Esophageal motility and outcomes following laparoscopic paraesophageal hernia repair and fundoplication

Background: The addition of an antireflux procedure to all giant paraesophageal hernia (PEH) repairs remains controversial. In addition there are no series evaluating the impact of hernia repair and fundoplication on esophageal physiology. This study examines the outcomes of PEH repair with fundoplication and examines the results of preoperative and postoperative motility and pH testing. Methods: An analysis of a data base containing all patients undergoing PEH repair between September 1994 and December 1997. Patients underwent laparoscopic sac reduction, hernia repair, and fundoplication. Follow-up was performed under protocol and consisted of a symptoms assessment form, 24 hour pH, and manometry. Results: Fifty-two patients (mean age 63) were treated: 59% complained of heartburn, 50% dysphagia, and 27% chest pain; 26% had a body motility disorder. Complete manometry was not possible in 41%. Mean operative time was 4 hours. There were 48 Nissen, 4 Toupet, and 7 Collis-Nissen procedures. There were 3 (6%) intraoperative and 3 (6%) postoperative complications. There were no operative mortalities. Hospital stay was 3 days (1 to 29). Late follow-up (18 months) was available for 96% of patients and showed dysphagia in 6%, heartburn in 10%, and recurrent herniation in 8%. Objective postoperative testing was available in 61% of the patients at a mean of 8 months. Twenty-four hour pH tests were abnormal in 4 patients (2 asymptomatic and 2 with a Collis). Lower esophageal sphincter pressures increased 63% and functioned well in 71% of patients; 50% of preoperative motility disorders improved following repair. Conclusions: Laparoscopic repair of giant PEH is technically difficult but feasible. Routine addition of a fundoplication is advised, as preoperative testing is unreliable for a selective approach and fundoplications are well tolerated in this group of patients.