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

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Abstract

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.

Related collections

Most cited references 45

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Guidelines for the management of hiatal hernia.

Geoffrey Kohn, Raymond Richard Price, Steven DeMeester … (2013)

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A prospective, randomized trial of laparoscopic polytetrafluoroethylene (PTFE) patch repair vs simple cruroplasty for large hiatal hernia.

Thomas A. Carlson, A Madan, Constantine Frantzides … (2002)

Large hiatal hernias are prone to disruption, resulting in reherniation, when repaired with simple cruroplasty. The use of mesh may decrease the rate of reherniation in the laparoscopic repair of large hiatal hernias. Prospective, randomized controlled trial. University-affiliated private hospital. Seventy-two individuals undergoing laparoscopic Nissen fundoplication with a hernia defect greater or equal to 8 cm in diameter. Nissen fundoplication with posterior cruroplasty (n = 36) vs Nissen fundoplication with posterior cruroplasty and onlay of polytetrafluoroethylene (PTFE) mesh (n = 36). Recurrences, complications, hospital stay, operative time, and cost. Patients in both groups had similar hospital stays, but the PTFE group had a longer operative time. The cost of the repair was $960 +/- $70 more in the group with the prosthesis. Complications were minor and similar in both groups. There were 8 hernia recurrences (22%) in the primary repair group and none in the PTFE group (P<.006). The use of prosthetic reinforcement of cruroplasty in large hiatal hernias may prevent hernia recurrences.

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Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial.

L Brunt, Nayak Polissar, Blair Jobe … (2006)

Laparoscopic paraesophageal hernia repair (LPEHR) is associated with a high recurrence rate. Repair with synthetic mesh lowers recurrence but can cause dysphagia and visceral erosions. This trial was designed to study the value of a biologic prosthesis, small intestinal submucosa (SIS), in LPEHR. Patients undergoing LPEHR (n = 108) at 4 institutions were randomized to primary repair -1 degrees (n = 57) or primary repair buttressed with SIS (n = 51) using a standardized technique. The primary outcome measure was evidence of recurrent hernia (> or =2 cm) on UGI, read by a study radiologist blinded to the randomization status, 6 months after operation. At 6 months, 99 (93%) patients completed clinical symptomatic follow-up and 95 (90%) patients had an UGI. The groups had similar clinical presentations (symptom profile, quality of life, type and size of hernia, esophageal length, and BMI). Operative times (SIS 202 minutes vs. 1 degrees 183 minutes, P = 0.15) and perioperative complications did not differ. There were no operations for recurrent hernia nor mesh-related complications. At 6 months, 4 patients (9%) developed a recurrent hernia >2 cm in the SIS group and 12 patients (24%) in the 1 degrees group (P = 0.04). Both groups experienced a significant reduction in all measured symptoms (heartburn, regurgitation, dysphagia, chest pain, early satiety, and postprandial pain) and improved QOL (SF-36) after operation. There was no difference between groups in either pre or postoperative symptom severity. Patients with a recurrent hernia had more chest pain (2.7 vs. 1.0, P = 0.03) and early satiety (2.8 vs. 1.3, P = 0.02) and worse physical functioning (63 vs. 72, P = 0.03 per SF-36). Adding a biologic prosthesis during LPEHR reduces the likelihood of recurrence at 6 months, without mesh-related complications or side effects.

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Author and article information

Contributors

E.-S. A. El-Magd: gec_drelsayedadel86@hotmail.com

Journal

Journal ID (nlm-ta): Hernia

Journal ID (iso-abbrev): Hernia

Title: Hernia

Publisher: Springer Paris (Paris )

ISSN (Print): 1265-4906

ISSN (Electronic): 1248-9204

Publication date (Electronic): 29 August 2023

Publication date PMC-release: 29 August 2023

Publication date (Print): 2023

Volume: 27

Issue: 6

Pages: 1555-1570

Affiliations

[1 ]Faculty of Medicine, Mansoura University, ( https://ror.org/01k8vtd75) Mansoura, Egypt

[2 ]Department of General Surgery, Faculty of Medicine, Gastrointestinal Surgical Center GISC, Mansoura University, ( https://ror.org/01k8vtd75) Gehan Street, Mansoura, 35511 Al Dakahlia Governorate Egypt

Article

Publisher ID: 2851

DOI: 10.1007/s10029-023-02851-7

PMC ID: 10700459

PubMed ID: 37642773

SO-VID: dd3c65b3-5cf5-4cf1-ba50-99ec4c6ef30f

License:

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