Long-term outcome and quality of life after laparoscopic treatment of large paraesophageal hernia.

BACKGROUND: Laparoscopy has been widely used for surgical repair of large paraesophageal hernias (PEHs). The technique, however, entails substantial technical difficulties, such as repositioning the stomach in the abdominal cavity, sac excision, closure of the hiatal gap, and fundoplication. Knowledge of the long-term outcome (>10 years) is scarce. The aim of this article was to evaluate the long-term results of this approach, primarily the anatomic hernia recurrence rate and the impact of the repair on quality of life.
METHODS: We identified all patients who underwent laparoscopic repair for PEH between November 1997 and March 2007 and who had a minimum follow-up of 48 months. In March 2011, all available patients were scheduled for an interview, and a radiologic examination with barium swallow was performed. During the interview the patients were asked about the existence/persistence of symptoms. An objective score test, the gastrointestinal quality of life index (GIQLI), was also administered.
RESULTS: A total of 77 patients were identified: 17 men (22 %) and 60 women (78 %). The mean age at the time of fundoplication was 64 years (range 24-87 years) and at the review time 73 years (range 34-96 years). The amount of stomach contained within the PEH sac was <50 % in 39 patients (50 %), >50 % in 31 (40 %), and 100 % (intrathoracic stomach) in 7 (9.5 %). A 360º PTFe mesh was used to reinforce the repair in six cases and a polyethylene mesh in three. In May 2011, 55 of the 77 patients were available for interview (71 %), and the mean follow-up was 107 months (range 48-160 months). Altogether, 43 patients (66 %) were asymptomatic, and 12 (21 %) reported symptoms that included dysphagia in 7 patients, heartburn in 3, belching in 1, and chest pain in 1. Esophagography in 43 patients (78 %) revealed recurrence in 20 (46 %). All recurrences were small sliding hernias (<3 cm long). In all, 37 patients (67 %) answered the GIQLI questionnaire. The mean GIQLI score was 111 (range 59-137; normal 147). Patients with objective anatomic recurrence had a quality of life index of 110 (range 89-132) versus 122 in the nonrecurrent hernia group (range 77-138, p < 0.01). Mesh was used to buttress the esophageal hiatus in nine patients. One patient died during the follow-up period. Five of the remaining eight patients (62 %) developed dysphagia, a mesh-related symptom. Three patients required reoperation because of mesh-related complications. Esophagography revealed recurrence in four (50 %) of the eight patients. GIQLI scores were similar in patients with recurrence (126, range 134-119) and without it (111, range 133-186) (p > 0.05).
CONCLUSIONS: Long-term follow-up (up to 160 months) in our study showed that laparoscopic PEH repair is clinically efficacious but is associated with small anatomic recurrences in ≤50 % of patients. Further studies are needed to identify the anatomic, pathologic, and physiological factors that may impair outcome, allowing the procedure to be tailored to each patient.