Current Concepts With Paraesophageal Hernia

1. Current Concepts With Paraesophageal Hernia P.A. Seshadri M.D., FRCSC October 2001

2. Purpose: Review current concepts of PEH�� Background Management Laparoscopy Technique Controversial Issues Video presentation

3. Conclude: Laparoscopic repair of PEH is �. Difficult Technically feasible, safe, effective Advantages over open repair However���.

4. PO Buenaventura, Semin Thorac Cardiovasc Surg 2000

5. Paraesophageal Hernia: Types Most (95%) are Type I PEH account for only 5-10% of all hiatal hernias Of PEH 95% are combined Type III Overall published recurrence rates are ~ 15% - important wrt esophageal shortening- important wrt esophageal shortening

6. Management problem because: Surgeons cannot agree - preoperative evaluation - to operate or not to operate - which operation and how - appropriate follow-up

10. Surgery is technically challenging�. Safe dissection of anatomically abnormal hiatus Dealing with a shortened esophagus Management of large diaphragmatic defect

11. Preoperative CXR

12. Upper GI: Organoaxial volvulus

14. Presentation is variable from asymptomatic to severe postprandial pain with inability to vomit and failure to pass an NG tube Most common reasons prompting evaluation in those with type III hernias is Postprandial distress Aneamia Obstructive symptomsPresentation is variable from asymptomatic to severe postprandial pain with inability to vomit and failure to pass an NG tube Most common reasons prompting evaluation in those with type III hernias is Postprandial distress Aneamia Obstructive symptoms

15. Preoperative evaluation: CXR Barium swallow - define anatomic relationships, esophageal length, volvulus UGI endsocopy - evaluation of herniated stomach (ulcers, ischemia�) Manometry/ pH - ? Tailor type of fundoplication - 5% not able to pass catheter - 35% not reliable d/t external compression Barium enema - assess contributing factors for anemia

16. Should we operate? Skinner and Belsey (1967) - nonoperative observation of 21 minimally symptomatic patients - 26% died of catastrophic complications Treacy and Jamieson (1987) - monitored 24 patients - elective surgery eventually in 13 (54%) because of progressive symptoms -none needed emergency surgery Haas (1990) - 21 patients intrathoracic volvulus (8 asymptomatic) -10 required emergency surgery

17. Surgical Issues/ Principles: Transabdominal vs. transthoracic approach Open vs laparoscopic approach Reduction of hernia contents Excision of hernial sac Dealing with shortened esophagus Repair of diaphragm Addition of antireflux procedure Intraabdominal fixation of stomach Transthoracic � good for complete excision of sac and full esophageal mobilization Transabdominal � facilitates reduction of volvulusTransthoracic � good for complete excision of sac and full esophageal mobilization Transabdominal � facilitates reduction of volvulus

18. Laparoscopic challenges: Experience Hernia contents/volvulus make identification of anatomy difficult Dissection of large sac ? bleeding ? poor visualization ++ redundant tissue at GEJ makes fundoplication difficult

19. Lithotomy position Large angle at hips to allow for instruments to move easily Support with bean-bag or tape to facilitate steep Fowler position

20. Port placement

21. Reduction of hernial contents

22. Atraumatic graspers Take care while reducing hernial contents b/c stomach wall may be ischemic/atrophic and prone to perforation Experienced assistant providing retraction Reduction of hernial contents

23. N Basso et al. Surg Laparosc Endosc 9:257-262, 1999 Dissect sac on a curved line from left to right Dissect left first because left gastric artery may be stretched and distorted

24. Hiatal defect

25. Esophageal Hiatus

26. Esophageal Hiatus Lighted bougie facilitates esophageal identification Endoscopy helps find the GEJ Need complete circumferential dissection of hiatus to promote closure and esophageal length Leave fascia/parietal peritoneum overlying crura Beware vagus nerves Change visual field often to give perspective

27. The shortened Esophagus: < 2.5 cm of intraabdominal esophagus without tension Poor preoperative prediction but suspect if�. Large hiatal hernia Esophageal stricture Barrett�s esophagus Reoperative surgery LES < 35 cm from incisors

28. Dealing with short esophagus: Excise GEJ redundant tissue Mobilize mediastinal esophagus circumferentially as high as possible A few cm gained by anterior displacement of esophagus with posterior diaphragm repair Lengthening procedure required in 5-20% Nissen-collis

29. LL Swanstrom et al. Arch Surg 133:869, 1998

32. Diaphragmatic defect: Nonabsorbable suture Simple closure Pledgets Mesh / PTFE Mesh over relaxing incision

35. Alternatively Mesh can be used to close very large defects

37. Mesh repair

39. Fundoplication: Most perform one 50% have a preop history of GERD Preop evaluation of GERD unreliable 20-30% will reflux postoperatively Circumferential dissection of GEJ disrupts natural antireflux mechanisms Facilitates intraabdominal anchor - recent article on gastropexy showed 23% recurrence- recent article on gastropexy showed 23% recurrence

40. Fundoplication: Anchor wrap to diaphragm Gastopexy not required Chest tube not needed Closed suction drain into chest/mediastinum

41. Results of Laparoscopic Repair PEH

42. PO Buenaventura, Semin Thorac Cardiovasc Surg 2000

43. Laparoscopic Repair of Giant Paraesophageal Hernia: 100 Consecutive Cases James Luketich et al. Ann Surg 232, 2000 1995 � 2000 (retrospective) 100 patients with laparoscopic repair (1/3 stomach in chest) 72 Nissen, 27 Nissen-Collis 3 conversions 1 death at 5 months d/t stroke

44. Laparoscopic Repair of Giant Paraesophageal Hernia: 100 Consecutive Cases Median LOS = 2 days Median F/U = 12 months 1 reoperation for recurrence 10 patients on PPI

45. Comparison of Laparoscopic versus Open Repair of Paraesophageal Hernia Phillip Schauer et al. Am J Surg 176, 1998 1990 �1998 (retrospective) Symptomatic PEH with acceptable OR risk 25 Open (chest, abdo) and 67 Laparoscopic OR time: Laparoscopic = 264 min Open = 208 min OR time decreased to 214 in last 15 cases

48. Laparoscopic Repair of Large Type III Hiatal Hernia: Objective Follow-up Reveals High Recurrence Rate Majid Hashemi et al. J Am Coll Surg 190, 2000 1985 - 1998 54 patients (13 laparotomy, 14 thoracotomy, 27 laparoscopy) All had antireflux operation Median of 24 months 94% answered questionnaire 75% had videoesophagram by one radiologist

50. Symptomatic Success - Laparoscopic 76% - Open 88% Recurrence (any herniation stomach above diaph) - Laparoscopic 9/21 (42%) - Open 3/20 (15%) 7/12 (58%) of recurrences were asymptomatic

51. Problems: Includes laparoscopic learning curve No pledgets Hernia sac removed via open approach and dissected but left laparoscopically Wide confidence intervals Only one Collis Still no RCT or prospective evaluation with standardized operation and follow-up

52. Conclusion: Management of PEH challenging Operative principles Reduce hernial contents Excise sac Repair diaphragm without tension Simlpe sutures ? pledgets ? Mesh Fundoplication

53. Laparoscopic repair is safe and effective but require�.. Experience (experienced assistant) May have to deal with shortened esophagus Remove GEJ fat pad With laparoscopy we are also learning how to perform the open procedure better Moving target Need more long term, well organized studies

54. Thank you

55. Presentation is variable from asymptomatic to severe postprandial pain with inability to vomit and failure to pass an NG tube Most common reasons prompting evaluation in those with type III hernias is Postprandial distress Aneamia Obstructive symptomsPresentation is variable from asymptomatic to severe postprandial pain with inability to vomit and failure to pass an NG tube Most common reasons prompting evaluation in those with type III hernias is Postprandial distress Aneamia Obstructive symptoms

56. Previous small wrap

57. Previous wrap divided with a stapler