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Ann Thorac Surg 2002;74:1909-1916
© 2002 The Society of Thoracic Surgeons
a Division of Thoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
b Minimally Invasive Surgery Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
* Address reprint requests to Dr Luketich, UPMC Presbyterian, Division of Thoracic Surgery, Suite C-800, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
e-mail: luketichjd{at}msx.upmc.edu
Presented at the Thirty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2002.
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Abstract |
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METHODS: We performed a retrospective review at our institution of patients undergoing laparoscopic repair of GPEH from July 1995 to July 2001. The GPEH was defined as greater than one-third of the stomach in the chest.
RESULTS: Elective laparoscopic repair of a GPEH was attempted in 203 patients. Mean age was 67 years. The most common symptoms included heartburn (96 patients), dysphagia (72), epigastric pain (56), and vomiting (47 patients). Laparoscopic procedures included 69 Nissens, 112 Collis-Nissens, and 19 other procedures. There were three open conversions due to adhesions, but no intraoperative emergencies. Median length of stay was 3 days (range, 1 to 120 days). Minor or major complications occurred in 57 patients (28%). There were six postoperative esophageal leaks (3%), and 1 death. Median follow-up was 18 months. Five patients required reoperation for recurrent hiatal hernia. Excellent results were reported in 128 (84%) patients, 12 (8%) had a good result, 7 (5%) fair, and 5 (3%) poor (based on postoperative follow-up and GERD questionnaire). The mean postoperative GERD Health-related Quality of Life Score was 2.4 (scale 0 to 45; 0 = no symptoms, 45 = worst).
CONCLUSIONS: Laparoscopic repair of GPEH is possible in the majority of patients with acceptable morbidity, a median length of hospital stay of 3 days and excellent intermediate-term results in an experienced center.
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Introduction |
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Without surgical intervention, GPEH are associated with progression of symptoms in up to 45% of patients [4]. In a classic report of nonsurgical observation of a group of minimally symptomatic patients with a GPEH, 26% died of catastrophic complications including torsion, gangrene, perforation, and massive hemorrhage [5]. In the group of patients who develop gastric volvulus, the death rate can be as high as 100% [6, 7]. Given the significant complications that can occur, GPEH should be electively repaired in most patients. When repair is performed electively, the death rate is less than 1% to 2% in most series [8–10].
Traditionally, repair of GPEH has been performed through an open laparotomy or thoracotomy. With the advent of laparoscopy, GPEH are now being approached with minimally invasive techniques. Less invasive procedures may decrease the amount of postoperative pain and the perioperative complication rate, and shorten recovery time. We have reported our initial experience with laparoscopic repair of GPEH and found the procedure to be technically challenging but feasible with low morbidity [11]. Other groups have found a higher rate of perioperative complications and recurrent herniation with the laparoscopic repair [12]. Herein we report our growing experience with 200 consecutive patients from a single institution, and extended follow-up.
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Material and methods |
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Surgical technique
The most common procedure performed was a laparoscopic Collis-Nissen. In the last 100 patients, more than 85% underwent this procedure. We have previously published our technique [11], but a brief description is given.
The patient is positioned supine on the operating table, and the surgeon works from the right side with the assistant on the left. Four 5-mm and one 10-mm laparoscopic ports (Versaport, United States Surgical Corp (USSC), Norwalk, CT) are placed in the upper abdomen (Fig 2). The left lateral segment of the liver is retracted anteriorly with a 5-mm flexible retractor (Snowden Pencer, Genzyme, Tucker, GA) and secured to a stationary holding device (Mediflex, Islanda, NY). After exposing the hiatus, the herniated stomach is reduced into the abdomen using atraumatic graspers (Snowden Pencer) in a "hand-over-hand" fashion (Fig 3). Dissection is started by dividing the gastrohepatic ligament and exposing the right crus of the diaphragm using the ultrasonic shears (USSC) or the harmonic scalpel (Ethicon, Cincinnati, OH). Then, the gastrosplenic ligament is divided along with the posterior attachments to the fundus. Dissection is continued to expose the joining of the right and left crura at the retroesophageal space. The hernia sac and the gastroesophageal fat pad are then carefully dissected out sweeping the anterior vagus nerve to the right of the esophagus with the fat pad (Fig 4). The distal esophagus is then mobilized superiorly to determine whether esophageal shortening is present. If the esophagogastric junction does not remain below the diaphragmatic hiatus with an adequate, tension-free segment of intraabdominal esophagus, a Collis-gastroplasty is added before fundoplication.
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Results |
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Fifty-five patients had had previous upper abdominal procedure, 6 had prior hiatal hernia operation. Of the 6 patients with a previous hiatal hernia operation, 4 had a previous open Nissen, 1 had a previous laparoscopic Nissen, and 1 had a previous open Belsey procedure. Of the 203 patients attempted laparoscopically there were three conversions to an open procedure due to adhesions, but there were no intraoperative emergencies.
The 200 laparoscopic procedures included 69 Nissens, 112 Collis-Nissens, 12 partial fundoplications, 5 simple gastric reduction with G-tube, 1 Collis-gastroplasty with a partial wrap, and 1 Rous-en-Y gastric bypass. Gore-Tex was used in the repair of the hiatal defect in 11% of patients. The median operative time was 3.3 hours (range, 2 to 12 hours). The median length of stay was 3 days (range, 1 to 120 days).
Minor or major complications occurred in 57 patients overall (28%). There were 6 postoperative esophageal leaks, and 1 death (Table 3). There were 6 intraoperative esophageal perforations and 3 intraoperative gastric perforations, all of which were relatively small and repaired laparoscopically. One of the intraoperative esophageal perforations was caused by a bougie in a 91-year-old female patient. This was recognized and repaired laparoscopically followed by a laparoscopic Dor fundoplication and G-tube insertion. Unfortunately, she developed a postoperative leak and ultimately died in the intensive care unit on postoperative day 38.
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Comment |
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Another recent report came from Wiechmann and colleagues [14] describing attempted laparoscopic repair of 60 GPEH from four different institutions. Conversion to open repair was required in 6 patients because of esophageal injury in 2, and difficult hernia sac dissection in 4. One postoperative mortality (1.9%) occurred as a result of sepsis and multiorgan failure after an intraoperative esophageal perforation. Reoperation for recurrent paraesophageal herniation was required in 3 patients (5.5%). They also concluded that laparoscopic repair of GPEH is a technically challenging procedure, but that with increasing experience the results can be similar to the open approach. It should be noted that in neither the Mayo Clinic series, nor this report from Wiechmann, was an esophageal lengthening procedure used.
Luketich and colleagues [11] published our group’s initial experience with 100 consecutive patients of a GPEH repaired laparoscopically. There were three conversions to open—all due to adhesions and poor visualization. There were no intraoperative emergencies. There were five intraoperative esophageal perforations and three gastric perforations. All eight of these perforations were repaired laparoscopically. There were two postoperative leaks, but no deaths. The median follow-up was only 12 months, but 91% of patients were satisfied with their outcome, and the postoperative mean GERD-HRQOL score was only 2.3 (0, best; 45, worst). After this initial report we concluded that laparoscopic repair of GPEH can be completed safely in more than 95% of patients with minimal complications, a 2-day length of stay, and good short-term results in an experienced minimally invasive center.
The laparoscopic repair of a GPEH is certainly a technical challenge. It requires considerable experience with minimally invasive operation of the foregut, but it also requires a complete understanding of esophageal disease and pathophysiology. In this current study we report our growing experience within a single institution specializing in minimally invasive foregut operation. At the University of Pittsburgh Medical Center we have performed more than 1,000 laparoscopic antireflux procedures and more than 200 thoracoscopic/laparoscopic esophagectomies. Skills gained from this experience enable the safe and effective repair of a GPEH.
Moreover, as our experience with antireflux surgery and GPEH has increased, we have come to recognize the role of esophageal shortening. This remains a controversial point among some clinicians, and the incidence of acquired shortening of the esophagus in association with typical gastroesophageal reflux disease is unknown. There is less controversy as to the existence of shortening of the esophagus in association with GPEH and we, as other investigators, believe this condition is a progression from a simple type I hernia in the majority of patients [10]. Altorki and colleagues [9] evaluated 52 patients with GPEH and found that in 77% the gastroesophageal junction was in the mediastinum.
Similarly, Maziak and associates [10], from the University of Toronto, found the gastroesophageal junction located well above the diaphragmatic hiatus in 91 of 94 patients with a GPEH. In that large series, a Collis-gastroplasty was added in 80% of patients as an esophageal lengthening procedure to deal with acquired shortening. Good to excellent results were achieved in 93% of patients at a mean follow-up of 7.8 years. On the basis of these results, an esophageal lengthening procedure as part of the repair of GPEH should be considered the gold standard for the management of GPEH.
Our utilization of the laparoscopic Collis-gastroplasty has increased during the last 100 GPEH repairs as we have come to better appreciate the concept of the short esophagus. In our previous report 27 Collis-gastroplasties were performed in 100 patients. In the last 103 patients, 86 Collis-gastroplasties were performed. In total 113 of 203 patients (56%) received a Collis-gastroplasty as part of their repair. In contrast, Ellis and colleagues [15] reported that of 55 surgical procedures performed for GPEH, only 2 patients were identified with a shortened esophagus and required a lengthening procedure. This may explain, in part, the high (9.3%) reoperation rate for recurrence reported in this study’s follow-up.
Few patients received pH studies or manometry before surgical repair in this study. Placement of these catheters can be difficult or dangerous in some patients. The barium swallow is the most important preoperative investigation and usually gives adequate information on esophageal motility.
This updated report confirms the technical feasibility and safety of elective laparoscopic repair in 200 patients with a GPEH. The perioperative mortality was 0.5%, the postoperative leak rate was 3%, and the length of stay was 3 days. Only one additional intraoperative esophageal perforation occurred after our first 100 patients, and no additional open conversions were required. The perforation was caused by a bougie in a 91-year-old woman. It was recognized and repaired laparoscopically but ultimately leaked postoperatively and resulted in sepsis and our only death. The surgical team now passes the bougie carefully in all patients while the assistant observes laparoscopically. This coordinated effort should prevent future bougie tip-related perforations.
Median follow-up in our series is now 18 months. Extended follow-up with a GERD-specific questionnaire was complete in 152 patients. The GERD-HRQOL score was 2.4 on a scale of 0 to 45. The preoperative GERD-HRQOL score for patients with a paraesophageal hernia is reported to be approximately 28 [13]. On the basis of the GERD-HRQOL score, 84% of patients had an excellent result and 8% had a good result. Only 3% of patients had a poor result, and only 6% of patients required dilation in follow-up. These outcomes are similar or better than other major open series, although the duration of follow-up is necessarily shorter [8–10].
Five patients have required reoperation for recurrent hiatal hernia. The first patient had a postoperative esophagogastric leak and developed a recurrent gastric volvulus. She was operated on 1.5 years after the original operation. The second patient had a laparoscopic Collis-Nissen followed by recurrent symptoms and hernia after 1 year. At the redo-operation he was found to have dilation of the Collis segment, which in retrospect was believed to have been constructed with too large of a diameter originally. We now take extreme care to construct the Collis segment flush against a 50F bougie. The third patient originally had a laparoscopic Nissen followed by a recurrent GPEH. She was reoperated on 3 years postoperatively and a Collis-Nissen was performed laparoscopically. The lack of a lengthening procedure was believed to contribute to this recurrence. The fourth patient developed a recurrent hernia 9 months after a laparoscopic Collis-Nissen. At reoperation there was a disruption of the crura and a large hiatal defect. The crura were reapproximated with Gore-Tex. The fifth recurrence took place 2 days after a laparoscopic Collis-Nissen. The postoperative barium swallow showed a dramatic superior displacement of the wrap. The patient was taken back to the operating room where the crural sutures were found to be separated. The crura were repaired laparoscopically. Technical factors and the failure to recognize esophageal shortening were the major reasons for failure in these 5 patients. Four of these five recurrences were originally operated on within our first 100 patients and hopefully we will see very few recurrences in the most recent 100 patients when long-term follow-up is evaluated.
More objective follow-up using barium swallows may also reveal a higher incidence of recurrent herniation as reported by the University of Southern California group [16] who found a 42% reherniation rate in their laparoscopic group compared to a 15% rate in their open group. Their high reherniation rate, we believe, is partly related to the learning curve, but mostly related to failure to recognize shortened esophagus and perform a lengthening procedure. There were no lengthening procedures in their laparoscopic group and only one Collis-gastroplasty in their open group. We now perform routine barium swallows at 1-year follow-up in all patients to detect asymptomatic recurrences.
In summary, the laparoscopic approach to the repair of GPEH is feasible, safe, and effective in centers with extensive experience in minimally invasive esophageal operation. Liberal use of the Collis-gastroplasty may reduce the incidence of recurrent herniation and improve long-term functional results. Laparoscopic repair seems to offer the benefit of a shorter hospital stay and a quicker recovery. Long-term follow-up is ongoing and will be required to confirm our good intermediate-term results.
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Discussion |
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TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsDiscussionReferences |
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These giant hernias are technically very difficult to repair regardless of the surgical approach—whether it is open abdominal or open transthoracic. One would have thought the repair would be even more difficult using the laparoscopic approach. I believe, however, the researchers have achieved exactly what they report in this abstract, and that is a high proportion of good to excellent results with intermediate-term follow-up, in a very large series of the most difficult patients undergoing antireflux operation. In their evaluation, they have also included the GERD-HRQOL scoring system, which does provide, as best we can get there, a little more objectivity in the evaluation of results.
I would agree that the majority of these giant hernias are indeed nothing more than very advanced, stage I sliding hernias, which occur in an elderly population. I would also agree, from a long experience with these giant hernias, that the incidence of short esophagus, both gross and subtle degrees of acquired shortening, is much higher than is generally appreciated. This important feature has been recognized by the University of Pittsburgh team. Indeed, they have added a gastric lengthening procedure, a gastroplasty, in about 85% of their last 100 patients.
We do not have accurate, absolute measurements for the preoperative evaluations of acquired shortening. It may be difficult to judge intraoperatively in patients with mild and subtle degrees of shortening, a judgment that may be clinically important in selecting the optimal technique of repair. This evaluation was not dealt with in any detail by Dr Pierre, and I would ask him if he might comment on how they judge whether or not the esophagus is short and requires the addition of a gastroplasty. Other surgeons reporting experience with laparoscopic repair of these giant hernias describe a variety of measuring techniques to determine the relative location of the esophagogastric junction and the diaphragmatic hiatus.
Until very recently, I had assumed that it would be difficult to duplicate the creation of a very precisely sized gastric tube using this kind of "distant, closed" technology. With the open operation, we have the stomach in our hand and we would set the stapler alongside the bougie to make a nice snug application.
Years ago Dr Joel Cooper and I did report on a group of about 60 patients who underwent gastroplasty and fundoplication and were evaluated by intraoperative manometric studies. There is no question that the diameter of the tube directly influences the level of pressure created in the reconstructed lower esophageal sphincter zone: the narrower the diameter of the gastric tube, the higher the resting pressure created within the lumen, and vice versa. Therefore, again Dr Pierre, would you comment, on the technique you used to create a gastric tube of the desired size and diameter.
I would again emphasize what a difficult operation this is, and I would add an important point. This laparoscopic repair is currently done very well by Dr Luketich and his colleagues. However, the level of expertise and experience required to achieve such uniformly good results is restricted to only a handful of centers in North America—I know less about Europe. But having attended several of the conferences on antireflux surgery in Pittsburgh, seen the operation done, watched on the video, I can truly say that everything that is done with those "distant chopsticks" is exactly what I would like to have done with the open operation over the years of experience I had with it. I am quite sure that this represents the appropriate approach and technology of the future and that with time we are going to find more and more centers with your capability.
DR STEVEN R. DEMEESTER (Los Angeles, CA): The researchers are to be congratulated on this excellent series. I had two questions for them. I noticed they had a very low recurrence rate, which is excellent, but, again, recurrence is always found when you look for it. The question I have is, how did you look for it? In those patients that you did find with recurrent hiatal hernias, did they present on the basis of symptoms or were they asymptomatic and this was identified on radiographic studies? Do you do routine radiographic studies postoperatively as your follow-up, and in what percentage of patients that had radiographic studies was recurrence identified? Many of these recurrences are asymptomatic, as we have found and reported, and so I think just going on quality of life studies or surveys can mislead you in terms of the true recurrence rate.
The second question I had, interestingly when you remove these big hernias laparoscopically, we found that the space of the hernia sac persists, and we have had problems with hematoma and hemorrhage in there. I noted none of your complications were reported in terms of that. What percentage of patients had a hematoma or a bleeding problem in that hernia sac?
Thank you very much.
DR PIERRE: Thank you very much, Dr Pearson, for your remarks. Pertaining to the issue of how to determine esophageal shortening, you have written much on the subject and I believe taught me well during my time in Toronto. In Pittsburgh, we evaluate this both preoperatively and postoperatively, but let me be brief. With respect to these giant hernia, we regard most of these as having acquired shortening of the esophagus. Evaluation can include barium swallow, manometry, endoscopy, and various factors that you might discern on those studies suggest esophageal shortening, but ultimately it is our intraoperative assessment of the position of the gastroesophageal junction after removing the fat pad, identifying the position accurately, and seeing the funneling out of the stomach at that point that determines whether or not the gastroesophageal junction, is going to lie in the chest or in the abdomen. And we have to keep in mind that laparoscopically we have a pneumoperitoneum, we are elevating the diaphragm superiorly, and some surgeons may have the intraoperative bougie positioned that tends to advance the esophagus or the gastroesophageal junction slightly lower than it would lie otherwise.
Those factors being considered, we frequently, as you see, apply the Collis gastroplasty lengthening procedure to the patient with a giant esophageal hernia, and, more frequently, we are beginning to recognize acquired shortening of the esophagus in the patients that do not have a giant hernia but who may have a peptic stricture or a long duration of symptoms with Barrett’s esophagus or esophagitis.
You asked a question about the technique for the creation of the gastric tube. Every step of this operation is critical to the functional outcome, and attention needs to be directed to each of them. With respect to the formation of the neoesophagus, after the insertion of the circular stapler, which needs to lay firmly against the bougie, we apply the EndoGIA stapler in multiple fires. The video only showed you the beginning of the first fire and perhaps misrepresents the alignment of the subsequent firings of the stapler to ensure that that gastric tube is not too wide or dilated. And, in fact, one of the recurrences of those five recurrences was believed to be related to a gastric neoesophagus that was too wide, and it was subsequently tapered down. And in fact, as I understand from Dr Luketich, over the years we have been progressively using smaller and smaller size bougies around which to form that gastric tube and that wrap, and, as I mentioned, the majority of our patients are done now with a 50F Maloney bougie.
Dr DeMeester, you asked about recurrences. Four of the 5 patients who were reoperated on were symptomatic and had recurrences typically around 9 months to a year and a half after the procedure. There was 1 patient who had a postoperative barium swallow, which is our routine to do either on day 1 or day 2 after the operation, and the wrap was noted to have slipped back up into the chest in a dramatic fashion. That patient was taken back to the operating room that day or the following day where the crural sutures were found to have basically come apart, constituting a clear technical error from the procedure. The wrap was brought back down into the abdomen and the crural sutures were repaired.
The majority of those five recurrences we believe were either related to technical factors such as the crural sutures coming undone, failure to recognize acquired shortening of the esophagus, that is, to just perform a Nissen fundoplication without a Collis procedure, or, in 1 patient, not recognizing tension on the crural repair, and that patient was ultimately brought back approximately 9 months after and underwent repair of the hiatus with a Gore-Tex patch completing it.
The question about the persistent space, we see that on computed tomographic scans. If we have done a computed tomographic scan to rule out a pulmonary embolism, we typically see the collection of fluid within that residual space. It has not been a clinical problem for us.
Thank you.
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