Characterization and management of paraesophageal hernias in children after antireflux operation

Purpose: The aim of this study was to determine the important factors in th e development and subsequent treatment of postoperative paraesophageal hern ia (PPEH). Methods: A retrospective analysis was performed in 464 consecutive children (ages 3 days to 18 years) for PPEH after a primary antireflux operation pe rformed at a Children's Hospital and University Hospital between 1985 and 1 997. Ail operations included a crural repair, but the Nissen fundoplication was performed with (n = 162) and without (n = 70) plication of the esophag us to the crus at 3 points. Patients with and without PPEH were compared wi th respect to the type of antireflux operation, the patient's age at operat ion, and the preoperative and postoperative clinical courses. A preoperativ e corrected gastric emptying value was obtained from a radionuclide gastric emptying study in 289 patients. The treatment of PPEH also was examined. Results, The incidence of PPEH in our patients was 4.5% (21 of 464). Althou gh there was a lower incidence of PPEH in patients with crural plication co mpared with patients without crural plication during Nissen fundoplication (5 of 162, 3% v 7 of 70, 10%; P = .035), 2 patients with crural plication h ad a postoperative esophageal leak. Patients with PPEH had a significantly increased prevalence of gagging before the initial antireflux operation com pared with patients without PPEH (3 of 21, 14.3% v 7 of 443, 1.6%; P = .007 ). A higher prevalence of slow corrected gastric emptying preoperatively al so was seen in patients with PPEH compared with patients without PPEH (8 of 15, 53% v 79 of 274, 29%; P = .046). The prevalences of central nervous sy stem disease, young age (<6 months) at initial operation, and a particular type of antireflux operation were not higher in patients with PPEH. Nine pa tients with a small PPEH treated by simple observation alone subsequently h ad resolution of symptoms. Conclusions: Patients who have gagging or slow corrected gastric emptying b efore an antireflux operation are at higher risk for a postoperative paraes ophageal hernia. Patients with a small postoperative paraesophageal hernia can be treated nonoperatively. Crural plication of the esophagus during Nis sen fundoplication reduces the occurrence of postoperative paraesophageal h ernia, but also may result in significant morbidity. Copyright (C) 1999 by W.B. Saunders Company.