Hiatal Hernia Repair Improves Quality of Life
I read with great interest the new study “Patient-Centered Outcomes after Laparoscopic Paraesophageal Hernia Repair” by Ujiki et al published in the current issue of JACS (Journal of the American College of Surgeons). 314 patients who underwent laparoscopic hiatal hernia repair were prospectively followed between 2009 and 2016. 188 had adequate follow up and were included in the analysis. Most common presenting symptoms were heartburn and food regurgitation. 82% of patients had type 3 hiatal hernia, 14% had type 4 hiatal hernia and the rest had type 2 hiatal hernia. 90% of all crural repair repairs were reinforced with prosthetic mesh. Absorbable mesh was mostly used except in 6 cases permanent mesh was chosen. Permanent mesh is not recommended around the hiatus for fear of esophageal erosion. The authors used a permanent mesh in select cases where the crura were weak and attenuated and a large defect was present to bridge. Nissen fundoplication was performed in 140 patients. The rest underwent Toupet or Dor fundoplication. Mean operative time was 2.3 hours. 5 intraoperative complications occurred including 4 esophageal perforations and one gastric perforation. All were detected and repaired intraoperatively.
Median length of hospital stay was 48 hours. Median number of postoperative days on narcotics for pain control was 3 days. Resumption of daily living activities occurred at a median of 6 days. The mean age of this patient sample is 69. The overall morbidity rate was 7% (infection (1), pneumonia (4), dehydration (2), dyspnea (1), esophageal perforation requiring reoperation (4), esophageal obstruction requiring reoperation (1). Mortality rate was 0.5%.
Reflux symptom index, GERD health related quality of life, Dysphagia, physical functioning/health, emotional well-being, energy and fatigue, social functioning, pain and general health scores all showed significant improvement 2 years after surgery.
The study validates the safety and effectiveness of laparoscopic hiatal hernia repair in treating GERD. In an elderly patient population, the recovery was swift, pain was minimal, and complication rate was low. The benefits of laparoscopic hiatal hernia repair are numerous. In addition to reliably eliminating heartburn and food regurgitation, quality of life greatly improves. Acid reflux is a chronic and progressive disease that slowly and insidiously erodes patient quality of life and energy levels. Laparoscopic hiatal hernia repair is described by most patient as a life changing surgery. At Houston Heartburn and Reflux Center, we advocate early hiatal hernia repair to stop disease progression. We believe that hiatal hernia causes acid reflux and acid reflux causes hiatal hernia to develop and grow. As gastric content refluxes into the esophagus, esophageal muscles retract cephalad favoring the development of hiatal hernia and the progression of type 1 to type 3 paraesophageal hernia. Along this progression, the right and left crura weakens and the esophagus contracts and shortens. As a result, hiatal hernia repair success rate decreases while recurrence and surgery complication rate increases.
Of note, I used hiatal and paraesophageal hernia interchangeably in this blog to avoid reader confusion. Technically speaking, a hiatal hernia is type 1 paraesophageal hernia also known as a sliding hernia.