A Case of Paraesophageal Hernia
A Case of Paraesophageal Hernia
The main principles for adequate PEH repair are:
Herbella and colleagues published a meta-analysis of antireflux surgical reports. They found that 11.87% of patients with PEH had a short esophagus -- 10 times greater than the incidence in the general population. A short esophagus can be secondary to reflux esophagitis, stricture formation, adhesions to the hernia sac, and chronic intrathoracic position of the stomach and the GEJ.
A common definition for a short esophagus does not exist, nor is there a preoperative test to determine the need for an esophageal lengthening procedure. Ultimately, the diagnosis of short esophagus is made during the operation after all attempts to achieve at least 3 cm of intra-abdominal esophageal length and a tension-free PEH repair have failed.
In our experience with aggressive mobilization of the mediastinal esophagus, enough length is typically achieved to bring the GEJ to at least 3 cm below the hiatus. A Collis gastroplasty is rarely needed. Madan and coworkers described a series of 628 patients, including 351 patients with PEH. No patients required an esophageal lengthening procedure after laparoscopic esophageal mediastinal dissection.
The Collis procedure was first described in 1957. The Collis-Nissen gastroplasty procedure was described by Orringer and Sloan in 1978, and the technique has been modified to a more user-friendly wedge gastroplasty with the use of linear staplers. This procedure uses a portion of the stomach to create a "pseudo" intra-abdominal neoesophagus that provides adequate esophageal length. However, outcomes are often suboptimum, with recurrent reflux, esophagitis, and abnormal distal esophageal motility occurring in some patients. These problems are caused by the retained gastric parietal cells in the neoesophagus.
Oelschlager and associates described use of vagotomy during complex esophageal surgery (ie, repeated antireflux surgery in 52 patients and PEH repair in 50 patients). In the PEH group, 17 patients underwent vagotomy. No difference was found between the vagotomy and no vagotomy groups with regard to abdominal pain, bloating, diarrhea, and early satiety. No patients required surgery for gastric outlet obstruction. The authors proposed vagotomy, unilateral or bilateral, as a maneuver to provide adequate esophageal length.
Complete excision of the sac is very important to eliminate the upward tension exerted on the esophagus and stomach. Furthermore, it allows identification of the GEJ and serves as a handle during full reduction of the intrathoracic stomach instead of requiring the surgeon to grasp the esophagus or stomach, thereby preventing injury to these organs. Edye and colleagues reported a 20% recurrence rate of PEH when the sac was not excised vs a 0% rate when it was excised.
Closure of the hiatus defect is a critical step in PEH repair; failure to close the defect is a major cause of recurrence. Several factors affect the integrity of the closure: (1) the diaphragm and crurae undergo significant tension; (2) the muscular pillars of the crurae may be attenuated because of constant stretching caused by the hernia sac;and (3) the size of the hiatal defect ensures significant tension if only sutures are used to reapproximate the crurae. The use of pledgets and relaxing incisions have been advocated to decrease the amount of tension during repair of PEH.
Recently, use of prosthetic and bioprosthetic mesh to reinforce hiatal repair has gained acceptance as a way to reduce recurrence. Kuster and Gilroy first described prosthetic hiatal closure in 1993, and since then several techniques have been published.
Frantzides and associates compared recurrence of PEH after simple hiatal closure with recurrence after polytetrafluoroethylene (PTFE) reinforcement. The study included 72 patients with a hiatal defect > 8 cm in diameter, with a mean follow-up of 40 months. The onlay mesh was placed and cut in a keyhole fashion. The nonmesh group had 8 recurrences (22%) within 6 months, but no recurrences were found in the mesh group. Granderath and colleagues showed a lower incidence of recurrence at 1 year in 50 patients using mesh compared with 50 patients in whom it was not used (8% vs 28%, respectively). No mesh-related complications were observed in either trial, but follow-up was only 1-3 years. Several sources have reported adverse outcomes associated with the use of PTFE mesh. Although uncommon, these complications can result in severe morbidity, such as esophageal, stomach, or GEJ erosions of the mesh that necessitate significant surgical intervention.
Because of complications with prosthetic mesh, new bioprosthetic meshes have been used to reinforce the hiatal closure. These biomaterials act as an extracellular matrix scaffold to augment native tissue healing and regeneration. They are pliable and temporary by nature; therefore, they should not have the risks associated with synthetic mesh materials. Bioprosthetic mesh seems to be a safe and effective alternative to synthetic mesh for PEH repair. Lee and coworkers showed acceptable recurrence rates (12%) in a group of patients whose hiatal defects were closed with acellular human dermal matrix mesh, with a mean follow-up of 14.4 months. A prospective randomized trial of 108 patients comparing a U-shaped reinforcement mesh made of porcine small intestine submucosa with primary hiatal closure showed a significantly lower recurrence rate in the mesh group at 6 months (9% vs 24%, respectively). However, at 5 years follow-up, no difference was found in long-term recurrence rates.
To achieve adequate fixation of the stomach in the subdiaphragmatic position, gastrostomy and gastropexy are commonly used, although both have a high incidence of recurrence when used alone.
Fundoplication also helps to anchor the stomach subdiaphragmatically and is our procedure of choice when repairing a PEH. Fundoplication is performed for the following 3 reasons: (1) a significant number of patients report heartburn or have a positive 24-hour pH monitoring test for GER; (2) extensive dissection can predispose patients to GER by disrupting the anatomical support responsible for competence of the esophageal sphincter; and (3) fundoplication helps to fix the stomach below the hiatus, potentially reducing the recurrence of PEH. In experienced hands, fundoplication does not considerably increase operative time, and very few patients experience postoperative dysphagia.
We perform Nissen fundoplication as a routine part of PEH repair, and 2-4 sutures are used to further affix the fundoplication to the diaphragm and the hiatus.
PEH in obese patients with a body mass index (BMI) > 35 is a challenge. Under these circumstances, the hiatal hernia and GER are just 2 conditions among several others, and the ideal treatment should focus on weight loss. Whether a BMI >35 is associated with a higher recurrence rate is controversial. Perez and associates showed an overall symptomatic recurrence of GER in 31.3% of obese patients (BMI > 30) compared with 4.5% in patients of normal weight after laparoscopic antireflux surgery. Other studies that supported this finding had an inadequate number of obese patients in the study sample. In contrast, some studies have shown outcomes in obese patients that are similar to those in nonobese patients. Alternatives to fundoplication include gastric bypass or sleeve gastrectomy. Both procedures remove the redundant fundus, which is often the problem when hiatal hernia recurs. Although there is no consensus, several small series showed good results when a laparoscopic Roux-en-Y gastric bypass was performed for this population. Recent studies suggest that this procedure was better for obese patients with reflux than sleeve gastrectomy, although it may pose more risks.
Basic Operative Principles
The main principles for adequate PEH repair are:
Complete tension-free reduction of herniated contents into the abdominal cavity;
Obtaining an adequate intra-abdominal esophageal length;
Complete circumferential excision of the hernia sac;
Closure of the hiatus defect;
Fixation of the stomach in the subdiaphragmatic position; and
Providing an antireflux procedure.
Esophageal Length
Herbella and colleagues published a meta-analysis of antireflux surgical reports. They found that 11.87% of patients with PEH had a short esophagus -- 10 times greater than the incidence in the general population. A short esophagus can be secondary to reflux esophagitis, stricture formation, adhesions to the hernia sac, and chronic intrathoracic position of the stomach and the GEJ.
A common definition for a short esophagus does not exist, nor is there a preoperative test to determine the need for an esophageal lengthening procedure. Ultimately, the diagnosis of short esophagus is made during the operation after all attempts to achieve at least 3 cm of intra-abdominal esophageal length and a tension-free PEH repair have failed.
In our experience with aggressive mobilization of the mediastinal esophagus, enough length is typically achieved to bring the GEJ to at least 3 cm below the hiatus. A Collis gastroplasty is rarely needed. Madan and coworkers described a series of 628 patients, including 351 patients with PEH. No patients required an esophageal lengthening procedure after laparoscopic esophageal mediastinal dissection.
The Collis procedure was first described in 1957. The Collis-Nissen gastroplasty procedure was described by Orringer and Sloan in 1978, and the technique has been modified to a more user-friendly wedge gastroplasty with the use of linear staplers. This procedure uses a portion of the stomach to create a "pseudo" intra-abdominal neoesophagus that provides adequate esophageal length. However, outcomes are often suboptimum, with recurrent reflux, esophagitis, and abnormal distal esophageal motility occurring in some patients. These problems are caused by the retained gastric parietal cells in the neoesophagus.
Oelschlager and associates described use of vagotomy during complex esophageal surgery (ie, repeated antireflux surgery in 52 patients and PEH repair in 50 patients). In the PEH group, 17 patients underwent vagotomy. No difference was found between the vagotomy and no vagotomy groups with regard to abdominal pain, bloating, diarrhea, and early satiety. No patients required surgery for gastric outlet obstruction. The authors proposed vagotomy, unilateral or bilateral, as a maneuver to provide adequate esophageal length.
Excision of the Hernia Sac
Complete excision of the sac is very important to eliminate the upward tension exerted on the esophagus and stomach. Furthermore, it allows identification of the GEJ and serves as a handle during full reduction of the intrathoracic stomach instead of requiring the surgeon to grasp the esophagus or stomach, thereby preventing injury to these organs. Edye and colleagues reported a 20% recurrence rate of PEH when the sac was not excised vs a 0% rate when it was excised.
Closure of the Hiatus Defect
Closure of the hiatus defect is a critical step in PEH repair; failure to close the defect is a major cause of recurrence. Several factors affect the integrity of the closure: (1) the diaphragm and crurae undergo significant tension; (2) the muscular pillars of the crurae may be attenuated because of constant stretching caused by the hernia sac;and (3) the size of the hiatal defect ensures significant tension if only sutures are used to reapproximate the crurae. The use of pledgets and relaxing incisions have been advocated to decrease the amount of tension during repair of PEH.
Recently, use of prosthetic and bioprosthetic mesh to reinforce hiatal repair has gained acceptance as a way to reduce recurrence. Kuster and Gilroy first described prosthetic hiatal closure in 1993, and since then several techniques have been published.
Frantzides and associates compared recurrence of PEH after simple hiatal closure with recurrence after polytetrafluoroethylene (PTFE) reinforcement. The study included 72 patients with a hiatal defect > 8 cm in diameter, with a mean follow-up of 40 months. The onlay mesh was placed and cut in a keyhole fashion. The nonmesh group had 8 recurrences (22%) within 6 months, but no recurrences were found in the mesh group. Granderath and colleagues showed a lower incidence of recurrence at 1 year in 50 patients using mesh compared with 50 patients in whom it was not used (8% vs 28%, respectively). No mesh-related complications were observed in either trial, but follow-up was only 1-3 years. Several sources have reported adverse outcomes associated with the use of PTFE mesh. Although uncommon, these complications can result in severe morbidity, such as esophageal, stomach, or GEJ erosions of the mesh that necessitate significant surgical intervention.
Because of complications with prosthetic mesh, new bioprosthetic meshes have been used to reinforce the hiatal closure. These biomaterials act as an extracellular matrix scaffold to augment native tissue healing and regeneration. They are pliable and temporary by nature; therefore, they should not have the risks associated with synthetic mesh materials. Bioprosthetic mesh seems to be a safe and effective alternative to synthetic mesh for PEH repair. Lee and coworkers showed acceptable recurrence rates (12%) in a group of patients whose hiatal defects were closed with acellular human dermal matrix mesh, with a mean follow-up of 14.4 months. A prospective randomized trial of 108 patients comparing a U-shaped reinforcement mesh made of porcine small intestine submucosa with primary hiatal closure showed a significantly lower recurrence rate in the mesh group at 6 months (9% vs 24%, respectively). However, at 5 years follow-up, no difference was found in long-term recurrence rates.
Fixation of the Stomach Subdiaphragmatically
To achieve adequate fixation of the stomach in the subdiaphragmatic position, gastrostomy and gastropexy are commonly used, although both have a high incidence of recurrence when used alone.
Fundoplication also helps to anchor the stomach subdiaphragmatically and is our procedure of choice when repairing a PEH. Fundoplication is performed for the following 3 reasons: (1) a significant number of patients report heartburn or have a positive 24-hour pH monitoring test for GER; (2) extensive dissection can predispose patients to GER by disrupting the anatomical support responsible for competence of the esophageal sphincter; and (3) fundoplication helps to fix the stomach below the hiatus, potentially reducing the recurrence of PEH. In experienced hands, fundoplication does not considerably increase operative time, and very few patients experience postoperative dysphagia.
We perform Nissen fundoplication as a routine part of PEH repair, and 2-4 sutures are used to further affix the fundoplication to the diaphragm and the hiatus.
PEH in Obese Patients
PEH in obese patients with a body mass index (BMI) > 35 is a challenge. Under these circumstances, the hiatal hernia and GER are just 2 conditions among several others, and the ideal treatment should focus on weight loss. Whether a BMI >35 is associated with a higher recurrence rate is controversial. Perez and associates showed an overall symptomatic recurrence of GER in 31.3% of obese patients (BMI > 30) compared with 4.5% in patients of normal weight after laparoscopic antireflux surgery. Other studies that supported this finding had an inadequate number of obese patients in the study sample. In contrast, some studies have shown outcomes in obese patients that are similar to those in nonobese patients. Alternatives to fundoplication include gastric bypass or sleeve gastrectomy. Both procedures remove the redundant fundus, which is often the problem when hiatal hernia recurs. Although there is no consensus, several small series showed good results when a laparoscopic Roux-en-Y gastric bypass was performed for this population. Recent studies suggest that this procedure was better for obese patients with reflux than sleeve gastrectomy, although it may pose more risks.
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