Paraesophageal hiatal hernia: Is an antireflux procedure necessary?

Williamson, Warren A.; Ellis, F. Henry; Streitz, John M.; Shahian, David M.

doi:10.1016/0003-4975(93)90878-l

Cited by 115 publications

(75 citation statements)

References 15 publications

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“…Failure of an antireflux procedure can commonly be attributed to: disruption of the wrap; construction of a wrap which is too tight or misplaced, or recurrent hiatal herniation [3]. The incidence of this last sequela ranges from 0 to 10% in series of primary antireflux procedures (both open and laparoscopic), but generally is about 1% [4, 5, 6, 7, 8, 9, 10, 11]. Recurrent hiatal herniation was the operative indication in up to 70% of reoperations in series of failed antireflux procedures [3, 12, 13, 14, 15].…”

Section: Introductionmentioning

confidence: 99%

Laparoscopic Prosthetic Reinforcement of Hiatal Herniorrhaphy

Carlson

Richards

Frantzides³

1999

Dig Surg

109

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Background/Aims: Primary repair of a large hiatal hernia is associated with a published recurrence rate of up to 10%; anecdotal rates even higher than this have been reported to the authors. The use of prosthetic material in the repair of other abdominal wall defects has often produced better results than primary repair. We wanted to compare laparoscopic primary repair of large hiatus hernias with laparoscopic primary repair reinforced with prosthetic. Methods: Thirty-one patients with symptomatic gastroesophageal reflux and a hiatal defect 8 cm or greater were randomized to Nissen fundoplication with posterior cruroplasty (n = 16) or Nissen cruroplasty, and onlay of polytetrafluoroethylene (PTFE) mesh (n = 15). All patients underwent preoperative esophagogastroduodenoscopy (EGD) and barium esophagography. After posterior cruroplasty with interrupted nonabsorbable suture, the mesh reinforcement group had an onlay of PTFE placed around the hiatus. A radial slit with 3 cm ‘keyhole’ (to accommodate the esophagus) was cut into the PTFE. The prosthetic was stapled to the diaphragm, and the two leaves of the slit were stapled to each other. All patients underwent EGD at 3 months and all had esophagrams every 6 months postoperatively. Follow-up ranged from 12 to 36 months. Results: Length of hospital stay was equal in both groups (2 days). The average cost to the patient with PTFE was USD 1,050 higher than to the patient with primary repair. There were 2 complications (1 pneumonia, 1 urinary retention) in the PTFE group, and 1 complication (pneumothorax) in the primary repair group. There were 3 recurrences (18.8%) in the primary group (p = 0.08, χ² test). Conclusion: The use of PFTE reinforcement for primary repair of large hiatal hernias may result in a lower rate of recurrent herniation compared to primary repair alone.

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Section: Introductionmentioning

confidence: 99%

Laparoscopic Prosthetic Reinforcement of Hiatal Herniorrhaphy

Carlson

Richards

Frantzides³

1999

Dig Surg

109

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“…In one report, 60% of patients with type III hernias had hypotensive lower esophageal sphincter and an abnormal 24-h pH test [16]. When an antireflux procedure is not performed, onefifth of patients will have reflux symptoms, postoper- atively [17]. These findings support routine performance of an antireflux procedure with paraesophageal hernia repair.…”

Section: Discussionmentioning

confidence: 94%

Laparoscopic repair of paraesophageal hernia

et al. 1995

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Large paraesophageal hernias are generally repaired by reduction of the stomach into the abdomen, sac excision, crural closure, and gastropexy or fundoplication. After gaining experience performing laparoscopic repair of sliding hiatal hernias and Nissen fundoplication we combined laparoscopic access with traditional surgical technique in treating patients with complex paraesophageal hernias. Ten adults, six males and four females, with type III paraesophageal hernias underwent laparoscopic repair between February 1993 and April 1994. The average age of the patients was 60.4 years (range 38-81). Using five ports (three 10 mm and two 5 mm), the stomach was reduced into the abdomen, the hernia sac was resected, and the defect was closed with pledgeted horizontal mattress sutures. In addition, nine patients had a Nissen fundoplication performed and one patient had a diaphragmatic gastropexy. The procedure was completed laparoscopically in all ten cases and the median operating time was 282 min (range 165-430). Two complications occurred, an intraoperative gastric laceration, and a postoperative mediastinal seroma. All patients were discharged on the 2nd or 3rd postoperative day. Eight of nine patients were asymptomatic at last follow-up (mean 8.9 months postop). One patient has mild dysphagia and heartburn from partial migration of the fundoplication into the chest. One patient died 3 months postoperatively of unrelated causes. Paraesophageal hernia can be reduced and repaired safely with laparoscopic access using standard surgical techniques.

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“…All symptomatic patients with PH should be considered for surgical repair [7]. Untreated patients have a very high mortality rate because of complications.…”

Section: Discussionmentioning

confidence: 99%