evaluated with univariate and multivariate analysis.

RESULTS

Laparoscopic primary repair was performed in 862 patients. The anatomical recurrence rate was 27.3% with median follow-up of 33 months (IQR 16, 68). Recurrence was symptomatic in 45% of cases and 29% of these underwent a revision operation. Hernia recurrence was associated with younger age, adversely affected quality of life, and were associated with non-composite repair. Multivariate analysis identified age < 70 years, presence of Barrett's esophagus, absence of "composite repair", and hiatus closure under tension as independent factors associated with recurrence (HR 1.27, 95%CI 0.88-1.82, p = 0.01; HR 1.58, 95%CI 1.12-2.23, p = 0.009; HR 1.72, 95%CI 1.2-2.44, p = 0.002; HR 2.05, 95%CI 1.33-3.17, p = 0.001, respectively).

CONCLUSION

Repair of giant PEH is associated with substantial anatomical recurrence associated with patient and technique factors. Patient factors included age < 70 years, Barrett's esophagus, and hiatus tension. "Composite repair" was associated with lower recurrence rate.

Dyspnoea improves following composite repair of giant paraoesophageal hernia

INTRODUCTION

Paraoesophageal hernias (PEH) are often symptomatic and can lead to life-threatening complications such as volvulus and ischaemia. Dyspnoea is one of the most prevalent symptoms of giant hiatus herniae. The primary outcome of this study is resolution of dyspnoea following composite repair of giant paraoesophageal hernia. Secondary outcomes include complications of surgery, hernia recurrence rates and effect of recurrence on dyspnoea.

METHODS

Data were extracted from a prospectively maintained single-surgeon database containing records of all patients undergoing composite repair of paraoesophageal hernia. Patients presenting with dyspnoea who underwent composite laparoscopic repair of giant (>30% of stomach above diaphragm) paraoesophageal hernia between March 2009 and December 2015 were included.

RESULTS

Inclusion criteria were met by 154 patients. The mean age at time of surgery was 71.2 years (range 49-93, SD 9.66) with an average BMI of 28 (range 19-38kg/m2, SD 4.1). On average hernia contained 64% of stomach (range 30-100%, SD 20.2). One procedure was converted to laparotomy. Surgery resulted in near complete resolution of dyspnoea (2.6% postoperatively, p<0.001). Recurrence rate was 24% and was not associated with persistent dyspnoea. There was one death and two significant complications.

CONCLUSION

Dyspnoea resolves following laparoscopic repair of giant paraoesophageal hernia. The presence of dyspnoea in patients with known large paraoesophageal hernia should be regarded as an indication for referral to a surgical service with expertise in hiatal hernia management.

Reflux Aspiration Associated with Oesophageal Dysmotility but Not Delayed Liquid Gastric Emptying

INTRODUCTION

Severe oesophageal dysmotility is associated with treatment-resistant reflux and pulmonary reflux aspiration. Delayed solid gastric emptying has been associated with oesophageal dysmotility; however, the role of delayed liquid gastric emptying (LGE) in the pathophysiology of severe reflux disease remains unknown. The purpose of this study is to examine the relationship between delayed LGE, reflux aspiration, and oesophageal dysmotility.

METHODS

Data were extracted from a prospectively populated database of patients with severe treatment-resistant gastro-oesophageal reflux disease. All patients with validated reflux aspiration scintigraphy and oesophageal manometry were included in the analysis. Patients were classified by predominant clinical subtype as gastro-oesophageal reflux (GOR) or laryngopharyngeal reflux. LGE time of 22 min or longer was considered delayed.

RESULTS

Inclusion criteria were met by 631 patients. Normal LGE time was found in 450 patients, whilst 181 had evidence of delayed LGE. Mean liquid half-clearance was 22.81 min. Reflux aspiration was evident in 240 patients (38%). Difference in the aspiration rates between delayed LGE (42%) and normal LGE (36%) was not significant (p = 0.16). Severe ineffective oesophageal motility (IOM) was found in 70 patients (35%) and was independent of LGE time. Severe IOM was strongly associated with reflux aspiration (p < 0.001). GOR dominant symptoms were more common in patients with delayed LGE (p = 0.03).

CONCLUSION

Severe IOM was strongly associated with reflux aspiration. Delayed LGE is not associated with reflux aspiration or severe IOM. Delayed LGE is more prevalent in patients presenting with GOR dominant symptoms.