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Geerts JH, de Haas JWA, Nieuwenhuijs VB. Lessons learned from revision procedures: a case series pleading for reinforcement of the anterior hiatus in recurrent hiatal hernia. Surg Endosc 2024; 38:2398-2404. [PMID: 38565689 PMCID: PMC11078792 DOI: 10.1007/s00464-024-10703-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/16/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Hiatal Hernia (HH) is a common structural defect of the diaphragm. Laparoscopic repair with suturing of the hiatal pillars followed by fundoplication has become standard practice. In an attempt to lower HH recurrence rates, mesh reinforcement, commonly located at the posterior site of the esophageal hiatus, has been used. However, effectiveness of posterior mesh augmentation is still up to debate. There is a lack of understanding of the mechanism of recurrence requiring further investigation. We investigated the anatomic location of HH recurrences in an attempt to assess why HH recurrence rates remain high despite various attempts with mesh reinforcement. METHODS A retrospective case series of prospectively collected data from patients with hiatal hernia repair between 2012 and 2020 was performed. In total, 54 patients with a recurrent hiatal hernia operation were included in the study. Video clips from the revision procedure were analyzed by a surgical registrar and senior surgeon to assess the anatomic location of recurrent HH. For the assessment, the esophageal hiatus was divided into four equal quadrants. Additionally, patient demographics, hiatal hernia characteristics, and operation details were collected and analyzed. RESULTS 54 patients were included. The median time between primary repair and revision procedure was 25 months (IQR 13-95, range 0-250). The left-anterior quadrant was involved in 43 patients (80%), the right-anterior quadrant in 21 patients (39%), the left-posterior quadrant in 21 patients (39%), and the right-posterior quadrant in 10 patients (19%). CONCLUSION In this study, hiatal hernia recurrences occured most commonly at the left-anterior quadrant of the hiatus, however, posterior recurrences were not uncommon. Based on our results, we hypothesize that both posterior and anterior hiatal reinforcement might be a suitable solution to lower the recurrence rate of hiatal hernia. A randomized controlled trial using a circular, bio-absorbable mesh has been initiated to test our hypothesis.
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Nguyen CL, Tovmassian D, Zhou M, Seyfi D, Isaacs A, Gooley S, Falk GL. Recurrence in Paraesophageal Hernia: Patient Factors and Composite Surgical Repair in 862 Cases. J Gastrointest Surg 2023; 27:2733-2742. [PMID: 37962716 PMCID: PMC10837213 DOI: 10.1007/s11605-023-05856-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 09/29/2023] [Indexed: 11/15/2023]
Abstract
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.
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Affiliation(s)
- Chu Luan Nguyen
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - David Tovmassian
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - Michael Zhou
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - Doruk Seyfi
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - Anna Isaacs
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - Suzanna Gooley
- Sydney Heartburn Clinic, Lindfield, NSW, 2070, Australia
| | - Gregory L Falk
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia.
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia.
- Sydney Heartburn Clinic, Lindfield, NSW, 2070, Australia.
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Tsoposidis A, Thorell A, Axelsson H, Reuterwall Hansson M, Lundell L, Wallenius V, Kostic S, Håkanson B. The value of "diaphragmatic relaxing incision" for the durability of the crural repair in patients with paraesophageal hernia: a double blind randomized clinical trial. Front Surg 2023; 10:1265370. [PMID: 38026477 PMCID: PMC10667682 DOI: 10.3389/fsurg.2023.1265370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Background Surgical repair of paraesophageal hernias (PEHs) is burdened with high recurrence rates, and hitherto various techniques explored to enforce the traditional crural repair have not been successful. The hiatal reconstruction in PEH is exposed to significant tension, which may be minimized by adding a diaphragmatic relaxing incision to enhance the durability of the crural repair. Patients and methods All individuals undergoing elective laparoscopic repair of a large PEH, irrespective of age, were considered eligible. PEHs were classified into types II-IV. The preoperative work-up program included multidetector computed tomography and symptom assessment questionnaires, which will be repeated during the postoperative follow-up. Patients were randomly divided into a control group with crural repair alone and an intervention group with the addition of a left-sided diaphragmatic relaxing incision at the edge of the upper pole of the spleen. The diaphragmatic defect was then covered by a synthetic mesh. Results The primary endpoint of this trial was the rate of anatomical PEH recurrence at 1 year. Secondary endpoints included symptomatic gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular and pulmonary symptoms, and patient satisfaction in the immediate postoperative course (3 months) and at 1 year. Postoperative complications, morbidity, and disease burden were recorded for each patient. This was a double-blind study, meaning that the operation report was filed in a locked archive to keep the patient, staff, and clinical assessors blinded to the study group allocation. Blinding must not be broken during the follow-up unless required by any emergencies in the clinical management of the patient. Likewise, the patients must not be informed about the details of the operation. Trial Registration ClinicalTrials.gov, identification number NCT04179578.
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Affiliation(s)
- A. Tsoposidis
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - A. Thorell
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - H. Axelsson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital Östra, University of Gothenburg, Gothenburg, Sweden
| | - M. Reuterwall Hansson
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - L. Lundell
- Division of Surgery and Oncology CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - V. Wallenius
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital Östra, University of Gothenburg, Gothenburg, Sweden
| | - S. Kostic
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital Östra, University of Gothenburg, Gothenburg, Sweden
| | - B. Håkanson
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Ersta Hospital, Stockholm, Sweden
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Petric J, Bright T, Liu DS, Wee Yun M, Watson DI. Sutured Versus Mesh-augmented Hiatus Hernia Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Ann Surg 2022; 275:e45-e51. [PMID: 33856379 DOI: 10.1097/sla.0000000000004902] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This meta-analysis systematically reviewed published randomized control trials comparing sutured versus mesh-augmented hiatus hernia (HH) repair. Our primary endpoint was HH recurrence at short- and long-term follow-up. Secondary endpoints were: surgical complications, operative times, dysphagia and quality of life. SUMMARY BACKGROUND DATA Repair of large HHs is increasingly being performed. However, there is no consensus for the optimal technique for hiatal closure between sutured versus mesh-augmented (absorbable or nonabsorbable) repair. METHODS A systematic review of Medline, Scopus (which encompassed Embase), Cochrane Central Register of Controlled Trials, Web of Science, and PubMed was performed to identify relevant studies comparing mesh-augmented versus sutured HH repair. Data were extracted and compared by meta-analysis, using odds ratio and mean differences with 95% confidence intervals. RESULTS Seven randomized control trials were found which compared mesh-augmented (nonabsorbable mesh: n = 296; absorbable mesh: n = 92) with sutured repair (n = 347). There were no significant differences for short-term hernia recurrence (defined as 6-12 months, 10.1% mesh vs 15.5% sutured, P = 0.22), long-term hernia recurrence (defined as 3-5 years, 30.7% mesh vs 31.3% sutured, P = 0.69), functional outcomes and patient satisfaction. The only statistically significant difference was that the mesh repair required a longer operation time (P = 0.05, OR 2.33, 95% confidence interval 0.03-24.69). CONCLUSIONS Mesh repair for HH does not offer any advantage over sutured hiatal closure. As both techniques deliver good and comparable clinical outcomes, a suture only technique is still an appropriate approach.
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Affiliation(s)
- Josipa Petric
- College of Medicine and Public Health, Flinders University, South Australia, Australia
- Department of Surgery, Flinders Medical Centre, South Australia, Australia
| | - Tim Bright
- Department of Surgery, Flinders Medical Centre, South Australia, Australia
| | - David S Liu
- Department of Surgery, Flinders Medical Centre, South Australia, Australia
- Department of Surgery, Austin Hospital, Victoria, Australia
| | - Melissa Wee Yun
- Department of Surgery, Flinders Medical Centre, South Australia, Australia
| | - David I Watson
- College of Medicine and Public Health, Flinders University, South Australia, Australia
- Department of Surgery, Flinders Medical Centre, South Australia, Australia
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Skancke M, Brody F, Haskins IN, Amdur R, Schoolfield C. Impact of Operative Times and Mesh Utilization on Paraesophageal Hernia Repair: Analysis of 30-Day Outcomes from the American College of Surgeons National Surgical Quality Improvement Project Database. J Laparoendosc Adv Surg Tech A 2018; 29:303-308. [PMID: 30036118 DOI: 10.1089/lap.2018.0369] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Using mesh to buttress the crural repair following a paraesophageal hernia repair remains controversial. This article evaluates recent trends in laparoscopic paraesophageal hernia repairs and analyzes the impact of mesh and operative time on postoperative morbidity. METHODS The 2013-2015 American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database was queried for elective laparoscopic paraesophageal hernia repair with and without mesh. Operative times were grouped into quartiles and statistical analysis was performed using analysis of variance univariate with post hoc testing and multivariate regression modeling. The outcomes of interest were composite morbidity scores and readmission rates within 30 days of surgery. RESULTS The database identified a cohort of 6234 laparoscopic paraesophageal hernia repairs. Mesh was utilized in 42% of cases per year and did not change over the study period (P = .367). Mesh was used 37%, 40%, 43%, and 49% of the time within operative quartiles 1, 2, 3, and 4, respectively (P < .001). Postoperative morbidity and readmission rates for each operative time quartile were 2.8%, 4.1%, 5.42%, and 6.13% (P < .001) and 4.4%, 5%, 6.2%, and 7.6% (P = .001), respectively. Post hoc testing indicated statistically significant differences in postoperative morbidity and readmission rates between quartiles 1 and 3/4. Multivariate regression analysis documented operative time as a risk factor for postoperative morbidities and readmission. Simply using mesh was not directly associated with postoperative morbidity. CONCLUSION Mesh utilization does not impact postoperative outcomes; however, as operative time increases, the incidence of postoperative morbidity also increases.
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Affiliation(s)
- Matthew Skancke
- Department of General Surgery, The Veterans Affairs Medical Center, George Washington University Hospital, Washington, District of Columbia
| | - Fred Brody
- Department of General Surgery, The Veterans Affairs Medical Center, George Washington University Hospital, Washington, District of Columbia
| | - Ivy N Haskins
- Department of General Surgery, The Veterans Affairs Medical Center, George Washington University Hospital, Washington, District of Columbia
| | - Richard Amdur
- Department of General Surgery, The Veterans Affairs Medical Center, George Washington University Hospital, Washington, District of Columbia
| | - Clint Schoolfield
- Department of General Surgery, The Veterans Affairs Medical Center, George Washington University Hospital, Washington, District of Columbia
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Wang WP, Ni PZ, Chen LQ. Laparoscopic surgical treatment of esophageal hiatal hernia. Shijie Huaren Xiaohua Zazhi 2016; 24:3087-3097. [DOI: 10.11569/wcjd.v24.i20.3087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Types II, III and IV esophageal hiatal hernia (EHH) which presents obvious symptoms or leads to potentially fatal complications requires surgical treatment. Laparoscopy has been used to repair EHH in the last two decades globally and proved to be minimally invasive compared to conventional open surgery. This review summarizes current status and prospectives of laparoscopic application in EHH treatment. The published articles on minimally invasive laparoscopic surgical treatment of EHH in PubMed, Cochrane Library and EMBASE databases were retrieved and analyzed. From 1992 to 2015, 86 English articles involving a total of 4771 patients receiving laparoscopic treatment for EHH were retrieved. Perioperative information including safety and feasibility of procedure, postoperative complications, and short/long-term outcome after laparoscopic repair was retrospectively analyzed. Laparoscopic surgical treatment of EHH is a safe, feasible and minimally invasive procedure with fast recovery after repair, low postoperative morbidity and recurrence.
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Furtado RV, Falk GL, Vivian SJ. Recurrence after composite repair of a giant hiatus hernia: 'the golf club' deformity is a distinctive clinical and radiological picture. Ann R Coll Surg Engl 2016; 98:e103-5. [PMID: 27241603 DOI: 10.1308/rcsann.2016.0154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Recurrence of a hiatus hernia after cardiopexy repair can obstruct the lower oesophagus but also provide characteristic radiographic images after a barium meal. Case History Two patients with recurrence of a hiatus hernia underwent repeat surgery. Here, we provide and discuss diagnostic imaging, surgical findings and outcome for these male and female patients. Conclusions Repeat surgery is indicated in patients with recurrence of a hiatus hernia after repair.
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Affiliation(s)
- R V Furtado
- Concord Repatriation General Hospital , Sydney , Australia
| | - G L Falk
- Concord Repatriation General Hospital , Sydney , Australia.,Macquarie University , Sydney , Australia
| | - S J Vivian
- Sydney Heartburn Clinic , Lindfield , Australia
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8
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Quality of Life Following Repair of Large Hiatal Hernia is Improved but not Influenced by Use of Mesh: Results From a Randomized Controlled Trial. World J Surg 2015; 39:1465-73. [PMID: 25651955 DOI: 10.1007/s00268-015-2970-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Laparoscopic surgery is the treatment of choice for repair of large hiatus hernia, but can be followed by recurrence. Repair with prosthetic mesh has been recommended to prevent recurrence, although complications following mesh repair have generated disagreement about whether or not mesh should be used. The early objective and clinical results of a randomized trial of repair with mesh versus sutures have been reported, and revealed few differences. In the current study, we evaluated quality of life outcomes within this trial at follow-up to 2 years. METHODS In a multicenter prospective double-blind randomized trial three methods for repair of large hiatus hernia were compared: sutures versus repair with absorbable mesh (Surgisis) versus non-absorbable (Timesh). Quality of life assessment using the Short-Form 36 (SF-36) questionnaire was undertaken at 3, 6, 12 and 24 months after surgery. SF-36 outcomes (8 individual scales and 2 composite scales) were determined for each group, and compared between groups, and across different follow-up points. RESULTS 126 patients were enrolled-43 sutures, 41 absorbable mesh and 42 non-absorbable mesh. 115 (91.3%) completed a preoperative questionnaire, and 113 (89.7%) completed the post-operative questionnaire at 3 months, 116 (92.1%) at 6 months, 114 (90.5%) at 12 months, and 91 (72.2%) at 24 months. The SF-36 Physical and Mental Component Scores (PCS and MCS) improved significantly following surgery, and this improvement was sustained across 24 months follow-up (p < 0.001 for PCS and MCS at each follow-up point). There were no significant differences between the groups for the component scores or the eight SF-36 subscale scores at each follow-up time. 29 individuals had a recurrence at 6 months follow-up, of which 9 were symptomatic. The PCS were higher in patients with recurrence versus without (p < 0.01), and in patients with a symptomatic recurrence versus asymptomatic recurrence versus no recurrence (p = 0.001). CONCLUSION SF-36 measured quality of life improved significantly after repair of large hiatal hernia at up to 2 years follow-up, and there were no differences in outcome for the different repair techniques. The use of mesh versus no mesh in repair of large hiatal hernia did not influence quality of life.
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Lebenthal A, Waterford SD, Fisichella PM. Treatment and controversies in paraesophageal hernia repair. Front Surg 2015; 2:13. [PMID: 25941675 PMCID: PMC4403251 DOI: 10.3389/fsurg.2015.00013] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 03/31/2015] [Indexed: 01/24/2023] Open
Abstract
Background Historically all paraesophageal hernias were repaired surgically, today intervention is reserved for symptomatic paraesophageal hernias. In this review, we describe the indications for repair and explore the controversies in paraesophageal hernia repair, which include a comparison of open to laparoscopic paraesophageal hernia repair, the necessity of complete sac excision, the routine performance of fundoplication, and the use of mesh for hernia repair. Methods We searched Pubmed for papers published between 1980 and 2015 using the following keywords: hiatal hernias, paraesophageal hernias, regurgitation, dysphagia, gastroesophageal reflux disease, aspiration, GERD, endoscopy, manometry, pH monitoring, proton pump inhibitors, anemia, iron-deficiency anemia, Nissen fundoplication, sac excision, mesh, and mesh repair. Results Indications for paraesophageal hernia repair have changed, and currently symptomatic paraesophageal hernias are recommended for repair. In addition, it is important not to overlook iron-deficiency anemia and pulmonary complaints, which tend to improve with repair. Current practice favors a laparoscopic approach, complete sac excision, primary crural repair with or without use of mesh, and a routine fundoplication.
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Affiliation(s)
- Abraham Lebenthal
- Department of Surgery, Brigham and Women's Hospital, Boston VA Health Care System , Boston, MA , USA ; Division of Thoracic Surgery, Brigham and Women's Hospital, Boston VA Health Care System , Boston, MA , USA
| | - Stephen D Waterford
- Department of General Surgery, Massachusetts General Hospital , Boston, MA , USA
| | - P Marco Fisichella
- Department of Surgery, Brigham and Women's Hospital, Boston VA Health Care System , Boston, MA , USA
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Morelli L, Guadagni S, Mariniello MD, Pisano R, D'Isidoro C, Belluomini MA, Caprili G, Di Candio G, Mosca F. Robotic giant hiatal hernia repair: 3 year prospective evaluation and review of the literature. Int J Med Robot 2014; 11:1-7. [PMID: 24869751 DOI: 10.1002/rcs.1595] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 04/10/2014] [Accepted: 04/11/2014] [Indexed: 02/05/2023]
Abstract
BACKGROUND While conventional laparoscopic repair for giant hiatal hernias is considered difficult, robotic technology is likely to result in an improved postoperative course. METHODS We prospectively analysed patients with giant hiatal hernias who underwent robotic repair during a 3 year period. Preoperative data, operative variables, complications, clinical outcomes and anatomical recurrence after 1 year were evaluated. RESULTS Six patients with giant hiatal hernias underwent robotic repair using the Da Vinci surgical system. The mean operative time was 182 min. The mean hospital stay was 6 days. No patients required reoperation for disease recurrence, and all claimed the absence of postoperative symptoms. CONCLUSIONS Robotic approaches can minimize surgical trauma in patients with giant hiatal hernias and result in favourable outcomes in terms of anatomical recurrence and quality of life. With the availability of the da Vinci System, all patients with giant hiatal hernias can be offered a minimally invasive surgical option.
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Affiliation(s)
- Luca Morelli
- General Surgery unit, Department of Oncology, Transplantation and New Technologies, University of Pisa, Italy; EndoCAS (Centre for Computer Assisted Surgery), University of Pisa, Italy
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12
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Falk GL, Chan BM, Falk SE. Primary Repair of Giant Hiatus Hernia Is Satisfactory Without Mesh: Early Results of a Method Revisited. J Laparoendosc Adv Surg Tech A 2012; 22:748-52. [DOI: 10.1089/lap.2011.0436] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Gregory L. Falk
- Department of Upper GI Surgery, Repartition General Hospital Concord, Concord, Sydney, New South Wales, Australia
- Sydney Heartburn Clinic, Lindfield, Sydney, New South Wales, Australia
| | - Belinda M. Chan
- Department of Upper GI Surgery, Repartition General Hospital Concord, Concord, Sydney, New South Wales, Australia
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Gibson SC, Wong SK, Dixon AC, Falk GL. Laparoscopic repair of giant hiatus hernia: prosthesis is not required for successful outcome. Surg Endosc 2012; 27:618-23. [DOI: 10.1007/s00464-012-2501-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 07/09/2012] [Indexed: 11/28/2022]
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Use of the falciform ligament flap for closure of the esophageal hiatus in giant paraesophageal hernia. J Gastrointest Surg 2012; 16:1417-21. [PMID: 22547347 DOI: 10.1007/s11605-012-1888-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 04/03/2012] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Laparoscopic repair of a giant paraesophageal hiatal hernia remains a challenging procedure. Several techniques have been developed in efforts to achieve tension-free reconstruction of the esophageal hiatus. In this report, we describe a technique whereby the falciform ligament is used as an autologous onlay flap to achieve tension-free closure of the crural defect of a giant paraesophageal hernia (GPEH). DISCUSSION Use of the falciform ligament as a vascularized autologous onlay flap is a safe and effective procedure to obtain closure of the crural defect of a GPEH. The falciform ligament should be adequately mobilized from the anterior abdominal wall to prevent lateral tension on the flap, but care must be taken to avoid devascularization. Interrupted vertical mattress sutures are used to fix the falciform ligament to the left and right hiatal crurae.
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15
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Oelschlager BK, Petersen RP, Brunt LM, Soper NJ, Sheppard BC, Mitsumori L, Rohrmann C, Swanstrom LL, Pellegrini CA. Laparoscopic paraesophageal hernia repair: defining long-term clinical and anatomic outcomes. J Gastrointest Surg 2012; 16:453-9. [PMID: 22215243 DOI: 10.1007/s11605-011-1743-z] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 10/13/2011] [Indexed: 01/31/2023]
Abstract
OBJECTIVE We recently reported in a multi-institutional, randomized study of laparoscopic paraesophageal hernia repair (LPEHR) that the anatomic recurrence rate at a median of approximately 5 years was >50%. This study focuses exclusively on the symptomatic response to LPEHR and its relationship with the development of a recurrent hernia. METHODS During 2002 to 2005, 108 patients underwent LPHER with or without biologic mesh. A standardized symptom severity questionnaire, SF-36 health survey, and upper gastrointestinal series were performed at baseline, 6 months, and during 2008-2009. RESULTS Of 108 patients, 72 (average age of 68 ± 10 years) underwent clinical assessment, and 60 of them also had radiologic studies at a median follow-up of 58 (40-78) months. Radiographic recurrence (≥ 20 mm) was 14% at 6 months and 57% at the time of follow-up, and the average recurrence size was 40 ± 10 mm. All symptoms were significantly improved at long-term follow-up and, with the exception of heartburn, were unaffected by the presence or size of the recurrence. Two patients (3%) with recurrent symptoms related to their hernia underwent reoperation. CONCLUSION Despite frequent radiologic recurrences after LPEHR, symptoms remain well controlled, patient satisfaction is high, and the need for reoperation is low.
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Affiliation(s)
- Brant K Oelschlager
- Department of Surgery, University of Washington, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195-6410, USA.
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Antoniou SA, Antoniou GA, Pointner R, Granderath FA. Regarding "laparoscopic repair of large hiatal hernia without prosthetic reinforcement: late results and relevance of anterior gastropexy". J Gastrointest Surg 2011; 15:2117-8. [PMID: 21573876 DOI: 10.1007/s11605-011-1565-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Accepted: 05/03/2011] [Indexed: 01/31/2023]
Affiliation(s)
- Stavros A Antoniou
- Department of General and Visceral Surgery, Center for Minimally Invasive Surgery, Hospital Neuwerk, Dünner Str. 214-216, 41066, Mönchengladbach, Germany.
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Giant hiatal hernias: direct hiatus closure has an acceptable recurrence rate. Updates Surg 2011; 63:75-81. [PMID: 21479718 DOI: 10.1007/s13304-011-0066-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 03/14/2011] [Indexed: 12/21/2022]
Abstract
The purpose of this retrospective study was to analyze our results after laparoscopic repair of giant hiatal hernias with direct closure of the hiatus, since the reports document a radiological recurrence rate as high as 42%. Various studies have shown that laparoscopic hernia repair is safe and effective, and carries a lower morbidity than the open approach, but the high recurrence rates still being reported (ranging from 10 to 42%) have prompted many authors to recommend using a prosthesis. This is a report on the follow-up of 38 patients with type III and IV hiatal hernia who underwent laparoscopic repair with direct hiatal closure without the aid of meshes. From January 2000 to March 2010, 38 patients with III and IV hiatal hernia were treated at the Surgery Division of Cisanello Hospital in Pisa. Data were collected retrospectively and included demographics, preoperative symptoms, radiographic and endoscopic findings, intraoperative and postoperative complications, postoperative symptoms, barium X-ray and follow-up by medical examination and symptoms questionnaire. The sample included 12 males and 26 females, between 36 and 83 years (median age 62) with 26 type III (68.4%) and 12 type IV (31.6%) hernias. There were no conversions to laparotomy and no intraoperative or postoperative mortality. A 360° Nissen fundoplication was performed in 22 patients (57.9%) and a 270° Toupet fundoplication in 16 patients (42.1%). One patient had intraoperative complications (2.6%), and postoperative complications occurred in another three (7.9%). The follow-up was complete in all patients and ranged from 12 to 88 months (median 49 months). Barium swallow was performed in all patients and recurrence was found in five patients (13.1%); three of these patients (7.9%) were asymptomatic, while two (5.2%) were reoperated. All 38 patients' symptoms improved. Judging from our data, the recurrence rate after laparoscopic giant hiatal hernia repair with direct hiatal closure can be lowered by complying with several crucial surgical principles, e.g., complete sac excision and appropriate crural closure, adequate esophageal lengthening, and the addition of an antireflux procedure and a gastropexy. We recorded a radiological recurrence rate of 13.1% (5/38) and patient satisfaction in our series was quite high (92%). Based on these findings, the laparoscopic treatment of giant hernias with direct hiatal closure seems to be a safe and effective procedure.
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Watson DI. Evolution and Development of Surgery for Large Paraesophageal Hiatus Hernia. World J Surg 2011; 35:1436-41. [DOI: 10.1007/s00268-011-1029-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Erosion of a composite PTFE/ePTFE mesh after hiatal hernia repair. Surg Laparosc Endosc Percutan Tech 2010; 19:175-7. [PMID: 19390288 DOI: 10.1097/sle.0b013e3181a11926] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Primary repair of large hiatal defects is associated with higher than acceptable recurrence rates. This has led to the increased use of fascial prostheses for reinforcement of the hiatal repair. We report a case of intraluminal mesh erosion after repair of a recurrent paraesophageal hernia with a composite polytetrafluoroethylene/expanded polytetrafluoroethylene prosthesis in an 80-year-old woman. Mesh erosion is a rarely reported complication after hiatal hernia repair, and because many cases will go unreported, their true incidence is unknown. Besides the durability of mesh repair, the ongoing clinical trials investigating laparoscopic correction of hiatal hernias should also focus on the risk of complications associated with the use of prosthetic materials and the mode of fixation.
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Frantzides CT, Carlson MA, Loizides S, Papafili A, Luu M, Roberts J, Zeni T, Frantzides A. Hiatal hernia repair with mesh: a survey of SAGES members. Surg Endosc 2009; 24:1017-24. [PMID: 19997755 DOI: 10.1007/s00464-009-0718-6] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2009] [Accepted: 08/29/2009] [Indexed: 12/16/2022]
Abstract
BACKGROUND Primary repair of large hiatal hernia is associated with a high recurrence rate. The use of mesh may reduce this recurrence rate. The indication for mesh use, the type of mesh to use, and the placement technique are controversial. A survey of surgeon practice was undertaken to obtain a better understanding of the controversies surrounding this clinical problem. METHODS A questionnaire on the technique and results of mesh hiatal herniorrhaphy was sent to 1,192 members of the Society of Gastrointestinal and Endoscopic Surgeons (SAGES). RESULTS There were 275 responses; 261 of these were analyzed. A total of 5,486 hiatal hernia repairs with mesh were reported; 77% and 23% were performed laparoscopically vs open, respectively. The most common indication for mesh usage was an increased size hiatal defect (46% of respondents). The most common mesh types were biomaterial (28%), polytetrafluoroethylene (25%), and polypropylene (21%). Suture anchorage was the most common fixation technique (56% of respondents). The findings showed a failure rate of 3%, a stricture rate of 0.2%, and an erosion rate of 0.3%. Biomaterial tended to be associated with failure, whereas nonabsorbable mesh tended to be associated with stricture and erosion. CONCLUSIONS The use of mesh during hiatal hernia repair resulted in a reported recurrence rate which appeared to be lower than that obtained historically without mesh. No one mesh type was clearly superior in terms of avoiding failure and complication.
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Furnée EJB, Draaisma WA, Simmermacher RK, Stapper G, Broeders IAMJ. Long-term symptomatic outcome and radiologic assessment of laparoscopic hiatal hernia repair. Am J Surg 2009; 199:695-701. [PMID: 19892314 DOI: 10.1016/j.amjsurg.2009.03.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Revised: 03/14/2009] [Accepted: 03/18/2009] [Indexed: 12/31/2022]
Abstract
BACKGROUND The long-term durability of laparoscopic repair of paraesophageal hiatal herniation is uncertain. This study focuses on the long-term symptomatic and radiologic outcome of laparoscopic paraesophageal herniation repair. METHODS Between 2000 and 2007, 70 patients (49 females, mean age +/- standard deviation 60.6 +/- 10.9 years) undergoing laparoscopic repair of paraesophageal herniation were studied prospectively. After a mean follow-up of 45.6 +/- 23.8 months, symptomatic (65 patients, 93%) and radiologic follow-up (60 patients, 86%) was performed by standardized questionnaires and esophagograms. RESULTS The symptomatic outcome was successful in 58 patients (89%), and gastroesophageal anatomy was intact in 42 patients (70%). The addition of a fundoplication was the only significant predictor of an unfavorable radiologic outcome in the univariate analysis (odds ratio .413; 95% confidence interval, .130 to 1.308; P = .125). CONCLUSIONS The long-term symptomatic outcome of laparoscopic repair of paraesophageal hiatal herniation was favorable in 89% of patients, and 70% had successful anatomic repair. The addition of a fundoplication did not prevent anatomic herniation.
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Affiliation(s)
- Edgar J B Furnée
- Department of Surgery, University Medical Center, Utrecht, The Netherlands
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Abstract
Australian surgeons have been prominent in the introduction, development, and consolidation of laparoscopic surgery of the upper gut. In doing this, some of the very best principles of surgical innovation have been in evidence: preliminary animal work in which to test hypotheses and techniques, followed by careful application and documentation in the clinical setting, randomized clinical trials and finally academic reporting and ongoing development. This review documents the introduction of laparoscopic surgery for gastroesophageal reflux, hiatus hernia, achalasia, gastroesophageal malignancy, obesity, and a range of emergency conditions in Australia. Those involved are regarded as world leaders in their field. A vital component of this success has been the close cooperation between surgeons and gastroenterologists within the Gastroenterological Society of Australia.
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Affiliation(s)
- David C Gotley
- Department of Surgery, University of Queensland, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane, Qld 4102, Australia.
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Tsunoda S, Jamieson GG, Devitt PG, Watson DI, Thompson SK. Early Reoperation After Laparoscopic Fundoplication: The Importance of Routine Postoperative Contrast Studies. World J Surg 2009; 34:79-84. [DOI: 10.1007/s00268-009-0217-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Pointner R, Granderath FA. [Hiatus hernia and recurrence : the Achilles heel of antireflux surgery?]. Chirurg 2008; 79:974-81. [PMID: 18317714 DOI: 10.1007/s00104-008-1496-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Long-term studies show good postoperative results after laparoscopic antireflux surgery, but still approximately 10% of patients suffer from new or recurrent symptoms of gastroesophageal reflux disease. In the majority of cases the symptoms are caused by morphological changes of the fundic wrap or are related to the hiatal closure. Closure of the esophageal hiatus is therefore becoming more and more the key point of antireflux surgery. The aim of this study was to show the problems caused by the esophageal hiatus and to offer possible solutions. Therefore 1,201 laparoscopic antireflux procedures and 240 refundoplications performed in our department between 1993 and 2007 were analyzed with respect to morphologic reasons for failures and the corresponding symptoms. The most common morphological reason for complications after surgery was failure of the hiatal closure with consecutive intrathoracic migration of the fundic wrap, the so-called slipped Nissen. In the past the typical problems after open antireflux surgery were either that the wrap was too loose, a breakdown of the wrap or a so-called telescope phenomenon, all caused by failure of the fundic wrap and now a rarity since laparoscopic surgery. Even after repeated laparoscopic refundoplications the main problem was always the hiatus. This shows the importance of the crural closure and the necessity of a specific definition of size and form of the hiatus.The aim of this study was to initiate a discussion leading to a new definition of the hiatus with the focus on the "hiatal surface area" for a better basis for comparison of the published results of antireflux or hiatal surgery.
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Affiliation(s)
- R Pointner
- Abteilung für Allgemeinchirurgie, A.ö. Krankenhaus Zell am See, A-5700, Zell am See, Osterreich.
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Hazebroek EJ, Ng A, Yong DHK, Berry H, Leibman S, Smith GS. Clinical evaluation of laparoscopic repair of large hiatal hernias with TiMesh. ANZ J Surg 2008; 78:914-7. [PMID: 18959648 DOI: 10.1111/j.1445-2197.2008.04691.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The use of mesh for laparoscopic repair of large hiatal hernias may decrease recurrence rates in comparison with primary suture repair. The type of mesh material, as well as its size and shape, is still a matter of debate. The aim of this study was to evaluate a lightweight polypropylene mesh (TiMesh) repair of hiatal hernias, with particular reference to symptomatic relief, patient satisfaction and quality of life (QOL). From a prospectively maintained clinical database, 40 consecutive patients were identified who underwent elective laparoscopic hiatal hernia repair with TiMesh between November 2004 and December 2006. QOL and symptom analysis was carried out using Quality of Life in Reflux and Dyspepsia (QOLRAD) and dysphagia questionnaires preoperatively, and postoperatively after 6 weeks, 6 months, and 1 year. The mean age of the patient was 65.2 years (range: 40-93 years). Total complication rate was 7.5%; all complications were treated without residual disability. There was no 30-day mortality. Median hospital stay was 2.7 days (range 2-13 days). Completed questionnaires were obtained from 37 (92.5%) of 40 patients. After 1 year, more than 90% of patients were satisfied with their symptomatic outcome and regarded their surgery as successful. There was a significant improvement in QOL, measured with QOLRAD at all postoperative time-points (P < 0.001). There was no difference between pre- and postoperative dysphagia scores. Laparoscopic repair of large hiatal hernias with TiMesh yields good symptomatic and clinical outcome. Further studies are needed to show whether the use of this lightweight polypropylene mesh is associated with a reduction in recurrence rates after hiatal hernia repair in the longer term.
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Affiliation(s)
- Eric J Hazebroek
- Department of Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Evaluation of lightweight titanium-coated polypropylene mesh (TiMesh) for laparoscopic repair of large hiatal hernias. Surg Endosc 2008; 22:2428-32. [PMID: 18626699 DOI: 10.1007/s00464-008-0070-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Revised: 04/13/2008] [Accepted: 04/24/2008] [Indexed: 01/06/2023]
Abstract
BACKGROUND The use of mesh for laparoscopic repair of large hiatal hernias may reduce recurrence rates in comparison with primary suture repair. However, there is a potential risk of mesh-related oesophageal complications due to prosthesis erosion. The aim of this study was to evaluate a lightweight polypropylene mesh (TiMesh) repair of hiatal hernias with particular reference to intraluminal erosion. METHODS Data were collected prospectively on 18 consecutive patients undergoing elective laparoscopic repair of a large hiatal hernia with the use of TiMesh between November 2004 and December 2005. Quality of life and symptom analysis was performed using QOLRAD questionnaires preoperatively and postoperatively after 6 weeks, 6 months, 1 year and 2 years. Barium studies were performed preoperatively and 2 years postoperatively to assess hernia recurrence. After 2 years, oesophagogastric endoscopy was performed to assess signs of mesh-related complications. RESULTS All operations were completed laparoscopically. There was no 30-day mortality and median hospital stay was 2.8 days (range 2-13 days). Complications occurred in two patients (11%), both of whom were treated without residual disability. Two years after hiatal hernia repair, there was significant improvement in quality-of-life scores (QOLRAD 5.79, p < 0.001). There was no difference between pre- and postoperative dysphagia scores. No signs of stricture formation or prosthetic erosion were identified during endoscopic follow-up. One patient had a small (2 cm) sliding hiatal hernia demonstrated by barium studies, which was asymptomatic. CONCLUSIONS Laparoscopic reinforcement of primary hiatal closure with TiMesh leads to a durable repair in patients with large hiatal hernias. Endoscopic follow-up did not show any signs of mesh-related complications after prosthetic reinforcement of the crural repair. Our preliminary results suggest that it is safe to proceed with this lightweight polypropylene mesh for reinforcement of the hiatal repair.
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Hazebroek EJ, Gananadha S, Koak Y, Berry H, Leibman S, Smith GS. Laparoscopic paraesophageal hernia repair: quality of life outcomes in the elderly. Dis Esophagus 2008; 21:737-41. [PMID: 18459987 DOI: 10.1111/j.1442-2050.2008.00831.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Paraesophageal hernias (PEH) occur when there is herniation of the stomach through a dilated hiatal aperture. These hernias occur more commonly in the elderly, who are often not offered surgery despite the failure of medical treatment to address mechanical symptoms and life-threatening complications. The aim of this study was to assess the impact of laparoscopic repair of PEH on quality of life in an elderly population. Data were collected prospectively on 35 consecutive patients aged >70 years who had laparoscopic repair of a symptomatic PEH between December 2001 and September 2005. The change in quality of life was assessed using a validated questionnaire, the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD), and by patient interviews. Patients were assessed preoperatively, and at 6 weeks, 6 months, 12 months, 1 year, and 2 years postoperatively. Mean patient age was 77 years (range 70-85); mean American Society of Anesthesiologists class was 2.7 (range 1-3). There were 28 women and 7 men. There was one readmission for acute reherniation, which required open revision. Total complication rate was 17.1%. All complications were treated without residual disability. There was no 30-day mortality, and median hospital stay was 3 days (range 2-14). Completed questionnaires were obtained in 30 of 35 patients (85.7%). There was a significant improvement in quality of life, as measured with QOLRAD, at all postoperative time points (P < 0.001). Laparoscopic PEH repair can be performed with acceptable morbidity in symptomatic patients refractory to conservative treatment and is associated with a significant improvement in quality of life. Our data support elective repair of symptomatic PEH in the elderly, a population who may not always be referred for a surgical opinion.
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Affiliation(s)
- E J Hazebroek
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
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Hazebroek EJ, Koak Y, Berry H, Leibman S, Smith GS. Critical evaluation of a novel DualMesh repair for large hiatal hernias. Surg Endosc 2008; 23:193-6. [PMID: 18320282 DOI: 10.1007/s00464-008-9772-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Revised: 11/18/2007] [Accepted: 12/11/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of mesh for laparoscopic repair of large hiatal hernias may reduce recurrence rates in comparison to primary suture repair. However, there is a potential risk of mesh-related oesophageal complications due to prosthesis erosion. The aim of this study was to critically evaluate a novel mesh (DualMesh) repair of hiatal hernias with particular reference to intraluminal erosion. METHOD Medical records of 19 patients who underwent laparoscopic hiatal hernia repair with DualMesh reinforcement of the crural closure were reviewed from a prospectively collected database. Quality of life and symptom analysis was performed using quality of life in reflux and dyspepsia (QOLRAD) questionnaires pre- and postoperatively after 6 weeks, 6 months, 1 year and 2 years. Barium studies were performed on patients pre-operatively and two years postoperatively to assess hernia recurrence. After 2 years, oesophagogastric endoscopy was performed to assess signs of erosion. RESULTS Mean patient age was 70.5 years (range 49-85 years). Two years after hiatal hernia repair, there was significant improvement in quality-of-life scores (QOLRAD: p < 0.001). Follow-up barium studies performed at 31.3 months (range 29-40 months) after surgery showed moderate recurrent hernias (>4 cm) in 1/14 patients (7%). Endoscopies performed at 34.4 months (range 28-41 months) after surgery did not show any signs of prosthetic erosion. CONCLUSION Laparoscopic reinforcement of primary hiatal closure with DualMesh leads to a durable repair in patients with large hiatal hernias. Long-term endoscopic follow-up did not show any signs of mesh erosion after prosthetic reinforcement of the crural repair.
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Affiliation(s)
- E J Hazebroek
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Level 2, Vindin House, St Leonards, Sydney, NSW, 2065, Australia.
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Kelty CJ, Falk GL. Mesh repairs in hiatal surgery. The case against mesh repairs in hiatal surgery. Ann R Coll Surg Engl 2007; 89:479-81. [PMID: 17688718 PMCID: PMC2063450 DOI: 10.1308/003588407x202182] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Clive J Kelty
- Department of Upper GI Surgery, Concord Repatriation General Hospital, Concord, Sydney, New South Wales, Australia.
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Safranek PM, Gifford CJ, Booth MI, Dehn TCB. Results of laparoscopic reoperation for failed antireflux surgery: does the indication for redo surgery affect the outcome? Dis Esophagus 2007; 20:341-5. [PMID: 17617884 DOI: 10.1111/j.1442-2050.2007.00719.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Short and medium term outcomes from laparoscopic antireflux surgery are generally excellent. A small number of patients suffer recurrent reflux or intolerable side-effects and may require reoperation. In this paper we describe our experience of 35 laparoscopic reoperations from a single center. Data on patients undergoing antireflux surgery in our unit has been prospectively collected and includes more than 600 primary laparoscopic antireflux operations since 1993. Laparoscopic reoperations have been performed between 1996 and 2005 for patients suffering recurrent reflux, dysphagia or severe gas bloat symptomatic despite medical treatment. All patients underwent preoperative barium studies and endoscopy with selective manometry and pH studies. Symptomatic outcomes were evaluated at 6 weeks and 12 months with Visick scores. Anatomical results were assessed with barium studies at between 6 and 12 months. Thirty-five laparoscopic reoperations were performed in 20 women and 13 men (median age 56 years). Primary surgery had been performed in our unit in 27 (77%) and elsewhere in eight (23%). Median time from primary surgery was 28.5 months (5-360). Two patients underwent a second reoperation. Indication was recurrent reflux in 28 (80%), dysphagia in five (14%) and gas bloat in two (6%). Thirty-two of the 35 reoperations (91.4%) were completed laparoscopically, median operating time was 120.5 min (65-210) and median hospital stay 2 days. There was no mortality and there were only five minor complications. Twelve-month follow-up was available for 32 reoperations (91%). Overall good symptomatic outcomes were obtained in 26 (74%) Visick I or II at 6 weeks and 24 of 32 (75%) at 12 months. In reoperations for dysphagia/gas bloat there was a relative risk of 4.26 of a poor symptomatic outcome (Visick III or IV) at 12 months compared to those for recurrent reflux (P < 0.05, Fisher's exact test). Laparoscopic reoperation is feasible with low conversion rates and minimal morbidity for patients who have undergone previous abdominal or thoracic hiatal repair. Symptomatic outcomes are generally good, particularly if the indication is recurrent reflux.
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Affiliation(s)
- P M Safranek
- Department of Upper Gastrointestinal Surgery, Royal Berkshire Hospital, London Road, Reading, Berkshire, UK
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