A. D. Newton1, D. A. Herbst1, K. R. Dumon1, D. T. Dempsey1 1Hospital Of The University Of Pennsylvania,Surgery,Philadelphia, PA, USA
Introduction: The optimal technique for paraesophageal hernia (PEH) repair has been debated. For the past several years, our surgical treatment algorithm for elderly patients with large symptomatic PEH has been formal laparoscopic repair if gastroesophageal reflux (GER) symptoms predominate, and laparoscopic anterior gastropexy alone if mechanical symptoms predominate. Our goal was to evaluate outcomes with this approach.
Methods: We retrospectively reviewed all first-time operations for large PEH (40% or more intrathoracic stomach) in patients ≥ age 65 performed by a single attending surgeon from 2011-2016. Primary outcome measures were perioperative morbidity and mortality, presence of herniated stomach or GER on upper gastrointestinal radiograph (UGI) 3 months postop, and subjective symptom improvement.
Results: A total of 83 patients (mean age 76.9 years, 84% female) had a primary laparoscopic operation for large PEH (type 3, n=75; type 4, n=8). Thirty patients had formal repair (sac removal, posterior crural repair, partial fundoplication, gastropexy) and 53 had gastropexy alone. There were no open or esophageal lengthening operations and one 30-day reoperation. Median intrathoracic stomach percentage was 50% vs. 90% for formal repair vs. gastropexy. Mean operative time was 161.7 vs. 100.6 minutes (P<0.0001) for formal repair vs. gastropexy, and mean postoperative length of stay was no different (2.6 vs. 2.8 days). ASA was ≥ 3 for 53% vs. 70% (P=0.133) for formal repair vs. gastropexy. Overall 90-day morbidity was 15.7% (16.7% with formal repair vs. 15.1% with gastropexy, P=0.85). There was one post-discharge 30-day mortality. On UGI 3 months postop, one patient (3%) had > 10% of stomach above the diaphragm after formal repair compared to 59% after gastropexy (P<0.001), and 69% had demonstrable GER on UGI after gastropexy compared to 24% after formal repair (P<0.001). However, 71% were asymptomatic and 98% had improvement in preop symptoms after gastropexy; 76% were asymptomatic and 92% had improvement in preop symptoms after formal repair.
Conclusion: Laparoscopic gastropexy alone is a reasonable treatment for large PEH in elderly patients with predominately mechanical symptoms while formal repair gives good results when GER symptoms predominate. Esophageal lengthening is unnecessary in most patients. Postop UGI findings often do not correlate with clinical symptoms in this group.