Outcomes after revisional surgery for paraesophageal hernias at a high-volume tertiary care center

Background Although recurrences after repair of giant paraesophageal hernias (PEH) are common, revisional procedures are challenging and associated with higher complication rates than primary repair. Therefore, repair of recurrent PEH is often avoided except in symptomatic patients. Data describing operative outcomes in these infrequent cases is lacking. Therefore, this study aimed to report and compare peri-operative outcomes of revisional PEH repair to similar patients undergoing primary surgery. Methods A single-institution, retrospective cohort study was conducted on all adult patients undergoing primary repair of Type II-IV PEH and any revisional surgery for recurrent hiatal hernia after previous primary PEH repair (2012-2019). Patient and operative characteristics and post-operative outcomes were extracted from medical records. Patients were grouped into revisional (rPEH) and primary repair (pPEH). Coarsened exact matching was performed to create balanced cohorts. Results A total of 347 cases were identified. The matched cohort included 234 patients (rPEH: 46, pPEH: 188). Patient sex and comorbidities were well balanced, while those who underwent revisions were younger (6413 vs. 69 +/- 11 years; p=0.01). Median time between primary and rPEH was 40[17-121] months. Incidence of emergency repair were similar among groups (rPEH: 9(15%), pPEH: 14(8%); p=0.10). All revisional cases commenced laparoscopically with 7(15%) requiring conversion to open. The conversion rate was higher for rPEH than primary surgery (7(15%) vs. 3(2%); p<0.01), with the most common reasons being adhesions and gastric fundus injury. Intra-operative complications occurred in 12(26%) revisional cases, of which 58% were gastric fundus injuries. Median length of stay was longer for rPEH than pPEH (2[1-5] vs. 1[1-2] day; p=0.02). Incidence of severe complications (rPEH: 5(11%), pPEH: 11(6%); p=0.23) and reoperations (rPEH: 2(4%), pPEH: 7(4%); p=0.84) were similar between groups. There were no peri-operative deaths. Conclusion In a high-volume tertiary care center, repair of recurrent giant paraesophageal hernias can be performed successfully laparoscopically in the majority of cases with acceptable morbidity and peri-operative outcomes in comparison to primary surgery.