A 32-year experience in 100 patients with giant paraesophageal hernia: Thecase for abdominal approach and selective antireflux repair

Background. Giant paraesophageal hiatal hernia (GPEH) presents a risk of ca tastrophic complications that include massive bleeding, strangulation, and perforation and should be repaired. Controversy persists as to the surgical approach and whether an antireflux repair is required. Methods. This study reviews the experience with 100 patients with GPEH who underwent surgical repair between 1967 and 1999. Eighty patients underwent an elective operation and 20 patients underwent an emergency procedure for complications of GPEH. The gastroesophageal junction was above the hiatus ( "combined" hernia with sliding component) in 23 patients and in the abdomen in 77 patients, including 3 patients with a true parahiatal hernia. Results. A thoracic approach was used in 18 patients, mostly early in our e xperience; postoperative gastric volvulus requiring transabdominal repair d eveloped in 2 patients. The remaining 82 patients underwent an abdominal re pair; with temporary gastrostomy to prevent gastric displacement in 75 pati ents; the hernial sac was resected, and the hiatus was reconstructed in all of the patients. Thirty-five patients with reflux on preoperative work up underwent a fundoplication, with gastroplasty in 2 patients because of a sh ort esophagus. No patient has experienced hernia recurrence. Whereas sympto matic relief was excellent in all patients with elective repair mild reflux was present in 2 patients after emergency operation. There were no deaths among the patients who underwent elective operation; there were 2 hospital deaths among those patients who underwent emergency operation (10%). Conclusions. GPEH should be repaired soon after recognition. Reflux should be evaluated before the operation, and if present, fundoplication should be part of the repair along with the reduction of the hernia, excision of the sac, gastropexy, and crural closure. These are best achieved with an abdom inal approach.