Surgical Management of Emergency and Elective Giant Paraesophageal Hiatus Hernias

Abstract

Background:

Uncertainty exists surrounding the laparoscopic approach to the repair of giant paraesophageal hiatus hernias (GPHHs), in regard to both long-term outcomes and its role in the emergency presentation. The aim of this study was to assess the outcome of laparoscopic GPHH repair, compared with traditional open surgery, in both the elective and emergency setting.

Subjects and Methods:

Data regarding all patients who underwent GPHH repair between January 1994 and June 2008 were retrieved from the prospectively maintained Lothian Surgical Audit database. Demographic details, surgical approach (open/laparoscopic), conversion to an open procedure, complications, and recurrences were analyzed.

Results:

Sixty-four patients had GPHH repair. Attempted laparoscopic repair and conversion rates were 52 of 64 (81.2%) and 12 of 52 (23.1%), respectively. Including these conversions, 24 of 64 patients had an open repair. The mean postoperative hospital stay, complications, and mortality were significantly lower among the laparoscopic cohort. Twenty-five of 64 patients had surgery as an emergency admission. Postoperative mortality after emergency surgery was 5 of 25 (20.0%) compared with 3 of 39 (7.6%) among elective patients (P=.146). The recurrence rate after laparoscopic and open repair was 25.0% (10 of 40) and 8.3% (2 of 24), respectively (P=.184).

Conclusions:

This study has confirmed that surgical repair of GPHH is associated with a significant morbidity and mortality, in both the elective and emergency setting. Although the laparoscopic approach should be attempted in the first instance, the open approach appears to have a lower recurrence rate.

Introduction

Henry Ingersoll Bowditch was the first person to coin the term paraesophageal hiatus hernia (PHH) in 1853.¹ In contrast to the sliding form of hiatus hernia, the esophagogastric junction in PHH remains in its native position. PHH accounts for 5%–10% of all hiatus hernias.² If left alone, they may progress into a giant PHH (GPHH), where more than half of the stomach migrates into the chest³ and usually undergoes some form of volvulus. In these cases the esophagogastric junction usually also moves proximally. It has been reported that nearly 50% of untreated GPHHs will present with symptoms to a varying degree.^4,5 Unlike sliding hernias, the main symptoms are related to the mechanical effect of the GPHH and include postprandial pain, vomiting, dysphagia, chest pain, and dyspnea.⁶ Some patients present acutely with potentially life-threatening complications such as hemorrhage, ischemic necrosis, and perforation due to strangulation of the intrathoracic gastric volvulus,⁶ and emergency repair of the GPHH in these patients has been reported to be associated with a six to seven times higher risk of mortality than for elective repair.⁷ Symptomatic GPHH patients tend to be elderly and thus commonly suffer multiple co-morbidities, which present an additional challenge in the emergency setting.⁷ As a result, the potential of minimally invasive surgery is particularly attractive in this group of patients.⁸ Although a laparoscopic approach appears to shorten the length of hospital stay, concerns remain surrounding its long-term outcome, including recurrence rate.^8,9 The aim of this study was to compare laparoscopic and open GPHH repair in both the emergency and elective setting in a consecutive series of patients admitted to a single upper gastrointestinal (UGI) surgical unit.

Subjects and Methods

Patient identification

Data for all patients undergoing antireflux surgery between January 1994 and June 2008 were collected using the Lothian Surgical Audit system. The Lothian Surgical Audit is a prospectively maintained database of all surgical admissions and procedures in the Royal Infirmary of Edinburgh, Edinburgh, Scotland, United Kingdom. This database contains clinic letters, coded operation notes, and discharge summaries. Patients undergoing GPHH repair were identified from this group of patients in addition to those patients undergoing similar surgery by the same surgeons at the local private hospital. Indications for repair were symptomatic GPHH in a patient considered fit for surgery. Demographic details, surgical approach and type of procedure, intraoperative and postoperative complications, mortality, length of postoperative hospital stay, and recurrence rates were analyzed.

Presentation

Patients who underwent planned surgery for GPHH after outpatient assessment were considered as elective repairs. Emergency repairs were considered to occur in patients who underwent surgery during their index emergency admission to the hospital with acute symptoms related directly to their GPHH.

Preoperative evaluation

Preoperatively patients were evaluated by a combination of contrast study, computed tomography scan, and/or endoscopy.

Operative technique

Routine surgical management consisted of a variable combination of four procedures—hernia sac reduction, crural repair, fundoplication, and gastropexy—depending upon the patient's condition and the surgeon's preference. For analysis the open group consisted of those patients undergoing both a primary open approach and those who were converted from an attempted laparoscopic approach. Open repair was carried out by a transabdominal route in all patients. The decision on type of surgery was left to the individual surgeon. In the early part of the series simple gastropexy was preferred, but because of high recurrence rates, subsequently the preferred option, where possible, was sac reduction, crural repair, and fundoplication. On occasions if crural repair was not possible, laparoscopic gastropexy was performed as converting to the open procedure would have increased the morbidity in elderly frail patients.

Postoperative complications

Postoperative complications were classified according to Dindo et al.¹⁰ Patients with more than one complication were graded by their most severe complication. This classification is based on the severity of the complication and intervention required to correct it. In brief, Grade I complications are minor and can be treated at the bedside without any pharmacological, surgical, or radiological intervention. Grade II complications require pharmacological intervention. Grade IIIa complications are managed by surgical, endoscopic, or radiological intervention without general anesthesia, whereas Grade IIIb complications require general anesthesia. Grade IVa is a life-threatening complication with single organ failure leading on to intensive care management, and Grade IVb complications produce multiorgan failure. Finally, Grade V complications result in patient death.

Recurrence

Recurrence was diagnosed according to either patient symptoms or the results of further investigations and classified as either early or late by the length of time from operation until re-presentation to the UGI surgical service. Recurrences within 3 months of surgery were classified as early recurrences, and those after 3 months were defined as as late recurrences. Where possible, patients' notes from our own hospital and/or the referring hospital were retrieved to establish whether they had re-presented to other services with potentially recurrent symptoms. All patients who were still alive were sent a questionnaire by mail asking them about any recurrent symptoms. Patients who did not re-present to the UGI service and who did not have any evidence of re-presentation to any other service from review of their notes, including the reports from referring hospitals, or who did not admit to any recurrent symptoms on the postal questionnaire were deemed not to have had a recurrence. Routine follow-up investigations were not carried out unless clinically indicated because of recurrent symptoms or as part of tests for other conditions. Patient consuming antacids only were considered not to have recurrences.

Follow-up

Follow-up was calculated by measuring the length of time from operation until June 2008. Where follow-up status could not be established from examination of a patient's notes, their registered general practice surgery was contacted. For those patients who had died since their operation, length of follow-up was recorded from the date of their operation until their date of death or, if this was not known, until their last contact with the UGI services.

Statistical analysis

Analysis was performed using the computer program Statistical Package for the Social Sciences (SPSS, Inc., Chicago, IL) version 17.0. Differences between the two surgical groups were analyzed by Fisher's exact test or the chi-squared test, and the one-way analysis of variance test was used to compare means. When severity of postoperative complications was compared, each grade was allocated its respective number from 1 to 7, and a mean score was calculated. A difference was considered statistically significant if a P value of ≤.05 or less was obtained.

Results

Patient demographics

In total, 64 patients underwent surgery for a GPHH during this study period: 58 at the Royal Infirmary of Edinburgh and 6 in the local private hospital. Patient demographic details are shown in Table 1. Thirty-nine patients (60.9%) underwent elective surgery, and 25 patients (39.1%) required surgery during an emergency admission. Laparoscopic repair was initially attempted in 52 patients, of whom 12 (23.1%) required conversion to an open procedure. The reasons for conversion were inability to reduce the hernia sac (n=5) and contents (n=2), esophageal perforation (n=2), dense adhesions (n=1), unclear anatomy (n=1), and uncontrollable bleeding (n=1). Including these 12 converted procedures, a total of 24 patients underwent open repair, and 40 underwent laparoscopic repair. Mean follow-up was 39.01±6.6 months (range, 0.4–146 months) and 46.7±8.7 months (range, 0.1–159 months) for the laparoscopic group and the open group, respectively (P=.48).

Table 1.

Patient Demographic Details in the Two Groups

	Laparoscopic group	Open group	P value
Number of patients	40	24
Age [mean±SE (range)] (years)	68.2±2.25 (31–87)	71±2.6 (35–85)	.367
Gender (M/F)	10/30	6/18
Presentation (elective/emergency)	29/11	10/14
Hospital stay [mean±SE (days)]	6.03±1.94 (0–75)	19.06±5.27 (5–88)	.006
Follow-up [mean±SE (months)]	39.01±6.6 (0.4–156)	46.7±8.7 (0.13–159)	.480
Postoperative complications	9/40 (22.5%)	16/24 (66.7%)	.001
Postoperative mortality	2/40 (5.0%)	6/24 (25.0%)	.019
Recurrence rate	10/40 (25.0%)	2/24 (8.3%)	.098

F, female; M, male; SE, standard error.

Operative technique

A combination of surgical procedures was used: 19 of 64 patients underwent sac reduction and gastropexy with or without crural repair, and 41 of 64 patients underwent sac reduction and fundoplication with or without crural repair and gastropexy (Table 2). Two patients underwent sac reduction and crural repair only, 1 patient had a partial gastrectomy (wedge resection), and 1 had a total gastrectomy. Of the 25 emergency repairs, 7 patients had only gastropexy without crural repair. The recurrence rate in patients who had a sac reduction and gastropexy with or without crural repair was 7 of 19 (36.8%), whereas the recurrence rate in patients who had a fundoplication as well was lower (5 of 41, 12.1%) compared with without fundoplication (7 of 23, 26.3%), but this was not significant (P=.1). In 3 patients biological mesh (SURGISIS; Cook Surgical, Bloomington, IN) was used to reinforce the crura.

Table 2.

Different Operative Techniques Used

Operative techniques used	Laparoscopic	Open
Sac reduction, crural repair, and fundoplication	24	12
Sac reduction, crural repair, fundoplication, and gastropexy	2	3
Gastropexy only	10	1
Sac reduction, crural repair, and gastropexy	3	5
Sac reduction and crural repair	1	1
Gastrectomy	0	2

Intraoperative complications (laparosocpic versus open repair)

Intraoperative complications, including excessive bleeding, splenic capsular tear, pleural injury, and esophageal perforation, occurred in 15 of 52 (28.8%) patients of the attempted laparoscopic group and 2 of 12 (16.7%) in the initial open group (P=.49).

Postoperative complications

A significantly higher rate of postoperative complications was found in the open group (16 of 24, 66.7%) compared with the laparoscopic group (9 of 40, 22.5%) (P=.001). The severity of such complications was also higher in the open group (P=.001). These complications included abdominal wall hematoma, pleural effusion, pneumonia, surgical emphysema, mediastinitis, and bleeding (Table 3). In addition, 6 patients suffered from dysphagia, and no patients had symptoms of bloating. Of all the patients with postoperative complications, 1 had recurrence.

Table 3.

Postoperative Complications

Group, grade	Condition (number of patients)
Laparoscopic
Grade I	Moderate abdominal wall hematoma (1), moderate pleural effusion requiring no treatment (1), atelectasis treated with physiotherapy (1)
Grade II	Pneumonia requiring antibiotics (1), urinary tract infection requiring antibiotics (1)
Grade IIIa	Mediastinal abscess requiring percutaneous drainage (1)
Grade IIIb	None
Grade IVa	Apnea following extubation requiring re-intubation in ICU (1)
Grade IVb	None
Grade V	Two deaths due to aspiration pneumonia (2)
Open
Grade I	Wound infection treated by dressing alone (2)
Grade II	Mediastinal collection treated with antibiotics (2), deep wound infection and required TPN (1), pneumonia requiring antibiotics (1), urinary tract infection requiring antibiotics (1)
Grade IIIa	Food bolus obstruction treated endoscopically (1)
Grade IIIb	Open surgical drainage of mediastinal abscess (1)
Grade IVa	Chest infection and apnea requiring intubation in ICU (1)
Grade IVb	None
Grade V	Six deaths due to aspiration pneumonia (2), multiorgan failure associated with sepsis from an ischemic stomach (2), hospital-acquired pneumonia (1), or ischemic heart disease (1)

The grading scale used is that of Dindo et al.¹⁰

ICU, intensive care unit; TPN, total parenteral nutrition.

Length of postoperative hospital stay

Mean length of postoperative stay for the laparoscopic group was significantly shorter than for the open group (6.0±1.9 days [range, 0–75 days] versus 19.1±5.3 days [range, 5–88 days], respectively; P<.006).

Postoperative mortality

Two (5.9%) patients in the laparoscopic group and 6 (25.0%) in the open group died in the postoperative period (P=.019). In the laparoscopic group both patients died as a result of aspiration pneumonia, one of whom required re-operation (open) for an early anatomical recurrence on postoperative Day 3. In the open repair group, 2 patients died from multiorgan failure associated with sepsis, 2 from aspiration pneumonia, and 1 each from ischemic heart disease and hospital-acquired pneumonia.

Emergency versus elective repair

Of the 64 patients, 25 (39.1%) underwent surgery after an emergency admission. Of these 25 patients, 7 required emergency procedures on the day of admission for suspected ischemic complications—at operation only 2 were found to have evidence of gastric ischemia, and 1 had a necrotic omentum. Sixteen emergency repairs were attempted laparoscopically with a conversion rate of 5 of 16 (31.2%). Including these conversions, 14 (56.0%) patients admitted during an emergency underwent open surgery.

Postoperative complications, mortality, and recurrence rates were not significantly different after elective or emergency repair (Table 4). However, the mortality among emergency patients requiring open surgery (5 of 14 [35.7%]) was significantly higher than for those patients whose repair was successfully completed by a laparoscopic approach (no mortality) (P=.027). There was no difference in mortality when comparing an open and laparoscopic approach in elective repair.

Table 4.

Comparison of Elective and Emergency Giant Paraesophageal Hiatus Hernia Repair

	Elective	Emergency	P value
Patients	39	25
Surgical approach (open/laparoscopic)	10/29	14/11
Rate of conversion to an open procedure	7/36 (19.4%)	5/16 (31.2%)	.477
Postoperative complications	13/39 (30.8%)	12/25 (48.0%)	.241
Postoperative mortality	3/39 (7.6%)	5/25 (20.0%)	.146
Recurrence rate	9/39 (23.2%)	3/25 (12.0%)	.268

Recurrence and re-operation rates

In total, 10 of 40 patients (25.0%) undergoing laparoscopic repair had recurrent symptoms, including vomiting and gastroesophageal reflux; in 6 (15.0%) this was early, but only 3 had a radiological abnormality. In 4 (10.0%) the symptoms returned later, and only 2 had a radiological abnormality. Six patients underwent revisional surgery. In the open group 2 of 24 patients (8.3%) had a recurrence (1 early and 1 late) Although both of these were symptomatic recurrences, neither required revisional surgery. There was no statistically significant difference in recurrence rates between the two groups (P=.098). Of the 6 patients who underwent revision surgery the laparoscopic and open approaches were performed in 3 each. Four of these patients had gastropexy only, because of difficult dissection associated with dense fibrosis, and 2 had fundoplication. A quality of life questionnaire was sent to all surviving patients in 2008. Twenty-nine of 47 replied, and of those 19 patients were taking some antacids.

Discussion

Controversy surrounds the best approach to GPHH repair, a procedure associated with significant morbidity and mortality. As this is a relatively uncommon condition, randomized control trials have been difficult to conduct, and consequently almost all published studies are observational, spanning between 4 and 36 years of experience.⁹

Although all patients in this series were symptomatic, controversy exists in relation to whether a policy of routine elective repair or watchful waiting is superior in the asymptomatic patient with an incidental diagnosis. It was suggested many years ago that nearly a third of GPHH patients will eventually present acutely with features of obstruction and incarceration,¹¹ and many surgeons still support routine repair once a GPHH has been diagnosed.^3,7,12 However, one study that examined the annual incidence of emergency surgery in patients with asymptomatic GPHH concluded that an observational policy was more appropriate in those patients older than 65 years.¹³ There have been some reports suggesting that the mortality from emergency surgery can be as high as 17%,¹⁴ and our results confirm high mortality in this group, although the results are not statistically significant relative to the elective group. Clearly there is a difference between a patient requiring an emergency admission due to acute symptoms that settle with nasogastric tube aspiration and then surgery carried out during the same admission as an “urgent” priority, compared with the emergency admission who requires immediate surgery for gastric ischemia. This difference is not adequately differentiated in the majority of reports, but this latter scenario is very uncommon in our experience. In this series 7 of 64 (10.9%) patients underwent immediate surgery, but only 2 had gastric ischemia; 5 of 7 were operated on using an open approach, and the remaining 2 underwent laparoscopic repair. Three of 7 patients (42.9%) who underwent immediate surgery died postoperatively; all had undergone open repairs.

Debate also exists as to whether an open or laparoscopic approach to repair is preferable, and what little literature does exist is conflicting.^15–21 In open surgery, the postoperative complication rate ranges from 32%¹⁶ to 60%,¹⁷ whereas with the laparoscopic approach this falls to between 10.5%¹⁷ and 22%.¹⁵ In our series a significantly higher morbidity and mortality were noted after open repair, suggesting that where possible laparoscopic repair should be attempted even in the emergency setting, recognizing that early conversion may be required if gastric ischemia or perforation is identified.

Some reports suggest that the laparoscopic repair results in higher recurrence rates compared with open surgery.^18,22 However, a review of 32 studies reported that no difference in recurrence rate could be observed between open or laparoscopic GPHH repair,²³ with the recurrence rate varying between 44% for open repair¹⁶ and 42% for laparoscopic repair,¹⁸ respectively. Furthermore, as already suggested, only a small number of recurrences may actually need revisional surgery.²⁴ Our study did, however, show a higher recurrence rate after laparoscopic surgery, although this was not statistically significant.

The major intraoperative complications are esophageal perforation, bleeding, splenic capsular tear, and pleural injury.^15,25 Similar to other reports,^15,17 no difference in intraoperative complications between open and laparoscopic repair was noted in our series. Esophageal perforation remains one of the major intraoperative complications, occurring in up to 11% of patients.^17,26 Similarly, gastric perforation is a known complication.²⁷ The laparoscopic approach appears to have a higher incidence of this complication, which may present later in the postoperative period if missed at initial surgery.¹⁷ Causes of esophageal perforation occur following direct instrumental injury to the esophagus, damage during extensive hernial sac dissection, and passage of an esophageal bougie. It may lead to delayed leakage and severe intra-abdominal sepsis, and, if not recognized early, there is a high risk of mortality.¹⁷

The main limitation of our study was incomplete follow-up with radiological assessment, and therefore overall recurrence rates are likely to be higher than reported. Furthermore, the two groups are not directly comparable, as the open group contained the more difficult procedures and significantly more patients admitted with emergency symptoms. It is therefore not surprising that the complication and mortality rates were higher in the open group.

Conclusions

Surgery for GPHH is associated with a significant morbidity and mortality. Current evidence would suggest that a policy of observation is appropriate for asymptomatic patients over the age of 65 years. For symptomatic patients, laparoscopic surgery should be offered in the first instance as it appears to be associated with a shorter hospital stay and fewer, less severe, postoperative complications than open repair. However, the surgery is often difficult, and conversion to an open procedure is required in a reasonably high number of patients.

Footnotes

Disclosure Statement

No competing financial interests exist. I.S. is responsible for data collection, data analysis, manuscript preparation, and revision of the manuscript. P.M. is responsible for data collection and manuscript preparation. P.D. is responsible for data collection, data analysis, and manuscript preparation. A.d.B. is responsible for data analysis, manuscript preparation, and critical review. G.C. is responsible for data collection, manuscript preparation, and critical review. S.P.B. is responsible for concept, data collection, manuscript preparation, and critical review.

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