Laparoscopic repair of paraesophageal hernia. Long-term follow-up reveals good clinical outcome despite high radiological recurrence rate.

Dallemagne, Bernard; Kohnen, Laurent; Perretta, Silvana; Weerts, Joseph; Markiewicz, Serge; Jehaes, Constant

OBJECTIVE The purpose of this report is to evaluate and compare the long-term objective and subjective outcome after laparoscopic paraesophageal hernia repair (LPHR). BACKGROUND Short-term symptomatic results of LPHR are often excellent. However, a high recurrence rate is detected at objective radiographic follow-up. METHODS Retrospective review of a prospectively gathered database of consecutive patients undergoing LPHR with and without reinforced crural repair at a single institution. Subjective and objective outcomes were assessed by using a structured symptoms questionnaire, Gastrointestinal Quality-of-Life Index, satisfaction score, and barium esophagogram. RESULTS From September 1991 to September 2005, LPHR was performed in 85 patients (median age, 66 years) with (25 patients) and without (60 patients) reinforced crural repair. Two patients (3%) underwent laparoscopic reoperation, for severe dysphagia and for symptomatic recurrence, respectively. Subjective outcome, available for 64 patients (75%), improved significantly at median follow-up of 118 months with a postoperative median Gastrointestinal Quality-of-Life Index score of 116. Radiographic recurrence (median follow-up, 99 months) occurred in 23 (66%) of the 35 patients, independently of age at operation, type of paresophageal hiatal hernias, and crural reinforcement, and showed no impact on quality of life. CONCLUSIONS Although providing excellent symptomatic results, long-term objective evaluation of LPHR reveals a high recurrence rate even with reinforced cruroplasty. A tailored, lengthening gastroplasty and reinforced cruroplasty based on objective intraoperative evaluation, and not only on surgeon's personal judgment, may be the answer to recurrences.