Interact CardioVasc Thorac Surg 2008;7:71-74. doi:10.1510/icvts.2007.163741
© 2008 European Association of Cardio-Thoracic Surgery
Institutional report - Esophagus |
Quality of life following primary vs. redo transthoracic paraesophageal hernia repairs
Matthew D. Taylora,
Alykhan S. Nagjia,
Benjamin D. Kozowera,
Vanessa M. Shamib,
Thomas M. Daniela and
David R. Jonesa,*
a Department of Surgery, University of Virginia, Box 800679, Charlottesville, VA 22908-0679, USA
b Division of Gastroenterology, University of Virginia, Charlottesville, VA, USA
Received 22 July 2007;
received in revised form 22 October 2007;
accepted 24 October 2007
 Presented at the 15th European Conference on General Thoracic Surgery, Leuven, Belgium, June 3–6, 2007.
*Corresponding author. Tel.: +1 (434) 243-6443; fax: +1 (434) 982-1026.
E-mail address: djones{at}virginia.edu (D.R. Jones).
 |
Abstract
|
|---|
The purpose of this study was to compare the quality of life (QOL) and functional results of 42 patients undergoing primary (60%) and 23 patients undergoing redo (40%) transthoracic paraesophageal hernia repairs. All patients had a floppy Nissen or Belsey anti-reflux repair with or without a Collis gastroplasty. Morbidity occurred in 12% of patients and was similar between groups (P=1.0). Overall QOL scores were not different between groups. Patients undergoing initial repair were found to have significantly higher QOL scores related to their GERD symptoms (P=0.02). Postoperative GERD symptom scores were not significantly different between groups for heartburn, regurgitation, epigastric/chest pain, or cough. Redo patients had more bloating (P=0.02) and dysphagia (P=0.04). Overall, total GERD scores were higher in the redo group compared to the initial group indicating worse GERD-related dysfunction in the redo group (15.8±3.8 vs. 6.3±1.6, P=0.03). Functional and QOL analysis of transthoracic paraesophageal hernia repairs indicates that redo procedures are associated with a higher incidence of specific gastrointestinal symptoms and worse GERD-related QOL when compared to initial procedures. These differences, while statistically significant, have limited clinical relevance as the overall QOL was not different between groups and low GERD symptom scores were found in both groups.
Key Words: Quality of life; Paraesophageal hernia repair
|
1. Introduction
|
|---|
Evidence-based evaluation of paraesophageal hernia repair has concluded that no approach has a significantly better long-term outcome [1]. Regardless of the approach, there is a 1–29% recurrence rate following initial repair for these large type III and type IV hernias [1]. More recent studies have suggested that an initial laparoscopic repair may result in a higher incidence of recurrence than open procedures [2, 3].
The transthoracic approach to repair paraesophageal hernias provides excellent exposure to evaluate the entire esophagus and determine the need for an esophageal lengthening procedure in addition to a fundoplication at the time of the procedure. We have favored a transthoracic approach for the initial repair of many, but not all, paraesophageal hiatal hernias and for nearly all redo-procedures.
In contrast to the literature regarding the morbidity and mortality surrounding paraesophageal hernia repairs, there are very few studies that have examined postoperative functional and quality of life (QOL) assessment [3]. In fact, there are no studies comparing gastrointestinal-specific postoperative symptoms and QOL in patients undergoing initial paraesophageal hernia repair vs. those patients undergoing redo repair of a paraesophageal hernia. An objective assessment of this is important as it is commonly thought that redo paraesophageal operations result in less favorable functional outcomes [4].
The purpose of this study is to compare the postoperative complications, symptoms, and QOL in patients undergoing initial vs. redo transthoracic repair for type III and type IV paraesophageal hernias in our institution.
|
2. Patients and methods
|
|---|
2.1. Patient population
Approval for the study was obtained from the Institutional Review Board for Health Sciences Research at the University of Virginia. A retrospective review identified 65 patients who underwent transthoracic paraesophageal hernia repair of type III and IV hernias between 1999–2006. Exclusion from the study included patients with primary esophageal motility disorders, esophageal diverticuli, and sliding type I hiatal hernias. All patients underwent preoperative esophageal manometry and esophagogastroscopy. Twenty-four hour pH probe analysis was performed selectively, depending on the presence of GERD specific complaints. All patients underwent either a Nissen fundoplication or Belsey fundoplication depending on their manometric studies and intraoperative findings. Patients were divided into two groups: those undergoing initial (n=42) or redo (n=23) paraesophageal hernia repair.
Of the 65 patients, follow-up data were complete on 50 patients (77%). The median length of follow-up in the initial repair group was 27 months as compared to the redo group of 35 months (P=0.15). In addition to demographic data, the type of operation performed, length of hospital stay, perioperative complications, and follow-up were collected. Furthermore, resumption of acid suppression medications was also recorded.
2.2. Assessment of postoperative upper gastrointestinal symptoms/function
To assess postoperative gastrointestinal symptoms in both groups, a previously validated, disease-specific symptom questionnaire developed by Allen et al. was utilized [5]. Patients were contacted by telephone and a questionnaire was completed by direct verbal communication with the patient in the presence of an independent observer blinded to the treatment group. Six specific symptoms were evaluated as a part of the questionnaire including heartburn, regurgitation, epigastric or chest pain, epigastric fullness, dysphagia, and cough. Each symptom was scored by severity (0–3) and frequency (0–4). Severity and frequency scores were multiplied together to obtain a symptom score of 0–12 with 0 indicating no symptoms and 12 indicating severe symptoms. All six symptom scores were added resulting in a score from 0–72 with a higher score indicating more severe symptoms.
2.3. Postoperative quality of life assessment
Patients were mailed two short-form QOL surveys. The short form generic health form survey (SF-12) was utilized to assess overall general health-related QOL [6]. In addition, a previously validated GERD symptom-specific QOL survey was used to ascertain the effect of GERD symptoms on the overall quality of life [7].
2.4. Statistical analysis
Values are expressed as mean±standard error of the mean unless otherwise stated. Student's t-test or the Fisher's exact test was performed where appropriate between treatment groups with statistical significance determined to be a P-value  0.05.
|
3. Results
|
|---|
The demographics of the 65 patients that underwent both initial (n=42) and redo (n=23) transthoracic paraesophageal hernia repair are shown in Table 1. There was nearly a 3:1 ratio of females to males that underwent surgery in both groups. There was no significant difference in age at operation between patients (P=0.26). There were 60 patients with type III (92%) and five patients with type IV (8%) hernias. There was no difference in body mass index between groups. Seventy-one percent of patients undergoing initial repair had an esophageal lengthening procedure compared to only 43% in the redo group. This was significantly different (P=0.03). No patients in the redo group had esophageal lengthening procedures with their initial repair. The median length of stay was no different between groups indirectly confirming that the perioperative morbidity was no different either.
Preoperative gastrointestinal specific symptoms are displayed in Table 2. There was no significant difference in the presenting symptoms between groups.
The majority of patients (n=21, 91%) undergoing a redo procedure had previously had a transabdominal Nissen fundoplication as the initial procedure. Fourteen (61%) of these procedures were performed laparoscopically (Table 3). In addition, 6/23 (26%) of the redo patients had had at least two previous hiatal hernia repairs. The median length of time between the last attempted repair and their last operation was 15 months (range 1–120).
Postoperative morbidity in the initial repair group included: esophageal leak requiring reoperation (1), chylothorax requiring reoperation (1), hernia recurrence (2), acute renal failure (1), dilatations for stricture (2), gastric outlet obstruction (1), and atrial fibrillation (1). In the redo repair group, complications included: esophageal leak requiring reoperation (1), gastric outlet obstruction requiring reoperation (1), hernia recurrence (1), dilatation for stricture (1), and atrial fibrillation (1). The in-hospital mortality was 1/65 (1.5%); this was related to complications from a postoperative chylothorax in an initial repair patient. There were an additional seven non-GI related late deaths noted in the follow-up period, all in the initial repair group.
When evaluating patients' postoperative symptoms and upper gastrointestinal function as assessed by the symptom scoring questionnaire, postoperative symptomatic bloating and dysphagia scores were significantly higher in the redo group compared to those undergoing an initial repair (Table 4). Interestingly, there was no difference between groups in symptoms related to heartburn, regurgitation, epigastric pain, or cough. However, when combining the six GERD-related symptoms into a total GERD score, patients undergoing an initial repair had less GERD-related symptoms compared to the redo repair group (P=0.03).
Assessment of patients' postoperative QOL related to their GERD symptoms demonstrated a significantly improved QOL in the initial repair group compared to the redo repair group (P=0.02) (Table 5). However, when evaluating general quality of life not specific to GERD symptoms, there was no significant difference in either the mental or physical scores between groups.
|
4. Discussion
|
|---|
This study illustrates that redo paraesophageal hernia repairs can be safely performed via a transthoracic approach with essentially the same perioperative complications as primary repairs. With the increased number of laparoscopic hiatal hernia repairs being performed, it is likely that thoracic surgeons will be increasingly asked to evaluate patients for recurrent and/or complicated paraesophageal hernias. While our study and others have demonstrated no immediate differences in patient outcome, this study examines the QOL following initial and redo paraesophageal hernia repair [8–10].
We found that major postoperative complications occurred in 12% of all patients undergoing transthoracic repair. These included anastomotic leak, recurrence, gastric outlet obstruction, and chylothorax. Furthermore, our perioperative mortality of 1.5% compares favorably with the other published reports [11, 12]. Early hernia recurrence rates of 4.2% were also similar to other published studies [11, 12].
In this study, patients undergoing an initial paraesophageal hernia repair had a higher percentage of having a concomitant gastroplasty performed compared to the redo repair group (71% vs. 43%, respectively). Of the 23 patients that underwent redo repairs, 43% had foreshortened esophagus, 30% had crural or diaphragmatic repair breakdown, and 27% had slipped wraps or too tight of a fundoplication or hiatal closure. The lower percentage of gastroplasty in the redo group appears surprising, but other groups have reported similar findings with respect to the need for a gastroplasty for redo hiatal hernia procedures. Ohnmacht reported on 124 patients undergoing redo procedures and found a need for a gastroplasty in only 32% of patients [10]. In fact, the choice of what approach and what operation to perform when considering a redo operation is best dictated by the anatomic or pathophysiologic reasons for failure. In the Mayo Experience, the majority of patients had a recurrent hiatal hernia with only 32% of patients having a concomitant foreshortened esophagus [10]. Similarly, Floch and colleagues reported on 46 patients that underwent redo antireflux surgery with the reasons for failure being hiatal herniation in 67%, fundoplication breakdown in 43%, fundoplication slippage in 20%, and a tight fundoplication in 11% [13]. Perhaps the most common theme for all redo hiatal hernia operations has been that currently 50–70% of the initial operations are being performed laparoscopically [4, 10].
The GERD symptom scoring method evaluates six symptoms associated with symptomatic gastroesophageal reflux. According to the validation study published by Allen et al. differences between treatment groups of seven or greater indicated a clinically significant symptomatology [5]. In our study, redo patients scored 9 points higher than those undergoing initial repair indicating significantly worse GERD symptoms. Postoperative symptoms of bloating and dysphagia were significantly higher in those patients undergoing redo transthoracic paraesophageal hernia repair. These observations certainly suggest the possibility of vagal nerve injury during the reoperation as a likely reason for these symptoms. The risk of injury to the vagal nerve fibers in our series was increased further given that 26% of the patients in the redo repair group had two or more prior attempts at antireflux surgery, which likely accounted for a more hostile surgical environment. Despite the difference in symptoms between groups, overall GERD-related scoring <20 in both groups indicates that both initial and redo repairs in our series have relatively minimal GI symptoms postoperatively.
Previous studies have determined that the GERD-related quality of life scoring (GERD-HRQL) has been shown to correlate with known physiologic parameters of gastroesophageal reflux disease [14]. GERD-HRQL scores between treatment groups were found to be statistically significant indicating that patients undergoing redo repairs have poorer quality of life as a result of their GERD symptoms compared to those undergoing initial repair.
To assess whether unrelated physical or mental stresses could be resulting in the significant differences between the calculated GERD-HRQL scores, we applied the generic SF-12 quality of life survey. The application of this general QOL SF-12 survey has previously been validated in patients with GERD [15]. The results of the SF-12 survey demonstrated no difference between groups. This strongly suggests that the differences found in the GERD-HRQL survey were not a result of an unrelated physical or emotional ailment, most notably the possibility of increased post-thoracotomy pain in the redo operative patients.
Limitations to our study include the retrospective data collection, which is therefore subject to the inherent biases associated with this type of analysis. A second limitation is that the completion of surveys and patient follow-up was only 77%. However, a follow-up of almost 80% in our series is acceptable for a tertiary referral center with many out-of-state patients. Third, routine, scheduled postoperative radiologic studies were not performed on asymptomatic patients, and this may have resulted in a falsely low rate of hernia recurrence following repair in both groups.
In conclusion, patients undergoing redo repair of a paraesophageal hernia appear to have more postoperative GERD symptoms, particularly related to dysphagia and bloating, and a decrease in their GERD-specific QOL when compared to patients undergoing initial repair. These differences, while statistically significant, have limited clinical relevance as the overall QOL between groups was not different and overall GERD symptom scores were relatively low in both groups indicating preserved gastrointestinal function.
|
References
|
|---|
- Callender CG, Ferguson MK. Giant paraesophageal hernia: thoracic open, abdominal, or laparoscopic approach. In: Ferguson MK. Difficult decisions in thoracic surgery: an evidence-based approach2007;New York: Springer 343–349. In:.
- Hashemi M, Peters JH, De Meester TR, Huprich JE, Quek M, Hagen JA, Crookes PF, Theisen J, De Meester SR, Sillin LF, Bremner CG. Laparoscopic repair of large type III hiatal hernia: objective follow-up reveals high recurrence rate. J Am Coll Surg 2000; 190:553–560. discussion 560–561.[CrossRef][Medline]
- Mehta S, Boddy A, Rhodes M. Review of outcome after laparoscopic paraesophageal hiatal hernia repair. Surg Laparosc Endosc Percutan Tech 2006; 16:301–306.[CrossRef][Medline]
- Smith CD, McClusky DA, Rajad MA, Lederman AB, Hunter JG. When fundoplication fails: redo? Ann Surg 2005; 241:861–869. discussion 869–871.[CrossRef][Medline]
- Allen CJ, Parameswaran K, Belda J, Anvari M. Reproducibility, validity, and responsiveness of a disease-specific symptom questionnaire for gastroesophageal reflux disease. Dis Esophagus 2000; 13:265–270.[CrossRef][Medline]
- Luketich JD, Raja S, Fernando HC, Campbell W, Christie NA, Buenaventura PO, Weigel TL, Keenan RJ, Schauer PR. Laparoscopic repair of giant paraesophageal hernia: 100 consecutive cases. Ann Surg 2000; 232:608–618.[CrossRef][Medline]
- Velanovich V. The development of the GERD-HRQL symptom severity instrument. Dis Esophagus 2007; 20:130–134.[CrossRef][Medline]
- Hunter JG, Smith CD, Branum GD, Waring JP, Trus TL, Cornwell M, Galloway K. Laparoscopic fundoplication failures: patterns of failure and response to fundoplication revision. Ann Surg 1999; 230:595–604. discussion 604–596.[CrossRef][Medline]
- Papasavas PK, Yeaney WW, Landreneau RJ, Hayetian FD, Gagne DJ, Caushaj PF, Macherey R, Bartley S, Maley Jr RH, Keenan RJ. Reoperative laparoscopic fundoplication for the treatment of failed fundoplication. J Thorac Cardiovasc Surg 2004; 128:509–516.[Abstract/Free Full Text]
- Ohnmacht GA, Deschamps C, Cassivi SD, Nichols 3rd FC, Allen MS, Schleck CD, Pairolero PC. Failed antireflux surgery: results after reoperation. Ann Thorac Surg 2006; 81:2050–2053. discussion 2053–2054.[Abstract/Free Full Text]
- Maziak DE, Todd TR, Pearson FG. Massive hiatus hernia: evaluation and surgical management. J Thorac Cardiovasc Surg 1998; 115:53–60. discussion 61–65.[Abstract/Free Full Text]
- Patel HJ, Tan BB, Yee J, Orringer MB, Iannettoni MD. A 25-year experience with open primary transthoracic repair of paraesophageal hiatal hernia. J Thorac Cardiovasc Surg 2004; 127:843–849.[Abstract/Free Full Text]
- Floch NR, Hinder RA, Klingler PJ, Branton SA, Seelig MH, Bammer T, Filipi CJ. Is laparoscopic reoperation for failed antireflux surgery feasible. Arch Surg 1999; 134:733–737.[Abstract/Free Full Text]
- Velanovich V, Karmy-Jones R. Measuring gastroesophageal reflux disease: relationship between the health-related quality of life score and physiologic parameters. Am Surg 1998; 64:649–653.[Medline]
- Colwell HH, Mathias SD, Pasta DJ, Henning JM, Hunt RH. Development of a health-related quality-of-life questionnaire for individuals with gastroesophageal reflux disease: a validation study. Dig Dis Sci 1999; 44:1376–1383.[CrossRef][Medline]
|
|
Top
Abstract
1. Introduction
