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Revista Española de Enfermedades Digestivas

versión impresa ISSN 1130-0108

Rev. esp. enferm. dig. vol.101 no.10 Madrid oct. 2009

 

ORIGINAL PAPERS

 

Paraesophageal hiatal hernia. Open vs. laparoscopic surgery

Hernia de hiato paraesofágica: cirugía laparoscópica vs. cirugía abierta

 

 

M. Díez Tabernilla, J. Ruiz-Tovar, R. Grajal Marino, P. Calero García, J. D. Pina Hernández, A. Chames Vaisman, V. Morales Castiñeiras, A. Sanjuanbenito Dehesa, E. Martínez Molina and V. Fresneda Moreno

Service of General Surgery and Digestive Diseases. University Hospital Ramón y Cajal. Madrid, Spain

Correspondence

 

 


ABSTRACT

Background: paraesophageal hiatal hernia represents 5-10% of hiatal hernias. Its importance is based on the severe complications it may have, including gastric volvulus, and surgical treatment is recommended when a diagnosis is established.
Material and methods: a retrospective study of all patients who underwent surgery for paresophageal hernia between 1985 and 2007.
Results: we studied 90 cases, 68 females and 22 males with a median age of 67.6 years (37-96). Forty-five patients reported pyrosis, 34 epigastric postprandial pain, and 15 dysphagia; eight patients were diagnosed with gastric volvulus. Eighty-one patients underwent elective surgery and 9 emergency surgery. Forty-seven cases underwent an open procedure and 43 a laparoscopic one; 5 (11.6%) of them required conversion. The techniques performed were D'Or fundoplication in 35 cases, Nissen in 35, Toupet in 14, simple hiatal closure in 2, Narbona in 1, and Lortat-Jakob in 1; in 10 patients a mesh was placed. The complication rate for open procedure was 10.6 and 9.5% for the laparoscopic one (p > 0.05). Median hospital stay was 9.1 days for the open procedure and 3.4 for the laparoscopic one (p < 0.05). As follow-up, we analyzed 84 patients. After a median follow-up of 12 years (1-19), 15 patients were still symptomatic (17.8%), with recurrence in 8 cases (5 required reoperation). The satisfaction rate was 95.5%.
Conclusion: equivalent results were observed after laparoscopic and open surgery and a significant shorter hospital stay in the laparoscopic one. Therefore, we think that laparoscopic surgery should be considered as the election procedure for paraesophageal hiatal hernia.

Key words: Paraesophageal hernia. Hiatal hernia. Laparoscopy. Hernia repair.


RESUMEN

Introducción: la hernia hiatal paraesofágica representa el 5-10% de las hernias hiatales. Su importancia radica en las graves complicaciones que pueden presentar, como el vólvulo gástrico, y se recomienda el tratamiento quirúrgico una vez establecido el diagnóstico.
Material y métodos: estudio retrospectivo de los pacientes intervenidos en nuestro centro de hernia hiatal paraesofágica entre 1985 y 2007.
Resultados: estudiamos 90 casos, 68 mujeres y 22 varones, con edad media de 67,6 años (37-96). Cuarenta y cinco pacientes presentaban pirosis, 34 dolor epigástrico postprandial y 15 disfagia; ocho pacientes fueron diagnosticados como vólvulo gástrico. Se realizaron 81 intervenciones programadas y 9 urgentes. En 47 casos el abordaje fue abierto y en 43 laparoscópico, de los cuales 5 se convirtieron a cirugía abierta. Se realizó funduplicatura D'Or en 35 casos, Nissen en 35, Toupet en 14, cierre simple de pilares en 2, Narbona en 1 y Lortat-Jakob en 1; en 10 pacientes se colocaron mallas. La tasa de complicaciones en cirugía abierta fue 10,6% y en laparoscópica 9,5% (p > 0,05). La estancia media fue 9,1 días en cirugía abierta y 3,4 en laparoscópica (p < 0,05). En el seguimiento, analizamos 84 pacientes, con una mediana de 12 años (1-19): 15 continuaban sintomáticos, objetivándose recidiva en 8 (5 fueron reintervenidos). El 95,5% de los pacientes estaban satisfechos con los resultados.
Conclusión: se obtuvieron resultados equivalentes tras cirugía laparoscópica y abierta, con estancia hospitalaria significativamente menor en los primeros. Por ello creemos que se debe considerar la cirugía laparoscópica como abordaje de elección para tratar la hernia hiatal paraesofágica.

Palabras clave: Hernia paraesofágica. Hernia hiatal. Laparoscopia. Reparación herniaria.


 

Introduction

Paraesophageal hiatal hernia is an uncommon condition which represents 5-10% of all hiatal hernias. Its importance is based on the severe complications it may have, such as obstruction, gastric perforation or gastric mucosal bleeding. This is the reason why treatment is recommended for all cases (1-3), even if some authors question this attitude and advocate for an expecting attitude in selected cases (4,5). The open procedure (OP) shows high complication rates and needs a long recovering time (1,6). In most recent series, the laparoscopic procedure (LP) has proven to be feasible and safe, and entails shorter hospital stays and lower complication rates, even though some authors suggest higher recurrence rates (7).

 

Material and methods

We retrospectively reviewed all patients who underwent surgery for paraesophageal hernia between 1985 and 2007. Data were collected on age, sex, clinical signs and symptoms, diagnostic studies, surgical technique, postoperative complications, and hospital stay.

To evaluate long-term results a survey was performed between January and April 2008, inquiring on recurrence and patient satisfaction. Deceased patients and those lost to follow-up were excluded.

A statistical analysis was performed using the Windows SPSS 12.0 program. Quantitative variables were defined by mean (median in no-Gaussian variables) and interval values; for discrete variables the number of cases and percentages were used. A comparison of discrete variables was performed using Student's t-method (Mann-Whitney for non-normal variables). Statistical significance was considered for p < 0.05

 

Results

Ninety patients were included, 22 males (24.4%) and 68 females (75.6%), with a median age of 67.6 years (37-96). Surgical treatment was indicated in all cases referred to our general surgery clinic, excluding those whose comorbidity contraindicated the surgical procedure. Clinical manifestations are showed in table I. Predominant symptoms were pyrosis (50%), epigastric postprandial pain (37.5%), gastric volvulus (8.9%), and dysphagia (5.6%). Diagnostic studies are summarized in table II. Chest X-rays were performed for 83% of cases, these being important to establish diagnostic suspicion, as well as for cases of gastric volvulus. Upper endoscopy and gastroduodenal radiology with barium were the studies with the highest diagnostic utility, and confirmed the diagnosis in 91% of cases. pH-metry provided information about the presence of gastroesophageal reflux (GER), and manometry informed about the esophagal dynamic function.

Eighty-one patients underwent elective surgery (90%) and 9 emergency surgery (10%) (8 for gastric volvulus and one for massive gastrointestinal bleeding). Emergency surgery was always an OP. Surgical procedures performed are shown in table III. Forty-seven cases underwent an OP (52.2%): surgical techniques chosen included D'Or fundoplication in 35 cases (74.5%), Nissen in 8 cases (17%), simple suture in 2 (4.3%), Narbona in 1 case (2.1%), and Lortat-Jakob in 1 case (2.1%). Forty-three patients underwent LP (47.8) and 5 (11.6%) of them required conversion. The surgical procedure was Nissen's for 27 cases (62.8%) and Toupet's for 16 cases (37.2%). A prosthetic mesh was placed in 8 cases during OP (18.6%) and in 2 cases during LP (4.3%).

Postoperative complications emerged in 5 cases (10.6%) for OP and in 4 cases (9.5%) for LP (p > 0.05) (Table IV). Median hospital stay was 9 days for OP and 3.4 for LP (p < 0.05). During follow-up we analyzed all other 84 patients (93.3%). When the survey was performed 3 patients (3.3%) had died from causes unrelated to surgery, and 3 (3.3%) could not be found. Median follow-up for the other 84 patients was 12 years (1-19).

Paraesophageal hernia recurrence, as shown by imaging tests, was found in 4 patients (5%): in 2 of them a simple open suture had been performed, and the other 2 had undergone laparoscopic Nissen fundoplication. Time between surgery and recurrence was 1, 2.2, and 4 years, respectively. Three of them were reoperated, and a fourth reoperation was rejected because of patient comorbidity. Open Nissen fundoplication and mesh placing was performed for the 3 patients.

Furthermore, 3 patients were reoperated because of GER symptoms. Two of them had undergone open D'Or fundoplication; in both cases Nissen's technique was used, in one of them with mesh placement. The third one was a laparoscopic Nissen, and the reintervention was a Nissen procedure with mesh placement. Overall reintervention rate was 7%. An OP was performed in all cases.

Eight patients (9%) reported persistent symptoms during follow-up, 4 in the OP group and 4 in the LP group. All of them reported pyrosis and 2 reported dysphagia, symptoms that were controlled using proton-pump inhibitors (PPIs). Eighty patients expressed their satisfaction or high satisfaction with surgery results, including 2 patients who had been reoperated and 2 symptomatic subjects at present.

Even though paraesophageal hernia is not frequent, it may potentially cause very serious complications. There is consensus about repairing once diagnosed, irrespective of whether they are symptomatic or not (1). Nevertheless, some authors still recommend observation for asymptomatic cases taking as a basis a mortality rate associated with surgery that can reach 5.4%, when only 1% is estimated to need emergency surgery (4).

Surgical repair has shown to be useful, and nowadays the debate focuses on checking whether the laparoscopic approach is as effective and brings the universal advantages of minimally invasive surgery. A great part of authors agree that LP is technically complex and requires extended operative time because of the size and anatomical distortion of paraesophageal hernias. However, OP may be as difficult as LP due to poor access to the upper abdomen and lack of vision (1).

Surgical repair consists of hernia reduction and pillar closure. An antireflux technique is often added since there is evidence of GER symptoms when a fundoplication was not performed, even in those previously asymptomatic (8). There is no consensus about the technique of choice. Some authors argue that esophageal dissection causes GER, while others argue that an anatomic repair would solve this problem, but there are no controlled studies to confirm these hypotheses (2,9). In all patients in our series an antireflux technique or gastropexy was associated, except in 2 patients in which simply a pillar closure was performed. Despite that, 11 patients had symptoms of GER, 3 of whom required reoperation for this reason.

 

Discussion

One of the most important complications is hernia recurrence, with an incidence between 9 and 25% depending on the series (2,10), that may suffer from incarceration and strangulation more often than the primary hernia due to a smaller hiatus after pillar closure. Since recurrence is not always accompanied by clinical manifestations, a close follow-up with imaging tests may be convenient to determine anatomic recurrence without necessarily implying a therapeutic attitude (5).

The use of mesh for repairing seems to reduce the number of relapses, but experience is still limited (2,11). We have placed mesh in 10 patients and 5 reinterventions with no recurrences to date. We consider that mesh is indicated for large hernias, in which pillar repair may be tense, as well as in relapsing hernia. The literature defines an optimal follow-up time of about 2 years for relapse control (12), but in our case we found one recurrence that showed up after 5 years. Therefore, we think that this monitoring should be extended in order not to underestimate asymptomatic recurrences that may occur at any time during follow-up.

Recent studies argue that the complication rate after LP is lower than after OP (4 vs. 16%) (2). In our series no significant differences in complication rate were reported between both groups (around 10%), but the abdominal wall complications of OP, absent in the LP group, should be highlighted.

There was no mortality related to surgery in any of both groups.

There was a statistically significant lower hospital stay in the LP group (median 3.5 days) when compared to the OP group (median 9 days), thus confirming what has been described in literature (1,2).

 

Conclusion

Results after laparoscopic and open surgery are equivalent in terms of efficacy and complication rates, with a significantly shorter hospital stay in the former group. Therefore, we think that laparoscopic surgery should be considered the approach of choice for the treatment of paraesophageal hiatal hernia. The use of mesh has emerged as a promising option to decrease relapse rates. In the absence of conclusive studies its main indication is large hernias and hernia recurrence. Follow-up with imaging tests should be performed for an indeterminate period of time.

 

References

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8. Treacy PJ, Jamieson GG. An approach to the management of paraesophageal hiatus hernias. Aust N Z J Surg 1987; 57: 813-7.        [ Links ]

9. Geha AS, Massad MG, Snow NJ, Baue AE. A 32-year experience in 100 patiens with giant paraeophageal hernia: the case for abdominal approach and selective antireflux repair. Surgery 2000; 128: 623-30.        [ Links ]

10. Andújar JJ, Papasavas PK, Birdas T, Robke J, Raftopoulos Y, Gagné DJ, et al. Laparoscopic repair of large paraeophageal hernia is associated with a low incidence of recurrence and reoperation. Surg Endosc 2004; 18: 444-7.        [ Links ]

11. Targarona EM, Novell J, Vela S, Cerdán G, Bendahan G, Torrubia S, et al. Mid term analysis of safety and quality of life after the laparoscopic repair of paraeophageal hiatal hernia. Surg Endosc 2004; 18: 1045-50.        [ Links ]

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Correspondence:
María Díez Tabernilla.
C/ Padre Francisco Palau y Quer, 7, 4º B.
28046 Madrid.
e-mail: mariadieztabernilla@gmail.com

Received: 05-02-09.
Accepted: 12-06-09.

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