Comparison of laparoscopic versus open repair of paraesophageal hernia

Comparison of laparoscopic versus open repair of paraesophageal hernia

Comparison of Laparoscopic versus Open Repair of Paraesophageal Hernia Philip R. Schauer, MD, Sayeed Ikramuddin, MD, Robert H. McLaughlin, MD, Toby O...

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Comparison of Laparoscopic versus Open Repair of Paraesophageal Hernia Philip R. Schauer, MD, Sayeed Ikramuddin, MD, Robert H. McLaughlin, MD, Toby O. Graham, MD, Adam Slivka, MD, PhD, K. K. W. Lee, MD, W. H. Schraut, MD, J. D. Luketich, MD, Pittsburgh, Pennsylvania

BACKGROUND: Recent reports suggest that laparoscopic paraesophageal hernia repair (LPHR) is feasible, but no direct comparisons with the standard open paraesophageal hernia repair (OPHR) have been reported. The purpose of this study was to compare the short-term outcome of LPHR versus OPHR at a single institution. METHODS: The operative and postoperative courses of 95 consecutive patients undergoing open or laparoscopic repair of a paraesophageal hernia (PEH) were retrospectively reviewed, and outcomes of LPHR versus OPHR were compared. RESULTS: PEH was associated with advanced age and significant comorbidity. Although the operative time was increased for LPHR, there was a significant reduction in blood loss, intensive care unit stay, ileus, hospital stay, and overall morbidity associated with LPHR compared with OPHR. CONCLUSIONS: PEH is associated with significant comorbidity that increases the operative risk. Short-term outcomes for LPHR are superior to OPHR, suggesting that the laparoscopic approach is the preferred approach to paraesophageal hernia repair. Am J Surg. 1998;176:659 – 665. © 1998 by Excerpta Medica, Inc.

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araesophageal hernia (PEH) is a disorder in which the fundus of the stomach and occasionally other intra-abdominal viscera herniate cephalad into the posterior mediastinum through a widened esophageal hiatus. In a true (type II) PEH, the esophagogastric junction remains fixed in its normal infradiaphragmatic location. When the EG junction is also displaced cephalad to the esophageal hiatus, it is termed a combined (type III) PEH. When the hiatal defect is very large, allowing herniation of the entire stomach or other viscera such as colon and spleen it is termed a giant (type IV) PEH. Paraesophageal hernias are uncommon, accounting for only 5% of all hiatal hernias treated surgically. However, unlike patients with type I sliding hiatal hernias, most patients with a paraesophageal hernia will develop symp-

From the University of Pittsburgh, Presbyterian University Hospital, Pittsburgh, Pennsylvania. Requests for reprints should be addressed to Philip R. Schauer, MD, Assistant Professor of Surgery, University of Pittsburgh, Presbyterian University Hospital, 200 Lothrop Street, C 800, Pittsburgh, Pennsylvania 15213-2582. Presented at the 50th Annual Meeting of the Southwestern Surgical Congress, San Antonio, Texas, April 19 –22, 1998.

© 1998 by Excerpta Medica, Inc. All rights reserved.

toms or complications, with potentially life-threatening results. For this reason, surgical repair is recommended for all patients with PEH who are surgical candidates. The standard approach to repair of PEH has been transabdominally via an upper midline vertical incision, with a transthoracic approach being used less frequently. Recently, however, the laparoscopic approach has been proposed as an alternative to the open approach. To our knowledge, no direct comparisons with the standard open repair of paraesophageal hernia (OPHR) have been reported. We have therefore undertaken a retrospective review of all patients undergoing repair of a paraesophageal hernia, either open or laparoscopic, at the University of Pittsburgh between February 1990 and April 1998 to determine if LPHR results in any short-term advantages or disadvantages over the standard open approach.

MATERIALS AND METHODS A review of the University of Pittsburgh affiliated hospitals patient database and of patient medical records identified all patients who underwent elective open or laparoscopic surgical repair of a paraesophageal hernia over an 8-year period between February 1990 and April 1998. Preoperative evaluation included for many but not all patients upper endoscopy, upper gastrointestinal contrast radiography, 24-hour esophageal pH study, and/or esophageal manometry. The indication for repair in all patients was the presence of a symptomatic paraesophageal hernia in a patient with an acceptable operative risk. Open repair included both the transabdominal and transthoracic approaches. The medical records were reviewed retrospectively with respect to patient demographics, operative parameters, and postoperative results. The laparoscopic approach was introduced at this institution in 1995, and all subsequent repairs have been attempted laparoscopically. Informed consent was obtained in all patients prior to surgery. Differences between patients undergoing laparoscopic or open repair were analyzed by Fisher’s exact test and Student’s t test. Operative Technique The open transabdominal and transthoracic procedures were performed by a larger group of affiliated surgeons with variable degrees of experience with paraesophageal hernia repair while the laparoscopic approach was performed primarily by two surgeons (PRS and JDL). The open transabdominal approach was variable from surgeon to surgeon but generally consisted of a midline laparotomy, reduction of herniated stomach and viscera, excision of hernia sac (variable), suture closure of diaphragmatic defect, an antireflux procedure (variable), and gastrostomy or gastropexy (variable). The transthoracic approach via thoracotomy 0002-9610/98/$19.00 PII S0002-9610(98)00272-4

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closed over a 54-60 French bougie. If the defect was excessively large, a patch of Goretex (W.L. Gore, Flagstaff, Arizona) was used to reinforce the closure (rarely necessary). We then proceeded with a Nissen or Toupet fundoplication in standard fashion over a bougie. A gastrostomy or formal gastropexy was not routinely performed. Before closing, endoscopy was performed routinely with intraluminal insufflation to identify esophageal or gastric leaks. Postoperatively, all patients were started on clear liquid oral intake on the day after surgery unless otherwise contraindicated. Most patients were discharged on the first or second postoperative day on a full liquid diet. The patients were permitted a soft diet and unrestricted activity by postoperative day 7.

RESULTS

Figure 1. Trocar placement for laparoscopic paraesophageal hernia repair.

consisted of the same components but was performed only on a limited basis. Our standard approach to the laparoscopic repair was employed with few exceptions. The patient was placed in a supine position with the surgeon on the right side and assistant on the left. Five 5-mm to 11-mm laparoscopic cannulas (Versaport; USSC, Norwalk, Connecticut) were placed in the upper abdomen as shown (Figure 1). The left lateral segment of the liver was retracted anteriorly with a 5-mm flexible retractor (Snowden Pencer, DSP, Tucker, Georgia), which was secured to a stationary holding device (Mediflex, Islanda, New York). After exposure was achieved, the herniated stomach was reduced utilizing atraumatic graspers (Snowden Pencer; DSP, Tucker, Georgia) in a hand-over-hand fashion (Figure 2A). Dissection then began by dividing the gastrosplenic ligament beginning just lateral to the midportion of the greater curvature of the stomach using ultrasonic dissection with the harmonic scalpel (Ethicon, Cincinnati, Ohio) or the ultrasonic shears (USSC, Norwalk, Connecticut). Dissection proceeded cephalad dividing all short gastric vessels and all posterior alveolar attachments to the fundus. Once the greater curvature was completely mobilized, the lesser omentum was divided starting anterior to the caudate lobe of the liver and proceeding proximal until the right crus of the diaphragm was identified. We then incised the hernia sac along the esophageal hiatus and dissected the hernia sac from the posterior mediastinum bluntly, a process that is typically bloodless (Figure 2B). The surgeon and anesthesiologist must be aware, however, of the possibility of creating a pneumothorax during the maneuver and respond appropriately. Following reduction, excess sac was divided and removed. We then proceeded with closure of the hiatal defect by approximating the crura below the esophagus with interrupted 0-braided polyester suture (Surgidac; USSC Norwalk, Connecticut), using the Endostich (USSC, Norwalk, Connecticut), a laparoscopic suturing device (Figure 2C and D). In the majority of cases, the crura can be closed primarily without excess tension. To prevent postoperative dysphagia, the hiatal defect was 660

Ninety-five consecutive patients underwent repair of paraesophageal hernia at the University of Pittsburgh Medical Center between February 1990 and April 1998. Of these, 25 were approached using an open technique (19 transabdominal, 4 transthoracic), 67 laparoscopically, and 3 (with in the first 10 laparoscopic cases) were begun laparoscopically and subsequently converted to open (conversion rate 5 4%). The transthoracic approaches were chosen to avoid adhesions related to prior upper abdominal surgery: PEH repair (2), Nissen fundoplication (1), and open cholecystectomy (1). Reasons for conversion included a suspected gastric tear in 1 patient (type III hernia) later proven not to be a full thickness tear, and in 2 patients (1 type III and 1 type IV) excessive adhesions from prior surgery were formidable. Patient demographic information is shown in Table I. As a group, these patients tended to be elderly and had significant underlying comorbidity, as indicated by ASA classification of 3 or 4. The majority of patients in both groups had two or more systemic illnesses. Overall, the two groups were comparable in age, obesity, prior abdominal surgery, and overall medical condition. All patients had symptoms related to their PEH, and the mean symptom duration was similar for both groups, 57 months for the open group and 61 months for the laparoscopic group. The type and distribution of symptoms were similar in both groups. The most common symptoms included postprandial abdominal and chest pain, heartburn, nausea, and vomiting. At operation the majority of patients in each group were found to have type II or III paraesophageal hernias, and a notable number also had a gastric volvulous (Table I). A higher rate of type II hernia was evident in the open group. Patients in both groups uniformly underwent reduction of stomach and crural repair. In the open group, 22 of 25 had an antireflux procedure (Nissen 18, Toupet 3, Belsey 1). Hernia sac excision was performed in 11 of 25, and 10 patients had a gastrostomy placed. In the laparoscopic group, 63 of 67 had and antireflux procedure (Toupet 41, Nissen 22). Sac excision was performed in 62 of 67, and a gastrostomy tube was placed in 4 patients. Mean operative blood loss was significantly lower for those patients undergoing LPHR (126 mL versus 299 mL, P ,0.05). Mean operative time was significantly longer for LPHR (264 minutes versus 208 minutes, P ,0.05). However, the operative time for LPHR decreased with experience, with the most recent 15 cases yielding a mean operative time of

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Figure 2. A. Reduction of stomach from intrathoracic cavity. B. Excision of hernia sac. C. Completed hiatal dissection. D. Closure of hiatal defect with interrupted sutures posterior to esophagus. E. Completion of 270° posterior fundoplication (Toupet).

214 minutes. The incidence of intraoperative complications was similar in each group (12% versus 11%, P .0.05; Table II). In the open group, the gastrotomy was promptly recognized and repaired. In the laparoscopic group, both the gastrotomy, and distal esophageal perforation during passage of the bougie, were immediately recognized and repaired laparoscopically without sequelae. With a mean follow-up of 48 months in the open group and 13 months in the laparoscopic group, symptomatic relief from PEH-related symptoms was achieved in 84% of patients undergoing OPHR versus 94% of patients undergoing LPHR (P .0.05). Patients undergoing laparoscopic PEH repair recovered from the operation faster than those undergoing the open procedure (Table I). The intensive care unit stay, time to oral intake, length of stay, and postoperative pain medication (MSO4) requirement were less for the laparoscopic group (P ,0.05). Specific complications (within 30 days of surgery) are listed in Table II.

Fewer overall complications were observed in the laparoscopic group. Sixty percent of patients in the open group experienced one or more complications compared with only 28% in the laparoscopic group (P ,0.05). Major complications, defined as those that were life threatening or significantly prolonged hospital stay, occurred less often in the laparoscopic group (10.5% versus 48%, P ,0.05) as did minor complications (10.5% versus 60%, P ,0.05). Three esophageal perforations with resultant peritoneal sepsis occurred in the laparoscopic group (4.5%). One patient with a recurrent PEH (type III) and a very large diaphragmatic defect requiring a Goretex patch for coverage developed a delayed esophageal perforation postoperatively requiring reoperation and patch removal. The leak was thought to be related to esophageal ischemia resulting from extensive dissection required to clear dense adhesions. The other two delayed esophageal leaks (type III hernias) occurred in a similar fashion and required reop-

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TABLE I Demographics, Paraesophageal Hernia Classification, and Recovery Characteristic Demographics Mean age, years (range) Female (%) Obesity (%) Prior abdominal surgery (%) Redo paraesophageal hernia repair (%) Two or more systemic diseases (%) ASA 3/4 (%) Paraesophageal hernia classification Type II (%) Type III (%) Type IV (%) Volvulous (%) Recurrent (%) Urgent (%) Postoperative recovery Mean ICU days ICU required (number of patients) Mean time to oral intake, days Mean hospital stay, days Mean pain medication requirement MSO4 (mg)

Open (n 5 25) 64 (30–84) 17 (68) 7 (28) 10 (40) 4 (16) 17 (68) 13 (52)

Laparoscopic (n 5 67)

P Value

65.2 (36–89) 45 (66) 24 (36) 46 (67) 10 (15) 56 (82) 39 (57)

NS NS NS NS NS NS NS

7 (30) 12 (48) 6 (22) 5 (20) 4 (16) 2 (8)

2 (3) 60 (90) 5 (8) 23 (32) 10 (16) 2 (3)

,0.05 ,0.05 ,0.05 NS NS NS

2.2 13 (52%) 6.1 10.3 (4–48) 94.8

0.54 8 (12%) 1.13 4.98 (1–16) 12.8

NS ,0.05 ,0.05 ,0.05 ,0.05

ICU 5 intensive care unit; MSO4 5 morphine sulfate; NS 5 not significant.

eration for repair and drainage. There was one death in the series after LPHR in an immunocompromised patient who developed adult respiratory distress syndrome. Aspiration of gastric contents on induction and endotracheal intubation was thought to be the inciting event. Late complications (.30 day) included recurrence of gastroesophageal reflux disorder symptoms for the open and laparoscopic groups (16% versus 6%, respectively, P .0.05). Two patients in the open group required reoperation for recurrent PEH with reflux symptoms occurring on postoperative day 5 (repaired via laparotomy) and 6 years after surgery (repaired laparoscopically). No patients in the laparoscopic group required reoperation for recurrent reflux. Other late complications included one incisional hernia (4%) after open repair and three trocar site hernias (5%) after laparoscopic repair (P .0.05). One patient developed a partial gastric outlet obstruction 1 year after laparoscopic repair that was related to adhesions. It was successfully corrected laparoscopically. Esophageal dilatation or reoperation was not required for dysphagia or gas bloat in either group. For the 3 patients requiring conversion to laparotomy the mean hospital stay was 12 days (range 7 to 21). Complications included a postoperative small bowel obstruction requiring operative intervention in the first patient, atrial fibrillation and atelectasis in the second patient, and pulmonary edema and ileus in the third patient. The first patient developed a recurrent, symptomatic PEH 1 year later that was repaired via an open technique.

COMMENTS This study of 95 patients summarizes our experience with the management of paraesophageal hernia at a single institution over an 8-year period, and evaluates the impact of 662

introducing the laparoscopic approach to this challenging problem. Since 1992, several series regarding short-term outcomes for laparoscopic paraesophageal hernia repairs have been published.1–11 These studies have demonstrated that the laparoscopic approach is feasible and effective in treating PEH-related symptoms, but it is technically very challenging and requires advanced laparoscopic skills. In addition, the laparoscopic approach appears to offer advantages over the conventional open repair in terms of reduced postoperative pain, a short hospital stay (2 to 5 days), and rapid convalescence (3 to 4 weeks). Complications, both intraoperative (technical) and postoperative (stress related), however, have remained considerably high. In a large multicenter study Trus et al.9 demonstrated complication rates as high as 37%. It is generally recognized that patients with paraesophageal hernias are elderly with significant comorbidity and are thus at greater risk for postoperative complications. The question remains whether the laparoscopic approach, which has been shown to reduce morbidity for many other procedures such as cholecystectomy, fundoplication, and colectomy, offers any advantage in reducing perioperative morbidity in patients with PEH. To our knowledge, our study is the largest contemporary series of PEH repair and the first to directly compare outcomes of the laparoscopic approach with that of the conventional approach at the same institution during a similar time period. Patients with PEH in this study (Table I) tended to be elderly with multiple comorbidities as opposed to patients with type I hiatal hernia who are younger without significant comorbidity. We thus anticipated that a less invasive operative approach might have a profound effect on perioperative morbidity in this relatively high-risk group.

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TABLE II Complications of Open and Laparoscopic Paraesophageal Hernia Repair* Open (n 5 25) Intraoperative Gastrotomy Gastric serosal tear Hypotension Total Major complications Arrhythmia CHF Ileus Respiratory failure Pneumonia Sepsis Pneumothorax Myocardial infarction Total Minor complications Atelectasis CHF Ileus Pleural Effusion Depression Wound infection Pneumothorax UTI Urinary retention Hypokalemia Recurrent GERD Total

Number

%

1 1 1

4.0 4.0 4.0

3

12

3 3 1 1 1 1 1 1 12

12 12 4 4 4 4 4 4 48

5 1 1 1 1 1 1 1 1 1 1 15

20 4 4 4 4 4 4 4 4 4 4 60

Laparoscopic (n 5 67) Intraoperative Pneumothorax Pleural tear Gastrotomy Esophageal perforation (bougie) Total Major complications Esophageal perforation (delayed) Myocardial infarction Pulmonary embolus Pneumonia Aspiration-ARDS-death Total

Minor complications Wound infection Pneumothorax Atelectasis UTI Pleural effusion Depression Total

Number

%

5 1 1 1 8

7.4 1.5 1.5 1.5 11.9

3 1 1 1 1 7

4.5 1.5 1.5 1.5 1.5 10.5

2 1 1 1 1 1 7

3.0 1.5 1.5 1.5 1.5 1.5 10.5

P ,0.05, LPHR versus OPHR for major and minor complications, not significant for intraoperative complications. * Less than 30-day morbidity. CHF 5 congestive heart failure; UTI 5 urinary tract infection; GERD 5 gastroesophageal reflux disorder; ARDS 5 adult respiratory distress syndrome; LPHR 5 laparoscopic paraesophageal hernia repair; OPHR 5 open paraesophageal hernia repair.

Both groups of patients, though noncontemporaneous and nonrandomized, were comparable. Average age, comorbidity, and history of prior abdominal surgery were similar in both groups (Table I). A higher rate of type II hiatal hernias was present in the open group; however, this was more likely a reflection of surgeon interpretation rather than a true difference. Review of operative reports of the open cases revealed that many of the surgeons did not distinguish between type II and III hernias. Gastric volvulous was slightly more common in the laparoscopic group (32 versus 20%, P .0.05) whereas urgent surgery was more common in the open group (8% versus 3%, P .0.05). Reoperations for PEH were equally prevalent in both groups. Comparison of operative data was mixed. The laparoscopic approach resulted in an average operating time of 1 hour more than the open approach (P ,0.05). Increased operating times is the norm for most advanced laparoscopic procedures at least in the early portion of the learning curve. As experienced increased, there was a trend toward shorter operating times for LPHR (214 minutes) approaching that of OPHR. The longer operating time did not appear to have an adverse affect on perioperative morbidity. As noted with other laparoscopic procedures, the op-

erative blood loss was less. This may be a significant advantage particularly in this high-risk population with little reserve. Whether the reduced blood loss is related to better visibility, more meticulous dissection, or specialized instrumentation, ie, ultrasonic dissection, is unclear. Intraoperative complications (12% and 11.9%) occurred equally in both groups and were comparable to other series in both the open and laparoscopic experience.10 The high intraoperative complication rate is probably related to both the technical difficulty of the procedure and the compromised status of the patients. In this study the overall success of LPHR and OPHR at controlling related symptoms and minimizing side effects, ie, dysphagia, appears to be favorable. The laparoscopic approach thus does not appear to compromise the goal of surgery, which is to prevent complications of PEH and control symptoms at least in the short term. The effect of LPHR on long-term complications such as hernia recurrence or recurrent gastroesophageal reflux must await longer follow-up. All outcomes related to recovery and perioperative morbidity favored LPHR over OPHR. Hospital stay and complication rates for OPHR for this study are comparable with results of other recent series of OPHR in the literature.10

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Patients undergoing LPHR were four times less likely to require intensive care support, and there was a trend toward shorter ICU stays when necessary. Time to oral intake, a reflection of postoperative ileus, was on average 5 days sooner for LPHR. The overall complication rate including minor and major complications was generally threefold to sixfold less for the laparoscopic group. Comparison of specific complications reveals that the open approach more commonly results in cardiopulmonary compromise, a common result of major open abdominal surgery. Although one death was observed in the laparoscopic group (1.5%), no statistically significant difference in perioperative mortality was observed between the groups. Despite the relatively high complication rate in the OPHR group, there were no deaths. Larger groups of patients (hundreds) would be necessary to detect any change in mortality related to the laparoscopic approach. Nevertheless, the dramatic improvement in complication rates and recovery after introduction of LPHR at our institution is highly suggestive that the laparoscopic approach is the preferred approach for PEH repair. Although overall complications were less after LPHR, two specific complications that occurred in our series require special mention. The first, gastroesophageal perforation, has been reported following laparoscopic antireflux surgery with an incidence as high as 1% to 5%.12 Two large series of LPHR also report a high incidence of gastroesophageal perforations between 4% and 11%.9,11 Mechanisms of perforation include injury during periesophageal dissection, passage of the bougie, or postoperative suture pullthrough. Extensive periesophageal dissection often required for adequate mobilization during PEH repair may lead to ischemia and delayed perforation. Delayed leaks are the Achilles heel of laparoscopic foregut surgery and may go unrecognized and lead to severe intraabdominal sepsis and possibly death. Careful dissection techniques as previously described should be employed.12 Patients undergoing redo PEH repair may be particularly vulnerable to gastroesophageal injury. The other complication in this series of significant concern is that of aspiration, which ultimately proved fatal. Since many patients with PEH have impaired gastric emptying related to partial obstruction, extreme caution against aspiration particularly during induction and intubation should be exercised. Gastric drainage with a nasogastric tube preoperatively is advisable in patients suspected of having gastric volvulous. The results of this study must be interpreted in light of limitations of a nonrandomized, noncontemporaneous study. Bias against more favorable outcomes in the open group potentially exists. The OPHR group involved a larger number of surgeons who may each have had a limited experience with PEH repair compared with the LPHR group that involved fewer surgeons who primarily focus on foregut surgery. However, the steep learning curve for LPHR may somewhat counter that bias. A higher rate of urgent cases in the OPHR group (8% versus 3%) slightly increases the risk of postoperative complications for that group. However, in the LPHR group, there tended to be a higher rate of obesity, prior abdominal surgery, and higher degree of comorbidity that carries its own added risk. Finally, the difference in hospital stay may in part relate to 664

the more recent pressure to discharge patients from the hospital sooner as opposed to the early 1990s. Because of the relative infrequency of PEH, a large, randomized controlled trial comparing laparoscopic and open repair may never be performed. Additional comparative studies will be of value to corroborate or refute our findings. The impact of LPHR on the overall management of PEH at our institution has been extraordinary. Prior to the introduction of LPHR, an average of five open PEH repairs a year were performed. Since LPHR was introduced, an average of 30 cases a year are now performed—a sixfold increase. We have similarly observed a dramatic increase in the repair of type I hiatal hernias associated with gastroesophageal reflux disorder since the introduction of laparoscopic Nissen fundoplication in the early 1990s. Their primary physicians had deemed many patients with PEH inoperable. The reduced morbidity associated with the laparoscopic approach has prompted many local physicians to reconsider and recommend elective surgical intervention. The laparoscopic approach thus potentially may reduce the number of patients who are treated nonoperatively and who are at risk for catastrophic complications, which are fatal in up to 27% of cases.13 Laparoscopic repair of paraesophageal hernia is a technically challenging procedure in relatively high risk patients. Our short-term results suggest that it is effective in providing relief of PEH-associated symptoms. Despite the increase in operating time, the laparoscopic approach results in a shorter intensive care unit stay, shorter hospital stay, and most importantly a significant reduction in postoperative morbidity compared with the open approach. The potential for serious operative complications is significant, thus extensive experience with advanced laparoscopic technique is recommended prior to performing LPHR. The laparoscopic approach has become our procedure of choice for repair of paraesophageal hernia.

REFERENCES 1. Congreve DP. Laparoscopic paraesophageal hernia repair. J Laparoendosc Surg. 1992;2:45– 48. 2. Cloyd DW. Laparoscopic repair of incarcerated paraesophageal hernias. Surg Endosc. 1994;8:893– 897. 3. Johnson PE, Persuad M, Mitchell T. Laparoscopic anterior gastropexy for treatment of paraesophageal hernias. Surg Laparosc Endosc. 1994;4:152–154. 4. Oddsdottir M, Franco AL, Laycock WS, et al. Laparoscopic repair of paraesophageal hernia: new access, old technique. Surg Endosc. 1995;9:164 –168. 5. Edelman DS. Laparoscopic paraesophageal hernia repair with mesh. Surg Laparosc Endosc. 1995;5:32–37. 6. Pitcher DE, Curet MJ, Martin DT, et al. Successful laparoscopic repair of paraesophageal hernia. Arch Surg. 1995;130:590 –596. 7. Casabella F, Sinanan M, Horgan S, Pellegrini CA. Systemic use of gastric fundoplication in laparoscopic repair of paraesophageal hernias. Am J Surg. 1996;171:485– 489. 8. Willekes CL, Edoga JK, Frezza EE. Laparoscopic repair of paraesophageal hernia. Ann Surg. 1997;225:31–38. 9. Trus TL, Bax T, Richardson WS, et al. Complications of paraesophageal hernia repair. J Gastrointest Surg. 1997;1:221–228. 10. Huntington TR. Short-term outcome of laparoscopic paraesophageal hernia repair. A case series of 58 consecutive patients. Surg Endosc. 1997;11:894 – 898. 11. Perdikis G, Hinder RA, Filipi CJ, et al. Laparoscopic paraesophageal hernia repair. Arch Surg. 1997;132:586 –590.

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12. Schauer PR, Meyers WC, Eubanks S, et al. Mechanisms of gastric and esophageal perforations during laparoscopic Nissen fundoplication. Ann Surg. 1996;223:43–52.

13. Skinner DB, Belsey RH. Surgical management of esophageal reflux and hiatus hernia: long-term results with 1,030 patients. J Thorac Cardiovasc Surg. 1967;53:33–54.

DISCUSSION

CLOSING

Patrick R. Reardon, MD (Houston, Texas): It’s important that we document when we make changes in our operative routine what the benefits may or may not be from laparoscopy. I note that in your institution, you only did 25 open repairs in the first 5 years and did 67 laparoscopic repairs in the last 3 years. In your manuscript you attributed this to changing attitudes of your local referring physicians. If this is true, this would be an interesting phenomenon to document, as I think that we have the same attitude changes at our institution, but I have no way to document this. I agree with your use of ultrasonic shears when you do your paraesophageal dissection. I think that this may reduce the incidence of unrecognized vagal and esophageal injuries that may occur when electrocautery is used, and there are electrothermal conduction injuries. With regard to gastroesophageal reflux, you mentioned that pH and manometry studies were done preoperatively on these patients, but you made no mention of whether or not they had symptoms or what the results of the studies might be. I think that it would be important to document this information in view of the high number, 63 out of 67, of your laparoscopic patients who had an antireflux procedure performed. What follow-up studies do you have planned for these patients? Along these lines, you also mentioned that 2 patients in the open group required reoperation for reflux problems. I have three questions. (1) Did they have preoperative reflux documented? (2) How far out from their surgery were they? Specifically, were they out greater than 13 months, which was the average follow-up in your laparoscopy group? Perhaps this group hasn’t had long enough to exhibit their problems. (3) Did they have an antireflux procedure performed at their first operation, since a high percentage of the open cases did as well? At first glance, the esophageal perforation rate seems high, but after reviewing the literature, I believe that this rate is comparable with other studies, and probably reflects the increased technical difficulty in doing these large hernia repairs in comparison with simple antireflux procedures. This is a point that needs to be emphasized before surgeons engage in performing this operation. You made no mention of costs in your study, and perhaps you can comment on this. Since symptoms may not correlate with early reherniation or reflux, what plans do you have in the future to follow up these patients to document whether or not they have these problems? Specifically, do you plan to do pH and manometry studies, barium studies, or endoscopy?

Philip R. Schauer, MD: You noted the issue of changing referral pattern. We found this to be quite an extraordinary finding of our study: A sixfold increase in the rate of performing this procedure has occurred over the last 2 and a half years. We think it’s because our referring doctors have recognized the good results and are now more likely to send these elderly, high-risk patients to us because of the apparent decrease in perioperative morbidity. In terms of the preoperative studies and preoperative symptoms, all these patients had symptoms prior to surgery, either gastroesophageal reflux disease related or postprandial abdominal or chest pain. In many, we tried to get manometry, because we feel that’s very important. However, our technicians had difficulty in accurately placing the probes on many of these patients, and therefore we felt in many cases the data were inaccurate. Our compromise position was to perform a Toupet fundoplication because we thought it would likely reduce the potential for postoperative dysphagia yet maintain an antireflux barrier. In terms of those 2 patients in the open group who developed recurrent disease, one patient did have an antireflux procedure with a Nissen, the other patient did not. The recurrences occurred rather early, within 6 months of the procedure. Looking back at the data, both of them did have preoperative reflux symptoms, and the actual cause of recurrence is not exactly clear. But in one of the patients, the wrap appeared to herniate up into the chest cavity. This is not altogether different from the experience published in the literature with a recurrence rate after repair of paraesophageal hernia as high as 15% to 20% over the long term. You asked a question about cost. We’ve not gone through the cost data yet. That would certainly be an interesting issue to look at. Particularly with the decrease in hospital stay and ICU care, I would suspect that the laparoscopic approach would be cheaper. We need to verify that. And finally, I think your point about follow-up studies is very, very important, and we plan an additional study performing upper GI studies to look at these patients in follow-up. Nat Soper, St. Louis, recently presented his experience with paraesophageal hernias at the SAGES annual meeting. There was a nearly 20% radiographic incidence of the wrap herniating up into the chest. Although most of these patients were asymptomatic, it’ll be important for us to look at this issue of recurrence over the next few years.

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