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James D. Luketich
Katie S. Nason
Neil A. Christie
Arjun Pennathur
Rodney J. Landreneau
Matthew J. Schuchert
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J Thorac Cardiovasc Surg 2010;139:395-404
© 2010 The American Association for Thoracic Surgery

General Thoracic Surgery

Outcomes after a decade of laparoscopic giant paraesophageal hernia repair

James D. Luketich, MD, Katie S. Nason, MD, MPH*, Neil A. Christie, MD, Arjun Pennathur, MD, Blair A. Jobe, MD, Rodney J. Landreneau, MD, Matthew J. Schuchert, MD

Division of Thoracic Surgery, University of Pittsburgh, Pittsburgh, Pa

Received for publication May 5, 2009; revisions received September 10, 2009; accepted for publication October 1, 2009.

* Address for reprints: Katie S. Nason, MD, MPH, 5200 Centre Ave, Suite 715, Shadyside Medical Building, Pittsburgh, PA 15232. (Email: nasonks{at}upmc.edu).

Objective: Laparoscopic repair of giant paraesophageal hernia is a complex operation requiring significant laparoscopic expertise. Our objective was to compare our current approach and outcomes for laparoscopic repair of giant paraesophageal hernia with our previous experience.

Methods: A retrospective review of patients undergoing nonemergency laparoscopic repair of giant paraesophageal hernia, stratified by early versus current era (January 1997–June 2003 and July 2003–June 2008), was performed. We evaluated clinical outcomes, barium esophagogram, and quality of life.

Results: Laparoscopic repair of giant paraesophageal hernia was performed in 662 patients (median age 70 years, range 19–92 years) with a median percentage of herniated stomach of 70% (range 30%–100%). With time, use of Collis gastroplasty decreased (86% to 53%), as did crural mesh reinforcement (17% to 12%). Current era patients were 50% more likely to have a Charlson comorbidity index score greater than 3. Thirty-day mortality was 1.7% (11/662). Mortality and complication rates were stable with time, despite increasing comorbid disease in current era. Postoperative gastroesophageal reflux disease health-related quality of life scores were available for 489 patients (30-month median follow-up), with good to excellent results in 90% (438/489). Radiographic recurrence (15.7%) was not associated with symptom recurrence. Reoperation occurred in 3.2% (21/662).

Conclusions: With time, we have obtained significant minimally invasive experience and refined our approach to laparoscopic repair of giant paraesophageal hernia. Perioperative morbidity and mortality remain low, despite increased comorbid disease in the current era. Laparoscopic repair provided excellent patient satisfaction and symptom improvement, even with small radiographic recurrences. Reoperation rates were comparable to the best open series.

Abbreviations and Acronyms BMI = body mass index; CCI = Charlson comorbidity index; CI = confidence interval; GERD-HRQoL = Gastroesophageal Reflux Disease Health Related Quality of Life; GPEH = giant paraesophageal hernia; IQR = interquartile range; LOS = length of stay; OR = odds ratio; SF-36 = Medical Outcomes Study Short Form-36 Health Survey




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