Esophageal motility and outcomes following laparoscopic paraesophageal hernia repair and fundoplication

BACKGROUND: The addition of an antireflux procedure to all giant paraesopha geal hernia (PEH) repairs remains controversial. In addition there are no s eries evaluating the impact of hernia repair and fundoplication on esophage al physiology, This study examines the outcomes of PEH repair with fundopli cation 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 laparos copic sac reduction, hernia repair, and fundoplication, Follow-up was perfo rmed 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 h eartburn, 50% dysphagia, and 27% chest pain; 26% had a body motility disord er, Complete manometry was not possible in 41%, Mean operative time was 4 h ours. There were 48 Nissen, 4 Toupet, and 7 Collis-Nissen procedures. There were 3 (6%) intraoperative and 3 (6%) postoperative complications. There w ere no operative mortalities. Hospital stay was 3 days (1 to 29), Late foll ow-up (18 months) was available for 96% of patients and showed dysphagia in 6%, heartburn in 10%, and recurrent herniation in 8%, Objective postoperat ive testing was available in 61% of the patients at a mean of 8 months. Twe nty-four hour pH tests were abnormal in 4 patients (2 asymptomatic and 2 wi th a Collis), Lower esophageal sphincter pressures increased 63% and functi oned well in 71% of patients; 50% of preoperative motility disorders improv ed 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. Am J Surg, 1999;177:359-363. (C) 1999 by Excerpta Medica, Inc.