Repair of paraesophageal hernias

Horgan, Santiago; Eubanks, Thomas R.; Jacobsen, Garth R.; Omelanczuk, Pablo; Pellegrini, Carlos A.

doi:10.1016/s0002-9610(99)00061-6

Cited by 94 publications

(55 citation statements)

References 15 publications

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“…19,28 However, several prominent surgeons have favored a more conservative approach. 3,4,29,38,47 Furthermore, there is growing appreciation that laparoscopic repair of large type III hiatal hernias can be a difficult operation that is associated with a high rate of hernia recurrence as well as other complications, such as vagal nerve injury. Hence, more experience, longer follow-up, and further refinement of the operative technique is indicated before laparoscopic repair of large hiatal hernias can be recommended as the standard approach.…”

Section: Discussionmentioning

confidence: 99%

Paraesophageal Hernias: Operation or Observation?

Stylopoulos¹,

Gazelle²,

Rattner³

2002

Annals of Surgery

363

208

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ObjectiveTo examine the hypothesis that elective laparoscopic repair should be routinely performed on patients with asymptomatic or minimally symptomatic paraesophageal hernias. Summary Background DataThe management of asymptomatic paraesophageal hernias is a controversial issue. Most surgeons believe that all paraesophageal hernias should be corrected electively on diagnosis, irrespective of symptoms, to prevent the development of complications and avoid the risk of emergency surgery. MethodsA Markov Monte Carlo decision analytic model was developed to track a hypothetical cohort of patients with asymptomatic or minimally symptomatic paraesophageal hernia and reflect the possible clinical outcomes associated with two treatment strategies: elective laparoscopic paraesophageal hernia repair (ELHR) or watchful waiting (WW). The input variables for ELHR were estimated from a pooled analysis of 20 published studies, while those for WW and emergency surgery were derived from the 1997 HCUP-NIS database and surgical literature published from 1964 to 2000. Outcomes for the two strategies were expressed in quality-adjusted lifeyears (QALYs). ResultsAnalysis of the HCUP-NIS database showed that published studies overestimate the mortality of emergency surgery (17% vs. 5.4%). The mortality rate of ELHR was 1.4%. The annual probability of developing acute symptoms requiring emergency surgery with the WW strategy was 1.1%. For patients 65 years of age, ELHR resulted in reduction of 0.13 QALYs (10.78 vs. 10.65) compared with WW. The model predicted that WW was the optimal treatment strategy in 83% of patients and ELHR in the remaining 17%. The model was sensitive only to alterations of the mortality rates of ELHR and emergency surgery. ConclusionsIf ELHR is routinely recommended, it would be more beneficial than WW in fewer than one of five patients. WW is a reasonable alternative for the initial management of patients with asymptomatic or minimally symptomatic paraesophageal hernias, and even if an emergency operation is required, the burden of the procedure is not as severe as was thought in the past.The need for surgical correction of asymptomatic paraesophageal hernias is controversial. Many surgeons, citing the influential studies of Belsey 1 and Hill, 2 advocate elective repair of all paraesophageal hernias irrespective of symptoms. The rationale for this approach is prophylactic; that is, prevention of life-threatening complications such as obstruction and strangulation and avoidance of the significant morbidity and mortality of an emergency operation. The perception that laparoscopic techniques offer a less morbid approach to surgical correction of paraesophageal hernias is cited as an additional reason to support the elective repair of paraesophageal hernias. However, beliefs held by the surgical community about the natural history of paraesophageal hernias and the morbidity and mortality of both elective and emergency operations are based on relatively small patient series and anecdotal case reports. Several recent ...

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Section: Discussionmentioning

confidence: 99%

Paraesophageal Hernias: Operation or Observation?

Stylopoulos¹,

Gazelle²,

Rattner³

2002

Annals of Surgery

363

208

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“…Several initial reports of laparoscopic repair showed it was a technically feasible and safe procedure in centers with extensive experience in laparoscopic surgery (Table 3). Horgan et al 9 reported that laparoscopic repair of PEH was a technically difficult procedure but effective, with a mean hospital stay of 4 days and a single surgical death among 41 patients. In another study, Edye et al 11 reported on 55 patients undergoing laparoscopic repair of PEH and again found it a safe and technically feasible procedure, with no reported surgical deaths 4 Giant Paraesophageal Hernia and acceptable outcomes, although details of hospital stay were not reported.…”

Section: Discussionmentioning

confidence: 99%

Laparoscopic Repair of Giant Paraesophageal Hernia: 100 Consecutive Cases

Luketich¹,

et al. 2000

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“…As laparoscopic antireflux surgery for GERD has become popularized, it is a natural extension of this technique for PEH. Numerous studies have demonstrated symptomatic improvement as a result of laparoscopic PEH repairs [21, 22, 23]. Schauer et al [8]compared 25 patients who underwent open PEH to 67 who underwent laparoscopic repair.…”

Section: Discussionmentioning

confidence: 99%

“…However, with the popularization of laparoscopic antireflux surgery for gastroesophageal reflux disease (GERD), the laparoscopic approach has been widely reported [2, 3, 4, 5, 6, 7, 8, 9, 10, 11]. Most of these reports focus on the technical success of completing the repair laparoscopically, perioperative complications, and short-term recurrence rates.…”

Section: Introductionmentioning

confidence: 99%

Surgical Management of Paraesophageal Hernias: Outcome and Quality of Life Analysis / with Invited Commentary

Velanovich

Karmy‐Jones²

2001

Dig Surg

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Background: Paraesophageal hernias (PEHs) have protean clinical manifestations, and a variety of surgical approaches may be appropriate. We report both surgical and quality-of-life (QoL) outcomes for PEH repairs. Methods: All patients undergoing elective repair of PEHs were evaluated preoperatively for symptoms and the radiologic appearance of the PEH. In addition, patients undergoing elective repair completed the SF-36, a generic QoL instrument, preoperatively and postoperatively. Short-term postoperative complications were recorded. Symptomatic outcomes and QoL outcomes were assessed. Results: Over a 50-month period, 44 PEH repairs were completed. 3 patients represented emergently – 2 with gastric ischemia, 1 with frank gastric necrosis. The most common presenting symptoms were heartburn (48%), chest pain (27%), abdominal pain (20%), regurgitation (20%), dysphagia (18%), and microcytic anemia (18%). Only 4 patients (9%) were truly asymptomatic. 31 repairs were attempted laparoscopically, 5 were converted to open procedures. There were no gastric or esophageal perforations. 91% of patients had resolution of preoperative symptoms. The only death was in a patient with gastric necrosis. 5 of 8 patients treated by crural repair without fundoplication developed postoperative heartburn. Patients treated laparoscopically had superior QoL scores than patients treated by open surgery in the domains of physical functioning (90 vs. 65), role-physical (100 vs. 0), role-emotional (100 vs. 66.7), vitality (80 vs. 55), and social functioning (100 vs. 75). However, there were 3 symptomatic recurrences in the laparoscopic group (11.5%), all in patients with large, type-III hiatal hernias. Conclusions: PEH is a potentially life-threatening disease. Although most can be repaired laparoscopically, specific principles must be individualized to each patient to minimize complications and recurrences. A fundoplication should be added to all repairs. Laparoscopic repairs can produce superior QoL results: however, patients with large, type-III hernias may not be appropriate candidates for laparoscopic repair.

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Repair of paraesophageal hernias

Cited by 94 publications

References 15 publications

Paraesophageal Hernias: Operation or Observation?

Paraesophageal Hernias: Operation or Observation?

Laparoscopic Repair of Giant Paraesophageal Hernia: 100 Consecutive Cases

Surgical Management of Paraesophageal Hernias: Outcome and Quality of Life Analysis / with Invited Commentary

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