Prospective study of giant paraesophageal hernia repair with 1-year follow-up

Abstract

Objective Evaluating giant paraesophageal hernia (GPEH) repair requires long-term follow-up. GPEH repair can have associated high recurrence rates, yet this incidence depends on how recurrence is defined. Our objective was to prospectively evaluate patients undergoing GPEH repair with one-year follow-up. Methods Patients undergoing elective GPEH repair between 2011 and 2014 were prospectively enrolled. Postoperatively, patients were evaluated at one-month and one-year. Radiographic recurrence was evaluated by barium swallow and defined as a gastroesophageal junction located above the hiatus. Quality of life was evaluated pre- and post-operatively using a validated questionnaire. Results One-hundred six patients were enrolled. The majority of GPEH repairs were performed laparoscopically (80.2%) and 7.5% were redo repairs. At one-year follow-up, 63.4% of patients were symptom free and radiographic recurrence was 32.7%. Recurrence rate was 18.8% with standard definition (> 2cm of stomach above the diaphragm). Quality of life scores at one year were significantly better following operative repair, even in patients with radiographic recurrence (7.0 vs. 22.5 all patients, 13.0 vs 22.5 with recurrence (P<0.001). Patients with small radiographic recurrences have similar satisfaction and symptom severity to patients with > 2 cm recurrences. Conclusions GPEH repair can be performed with low operative mortality and morbidity. The rate of recurrence at one year depends on the definition used. Patient satisfaction and symptom severity are similar between patients with radiographic and >2cm hernia recurrences. Longer follow-up and critical assessment of our results are needed to understand the true impact of this procedure and better inform perioperative decision making.

Preoperative botulinum toxin type A: A case report of a proposed new strategy for giant hiatal hernia management

“…2 Several strategies have been reported to reduce recurrence after hiatoplasty, such as pledgeted interrupted nonabsorbable sutures, 3 mesh crural reinforcement, or wedge gastroplasty. 4 In a pilot animal experimental study, Cakmak et al 5 showed that local injection of BTX causes paralysis in abdominal wall muscles, increases the intra-abdominal volume, and decreases the pressure. Considering that the risk for hiatal hernia recurrence may be affected by the intra-abdominal pressure, 2,6,7 our team proposed a preoperative BTX injection strategy for the giant hiatal hernia management.…”

Health-related quality of life after laparoscopic repair of giant paraesophageal hernia: how does recurrence in CT scan compare to clinical success?

“…While this group had fewer problems in bladder and bowel functions, the association with GPEH is uncertain. The preoperative quality of life was not measured here, but overall HRQoL improves with a laparoscopic GPEH repair [22].…”

“…A recurrent hernia was defined as a hernia with > 2 cm of the stomach above the diaphragm. The hernia was considered small, or minor recurrence, if it was 2 to 5 cm and a large recurrent hernia, or major recurrence, was > 5 cm, as defined in prior studies [18,22,27].…”

“…Health-related quality of life (HRQoL) has been measured individually in previous studies with generic or diseasespecific instruments. Minimal correlation between radiological findings and HRQoL has been shown [14,18,22].…”

The role of small or single-institution prospective studies in thoracic research

“…An example of this is Giant Paraesophageal Hernias (GPEH) that are relatively rare and often misunderstood. Stringham et al (6) studied 106 GPEH patients at a single institution and found that surgical repair is safe and carries a low postoperative complication rate. Additionally, the study compared a new, radiographic recurrence definition (any amount of stomach above the diaphragm on barium swallow) to the conventional recurrence definition most often used in GPEH literature (>2 cm or >10% of the stomach above the diaphragm) and found a 1-year radiographic recurrence rate of 32.7% compared to a conventional recurrence rate of 18.8%.…”