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Laparoscopic repair for gastroesophageal reflux disease is now an accepted therapy. However, controversy exists with regard to the choice of operation between complete 360-degree Nissen fundoplication versus partial 270-degree Toupe fundoplication. In addition there is some controversy with regard to the proper choice of operation in patients with poor esophageal motility. Another class of hiatal hernia patients are those patients with paraesophageal herniation. Questions regarding the approach to these patients include whether or not to use a reflux procedure at the time of repair and the role of mesh in repair of these large hernias. This retrospective study was undertaken to compare the results of laparoscopic Nissen fundoplication and Toupe fundoplication in patients with both normal and abnormal esophageal motility. In addition the subset of patients with paraesophageal herniation was studied in an effort to ascertain the best surgical approach in these patients. In this study a retrospective analysis was performed on 188 consecutive patients during the period 1995 to 2001. All patients who presented with hiatal hernia surgical problems during this period were included. Endoscopy was performed in all patients with esophageal reflux. Manometry was performed in all patients except those presenting as emergency incarcerations. pH probe testing was performed in those patients in whom it was deemed necessary to establish the diagnosis. Upper gastrointestinal radiographs were used to define anatomy in paraesophageal hernia patients when possible. All patients with esophageal reflux were first treated with a trial of medical therapy. Patients with esophageal reflux and normal esophageal motility underwent 360-degree Nissen fundoplication. Those patients with poor esophageal motility (less than 65 mm of mercury) underwent laparoscopic 270-degree Toupe fundoplication. Patients presenting with paraesophageal herniation underwent laparoscopic repair. When possible esophageal manometry was performed on these patients preoperatively and if normal peristalsis was documented a Nissen fundoplication was performed. If poor esophageal motility was documented before surgery a Toupe fundoplication was performed. Mesh reinforcement of the diaphragmatic hiatus was used if necessary to complete a repair without tension. Patients were followed both by their primary gastroenterologist and their surgeon. Follow-up studies including endoscopy, pH probe, and upper gastrointestinal series were used as necessary in the postoperative period to document any problems as they occurred. Of the 188 patients in the study 141 patients underwent Nissen fundoplication, 21 patients underwent Nissen fundoplication and repair of paraesophageal hernia, 15 underwent Toupe fundoplication, seven underwent Toupe and paraesophageal hernia repair, and four paraesophageal hernia repair alone. One hundred eighty-three patients underwent a laparoscopic operation. Five patients of the 188 underwent an initial open operation-two of these patients because of the size of their paraesophageal hernia. Three of these patients had reoperations of remote operations done years before at other institutions. Twenty-two patients with poor esophageal motility (11.7 %) were included in the study. Fifteen patients required Toupe fundoplication whereas seven patients required Toupe fundoplication and repair of paraesophageal hernias. Mesh repair of paraesophageal hernias was accomplished in ten patients. Patients undergoing Toupe fundoplication had a 13 per cent dysphagia rate less than 4 weeks postoperatively and a 0% dysphagia rate greater than four weeks postoperatively. Patients undergoing Nissen fundoplication had a 16 per cent dysphagia rate less than 4 weeks postoperatively, 2 per cent dysphagia rate greater than 4 weeks postoperatively and no dysphagia at 6 weeks postoperatively. Recurrent symptomatic reflux occurred in 1.4 per cent of Nissen fundoplications and 6.7 per cent of Toupe fundoplications. Of Nissen and paraesophageal repairs 14.2 per cent had reflux and 14.3 per cent of Toupe and paraesophageal repairs had recurrent symptomatic reflux. Overall, complication rate was low. Use of mesh to repair large paraesophageal hernias resulted in a recurrence rate of 0 per cent. There was no instance of infection or bowel fistulization related to the use of mesh. We conclude that laparoscopic Nissen fundoplication in patients with normal esophageal motility is associated with a low rate of dysphagia and a low rate of recurrent reflux. Toupe fundoplication when used in reflux patients with poor esophageal motility is associated with a low rate of dysphagia and an acceptable rate of recurrent reflux. Laparoscop
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PMID:Laparoscopic hiatal hernia repair in patients with poor esophageal motility or paraesophageal herniation. 1160 59

Disorders of the oesophagus present a diagnostic and therapeutic challenge. The presenting symptoms of dysphagia, reflux, pain and vomiting are almost universal, irrespective of the underlying pathology. A combination of endoscopy, barium studies, pH studies and manometry are often required to determine the exact diagnosis and to plan the most effective treatment. Paraoesophageal hiatal hernia is an uncommon condition, present in 14% of all hiatal hernias, which requires urgent correction to prevent life-threatening complications. It is unusual for other oesophageal disorders to coexist. We present a case where achalasia and a paraoesophageal hiatal hernia probably coexisted.
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PMID:Coexisting achalasia and paraoesophageal hiatal hernia. 1178 83

A 40-year-old woman with complaints of relapse in the upper abdomen and dysphagia was referred for laparascopic hiatal hernia repair. Chest radiograph, barium-swallow, and upper endoscopy revealed a paraesophageal hernia. Esophageal manometry and 24-h-pH study showed no pathological findings. A laparoscopic gastropexy was planned. Intraoperatively, in contradiction to the preoperative findings, an extrahiatal hernia containing most of the stomach was found. After resection of the hernia sac, the beating heart without covering pericardium was seen. These findings were confirmed by an additional thoracoscopy at the end of the operation. The defect was closed by direct suturing. The postoperative course and 2-month follow-up were uneventful. The resected parts of the hernia sac showed an embryonic and dysgenetic etiology. This rare malformation has been reported in combination with complex syndromes, which appear with serious clinical and morphological signs in the neonatal period. In adults, the pericardial aplasia can be observed during diagnostic or surgical interventions. In these patients, complaints are usually not caused by the malformation but may be due to the occasional herniation of abdominal organs. We consider laparoscopic repair to be a gentle and safe procedure for the treatment of extrahiatal hernias.
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PMID:Laparoscopic repair of an extrahiatal hernia caused by congenital dysplasia: a case report. 1196 97

Recent literature has reported as high as a 42 per cent recurrence rate after laparoscopic paraesophageal hernia repair (LPEHR). We report long-term follow-up in a cohort of patients undergoing LPEHR at Vanderbilt University. Thirty-one patients underwent attempted LPEHR between September 1993 and May 2000. Six of 31 patients (19%) were converted to an open procedure and were excluded from the study. All patients had complete excision of the sac, primary closure of the crura, and an antireflux procedure. An Institutional Review Board-approved follow-up barium esophagram was performed at a mean of 25 months postoperatively. Three experienced laparoscopic surgeons (K.S., M.H., and W.R.) collectively reviewed the esophagrams for evidence of recurrence. The mean age of patients was 61 years (range 41-92). There were six males and 19 females. Fifteen of 25 patients (60%) returned for an esophagram. Only one of 15 patients (7%) had a recurrent paraesophageal hernia. However, five of 15 patients (33%) had herniated an intact wrap 2 to 4 cm above the diaphragm. The patient with a true paraesophageal hernia recurrence returned with symptoms of dysphagia. Two of the five patients (40%) with a herniated wrap complained of heartburn, which was controlled with a proton pump inhibitor. All other patients were asymptomatic. Our recurrence rate of true paraesophageal hernias after LPEHR is low (7%) and compares with that reported in the literature for open repairs. However, 33 per cent of the patients in this study were found to have a herniated wrap. Because there is no risk of strangulation we have not operated on any of these patients. LPEHR is our procedure of choice for Type II and III hiatal hernias with good symptom relief and a low true recurrence rate.
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PMID:Laparoscopic paraesophageal hernia repair has an acceptable recurrence rate. 1207 37

Although esophageal lengthening procedures (Collis gastroplasty) have been recommended as an adjunct to antireflux surgery in patients with shortened esophagus, there are few data on physiologic outcomes in these patients. This study details the long-term outcomes in patients who underwent antireflux surgery with Collis gastroplasty. All patients undergoing esophagogastric fundoplication (EGF) with a Collis gastroplasty for the management of gastroesophageal reflux disease or paraesophageal hernia were identified from a prospectively maintained database. Symptom questionnaires were used during follow-up to assess symptomatic outcomes. Barium esophogram, upper endoscopy with biopsy, and catheterless esophageal acid monitoring (BRAVO system) were recommended for all patients. Patients with abnormal results of physiologic studies underwent further treatment based on a standardized algorithm. Between 1996 and 2002, a total of 68 patients underwent EGF with Collis gastroplasty. Twenty-seven (40%) had a large paraesophageal hernia, and 20 (30%) had undergone a prior EGF. Fifty-six (82%) of the procedures were performed laparoscopically. Mean follow-up time was 30 months, with 10 (15%) patients lost to latest follow-up. Symptomatic outcome data were available for 85% of patients, with significant improvements reported for heartburn (86%), chest pain (90%), dysphagia (89%), and regurgitation (91%). Most patients (84%) were off medications. Physiologic data were completed in 37% of the patients. Of those undergoing physiologic follow-up studies, 17% had recurrent hiatal hernia, and 80% had endoscopically identified esophagitis and pathologic esophageal acid exposure on pH testing. Despite this, 65% of the patients with objectively identified abnormalities reported significant symptomatic improvement compared to their preoperative symptoms. Two patients developed changes associated with Barrett's esophagus that were not present preoperatively. Distal esophageal injury can persist after EGF with Collis gastroplasty, despite significant symptomatic improvements. Appropriate follow-up in these patients requires objective surveillance, which should eventuate in further treatment if esophageal acid is not completely controlled. Although the Collis gastroplasty is conceptually appealing, these results call into question the liberal application of this technique during EGF.
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PMID:Disparity between symptomatic and physiologic outcomes following esophageal lengthening procedures for antireflux surgery. 1474 33

The presence of a hiatal hernia is generally considered a contraindication to gastric banding in the morbidly obese, despite recent reports indicating favorable outcomes following simultaneous repair of sliding hernias and laparoscopic adjustable gastric banding (LAGB). A 66-year-old woman weighing 120 kg (BMI 45) with arterial hypertension and gastroesophageal reflux-related chronic obstructive pulmonary disease underwent repair of a large paraesophageal hernia and LAGB. At 40 months followup, the patient had lost 44% excess body weight (BMI 36) and had no complaints of heartburn, regurgitation or dysphagia. She was no longer hypertensive and her pulmonary condition had improved significantly. Barium swallow at 30 months showed normal anatomy and positioning of the band. Because other minimally traumatic surgical options are lacking, the author believes morbidly obese patients with hiatal hernia should not be denied the advantages of LAGB. Adequate weight reduction, resolution of gastroesophageal reflux and other co-morbidities can be expected if an appropriate surgical technique is used.
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PMID:Simultaneous paraesophageal hernia repair and gastric banding. 1582 83

A 58-year-old male patient was operated for complaints of dysphagia, anemia and retrosternal discomfort due to a type II hiatal hernia. A complete hernia sac excision and posterior crural repair was performed laparoscopically with support of the da Vincitrade mark robotic system. An antireflux procedure was not performed because of the absence of gastroesophageal reflux disease. Nine months after surgery the patient presented with recurrent complaints of dysphagia and retrosternal pain. Barium esophagram series revealed a recurrent paraesophageal hernia which was confirmed on esophagogastroscopy. A robot-assisted re-laparoscopy was performed. Left to the still intact hiatoplasty of the original operation a tear in the diaphragm, through which part of the stomach covered with peritoneum had herniated, was encountered. The hernia sac was excised, the diaphragmatic defect closed and reinforced with an expanded polytetrafluoroethylene strip of 5 x 8 cm. After surgery the patient recovered quickly, oral intake was resumed on the first postoperative day and the hospital stay was 3 days. The use of prosthetic mesh to reinforce the hiatoplasty and the addition of an antireflux procedure after hiatal hernia repair are ongoing controversial aspects of hiatal hernia repair. Reports on laparoscopic redo surgery for recurrent diaphragmatic hernia are limited and will be addressed in this case report, in perspective of the aforementioned controversial components.
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PMID:Recurrent paraesophageal hernia due to diaphragm rupture: a case report. 1645 74

Paraesophageal hernia repair has been associated with a recurrence rate of up to 42%. Thus, in the last decade, there has been increasing interest in the use of mesh reinforcement of the hiatal repair. Polytetrafluoroethylene (PTFE) is one of the materials that have been used for this purpose, as it is thought to induce minimal tissue reaction. We report two cases in which complications specific to the use of PTFE mesh in this location developed over time. In the first patient, a gastrectomy was required to remove a large PTFE mesh which had eroded into the esophagogastric junction and gastric cardia. The second patient experienced severe dysphagia resulting from a stricture caused by the implant, requiring removal of the mesh. Although such complications have only rarely been reported, the severity and consequences of these incidents, as reported in the literature and in light of our observations, suggest that an alternative to PTFE should be considered for crural reinforcement during paraesophageal hernia repair.
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PMID:Complications of PTFE mesh at the diaphragmatic hiatus. 1788 2

The purpose of this study was to compare the quality of life (QOL) and functional results of 42 patients undergoing primary (60%) and 23 patients undergoing redo (40%) transthoracic paraesophageal hernia repairs. All patients had a floppy Nissen or Belsey anti-reflux repair with or without a Collis gastroplasty. Morbidity occurred in 12% of patients and was similar between groups (P=1.0). Overall QOL scores were not different between groups. Patients undergoing initial repair were found to have significantly higher QOL scores related to their GERD symptoms (P=0.02). Postoperative GERD symptom scores were not significantly different between groups for heartburn, regurgitation, epigastric/chest pain, or cough. Redo patients had more bloating (P=0.02) and dysphagia (P=0.04). Overall, total GERD scores were higher in the redo group compared to the initial group indicating worse GERD-related dysfunction in the redo group (15.8+/-3.8 vs. 6.3+/-1.6, P=0.03). Functional and QOL analysis of transthoracic paraesophageal hernia repairs indicates that redo procedures are associated with a higher incidence of specific gastrointestinal symptoms and worse GERD-related QOL when compared to initial procedures. These differences, while statistically significant, have limited clinical relevance as the overall QOL was not different between groups and low GERD symptom scores were found in both groups.
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PMID:Quality of life following primary vs. redo transthoracic paraesophageal hernia repairs. 1800 23

Laparoscopic repair of paraesophageal hernia (PEH) involves removal of the hernia sac, cruroplasty, and fundoplication. Mesh application to cruroplasty seems to reduce hernia recurrence rate, but may be associated with dysphagia. The aim of the study was to review the clinical and laboratory outcomes of a series of patients with PEH after laparoscopic repair. Patients with PEH, who had laparoscopic repair and 1-year postoperative follow-up, were included in the study. Pre- and postoperative testing included symptom questionnaires, barium esophagogram, pH-monitoring, barium swallow testing. In the first half cases, suturing of large hernia gaps was reinforced with prosthesis (PR), whereas in the second half only suture cruroplasty (SC) was performed. Sixty-eight patients (36 male) with PEH were included in the study. There were no conversions to open. Postoperatively, dysphagia grading was significantly correlated to esophageal transit time (P < 0.001). There were seven recurrences; one paraesophageal and six wrap migrations. Also, four cases with stenosis were identified all in the PR group. Dysphagia was more common (P= 0.05) and esophageal transit more delayed (P= 0.034) after PR than after SC. Two revisions, one for esophageal stenosis and one for recurrent PEH, derived from the SC group. Reflux was more common after Toupet fundoplication than after Nissen fundoplication (NF) (P= 0.031) in patients with impaired esophageal motility. Laparoscopic repair of PEH with SC is associated with satisfactory clinical outcomes and low rate of wrap migration, at least similar to PR hiatal repair. NF is effective as an antireflux procedure in all cases.
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PMID:Simple suture or prosthesis hiatal closure in laparoscopic repair of paraesophageal hernia: a retrospective cohort study. 2065 44


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