In this single institution, decade-long series of 662 patients, we demonstrate that laparoscopic GPEH repair is feasible, safe, and provides excellent patient satisfaction and symptom resolution despite an increase in patient comorbid conditions over the study period. Laparoscopic repair of GPEH was successfully accomplished in 98.5% of patients with a post-operative mortality rate of 1.7% and major morbidity of 19%. Thromboembolic complications were a significant source of post-operative morbidity, despite routine use of anti-thrombotic compression stockings and subcutaneous heparin. Patient factors that were predictive of increased risk of post-operative death and significant major adverse events were age ≥70 years, BMI ≥35, and CCI score ≥3 and urgent operation. Symptom relief after laparoscopic repair was excellent, with 89% of patients expressing satisfaction with the surgical result at 30 months median clinical follow-up. Importantly, patients with a limited radiographic recurrence compared to those with no radiographic recurrence were equally satisfied with surgery and reported similar GERD-HRQoL outcomes.
When the current era of operation (July 1, 2003–June 30, 2008) was compared to the early era (January 1, 1997 to June 30, 2003), patients were 50% more likely to have significant age-adjusted comorbidities and 60% more likely to have an underlying pulmonary disease. Despite this, the risk of adverse outcome in the current era was the same as in the early era. Operative time and need for reoperation in the immediate post-operative period were significantly less in the current era, reflecting the experience of the surgical team, on-going efforts to refine the operative approach and perioperative patient care.
The only patient characteristic which was associated with a risk for radiographic recurrence and reoperation on multivariate analysis was age younger than 70 years at initial operation. This association with younger age has not been previously described, but one possible hypothesis for this observation is that younger patients are healthier and more active, thereby exerting greater stress on the hiatal repair. This may be a subpopulation where routine crural reinforcement with mesh can lead to improved long-term durability of the repair. Further studies are needed to confirm this association and test this hypothesis.
Laparoscopic Giant Paraesophageal Hernia is comparable to Open Repair
The operative outcomes, long-term symptomatic relief and freedom from radiographic recurrence after laparoscopic repair of GPEH reported here are similar to the outcomes for open repair as reported in the literature. Our operative mortality of 1.7% compares quite well to mortality rates of 0–3.7% that have been reported by Hashemi, Low and others.10–12
Interestingly, we found that the operative mortality for elective repair was significantly lower than urgent repair (0.5% versus 7.5%), which contradicts recent studies13
suggesting that mortality for elective and emergent repairs are not substantially different. In our series, elective repair in the hands of experienced surgeons has significantly better outcomes than urgent repair by the same surgeons. This observation warrants further study to more clearly describe this association.
Our radiographic recurrence and symptom outcomes also compared favorably to the outcomes reported for open repair and contrast with the very high rates of radiographic recurrence published in some series of laparoscopic repair.7, 10, 14–16
. Hashemi and colleagues, in 2000,10
were among the first to publish a high-rate of radiographic recurrence in patients undergoing laparoscopic repair (42% radiographic recurrence rate in 27 patients; median time to barium esophagram 17 months). This sharply contrasted with the 15% radiographic recurrence rate in the open group (median time to barium esophagram 35 months). Symptomatic relief was also worse in the laparoscopic group; 77% of patients reported a good to excellent outcome compared to 88% in their open group. These results should emphasize the need for surgeons to assess their ongoing clinical outcomes and strive for superior outcomes using the surgical approach that works best for their group. In our center, extensive minimally invasive surgical experience and good to excellent results in close to 90% of our patients undergoing laparoscopic repair of their GPEH led to our adoption of this approach in preference over the open approach.
The On-going Debate Regarding Mesh Cruraplasty and Esophageal Lengthening
The use of esophageal lengthening and mesh cruraplasty in repair of GPEH continues to be debated among surgeons and a clear answer does not exist.7, 17–21
Hiatal herniation is associated with two distinct processes: axial tension caused by proximal migration of the GEJ in the setting of acquired short esophagus; and radial tension exerted on the hiatal orifice as the hernia enlarges.22
The goal of esophageal lengthening is to eliminate the axial tension exerted on the hiatus by creating an adequate length of intra-abdominal neoesophagus. The goal of mesh cruraplasty is to strengthen the ability of the hiatus to resist radial tension created by the pressure differential between the abdomen and thorax. As such, use of esophageal lengthening and/or mesh cruraplasty is an intraoperative decision and should be made after optimal surgical mobilization of the esophagus and diaphragm. The surgeon then determines the best repair for the patient. The optimal repair may require esophageal lengthening and mesh cruraplasty, one but not the other, or neither.
In our series, use of mesh cruraplasty was not necessary in the opinion of the surgeon in the majority of cases. We believe that two factors are critical to the success of primary crural re-approximation: 1) maintenance of the peritoneal lining over the crura; and 2) complete division of all attachments from the diaphragm to the stomach and spleen. This allows free mobility of the left limb of the crus and facilitates re-approximation without tension. In our experience, we accomplished these the majority of the time and mesh was only required in 13% of cases when the overlying peritoneum had been compromised, leading to exposed muscle fibers of poor integrity or the hiatal opening was unable to be closed without undue tension. The finding in our series that mesh cruroplasty is associated with a significantly increased odds of reoperation for recurrence over time and is not protective against radiographic recurrence reflects the fact that mesh, in our hands, is only used when the crural closure is compromised. Similarly, it may also indicate that the type of mesh and the technical aspects of the cruroplasty are still in evolution and the ideal approach has not been determined.
Conversely, Collis gastroplasty for esophageal lengthening was used in 63% of patients in this series. The majority of our patients had a Type III paraesophageal hernia. Restoring adequate length to the intraabdominal esophagus returns the GEJ to the abdomen and releases the axial tension created by the shortened esophagus, thereby minimizing the axial forces exerted on the hiatal repair. While the use of esophageal lengthening has decreased over time in our series, in our opinion, this is due to the increased experience and success of extended mediastinal mobilization. Extended mobilization may obviate the need for an esophageal lengthening procedure in some patients with mild to moderate shortening or, at least limit the length of the Collis gastroplasty to a shorter segment. This is clearly an important component of the repair and every effort should be made to strive for adequate esophageal length using laparoscopic esophageal mobilization to the maximal degree prior to determining if a Collis gastroplasty is indicated.
Discussion of Study Limitations
This study has several strengths and limitations. Long-term follow-up on this patient population can be difficult to obtain due to the extremes of age and also to the costs of maintaining a clinical outcomes research team. We present mid-term validated patient-reported outcomes in 74% of patients at a median follow-up of 30 months. Radiographic follow-up at least 3 months after operation was available for 67% of patients at a median follow-up of 25 months. While these numbers are comparable to other series,10, 14, 15, 23, 24
a concerted effort has been made over the past two years to improve our longitudinal care for these patients and clinical pathways, have been instituted at our center to provide routine and standardized follow-up. In spite of these measures, serial time-points were not available for most patients, limiting assessment of the time course for radiographic and/or symptom recurrence.
The degree of missing data for the outcomes measured in this study is also a limitation of the study. When factors associated with missing data were analyzed, we found that patients of who were 80 years or older at the time of operation, those with significant comorbid illness and early era of operation were more likely to be missing follow-up symptom questionnaires and validated quality of life studies. Octogenarians were also more likely to be missing a barium esophagram obtained at least 3 months after operation. This degree of missing data introduces bias into the analysis that must be taken into consideration. For example, the percentage of patients complaining of postoperative dysphagia may be under-estimated by the findings of study given that elderly patients are more likely to experience dysphagia than are younger patients. It is also possible that the increased rate of radiographic recurrence in younger patients is reflective of the higher rate of availability of follow-up barium esophagram in this group rather than a true association with increased risk of radiographic recurrence.
Analysis of preoperative symptoms was also limited by the fact that the majority of these data were derived from retrospective review of existing medical records. While most patients had clear prospective documentation of the presence or absence of symptoms such as reflux, regurgitation, dysphagia, and shortness of breath, other symptoms, such as cough and hoarseness were less well-documented. Important post-operative complaints, such as early satiety, diarrhea and excessive flatulence, were rarely assessed preoperatively. These symptoms can be the source of long-term patient dissatisfaction and warrant further study.
In the largest series to date, we found that laparoscopic repair of GPEH is technically feasible, associated with good to excellent outcomes in close to 90% of patients, and has a low morbidity and mortality in the hands of experienced surgeons. Patients who are obese, older and who have more comorbid illness are at higher risk for adverse post-operative outcomes, but the majority of such cases can still be accomplished laparoscopically with good results. Decisions regarding esophageal lengthening and mesh cruraplasty are best made at the time of operation related to the specific anatomic considerations of the individual patient. Laparoscopic repair of paraesophageal hernia provides excellent patient satisfaction and symptom resolution, with reoperation rates that are comparable to the best open series.10, 25