Open repair of paraesophageal hernia: Reassessment of subjective and objective outcomes

Background. Surgical repair of paraesophageal hernias (PEH) remains a challenging operation. Increasing numbers of patients are undergoing laparoscopic repair. This series provides an up-to-date benchmark of the results of open repair of PEH to compare with current laparoscopic series. Methods. All patients undergoing surgical repair of PEH by a single surgeon between April 1996 and November 2001 were included. Follow-up included postoperative SF-36 survey and objective reassessment (barium swallow or endoscopy) at a mean of 29.8 months. Results. Seventy-two consecutive patients (mean age, 68.7 years) presented with large PEH. Presenting symptoms included heartburn (60%), dysphagia (43%), chest pain (42%), anemia (39%), and dyspnea (32%). Surgical treatment involved transabdominal open repair including sac excision, crural closure (primary closure 98.6%), and antireflux procedure (Hill procedure, 96%; Nissen fundoplication, 4%). No patient required a Collis procedure. Postoperative assessment (subjective, 97%; objective, 88%) was prospective. Median operative length was 155 minutes. Median length of stay was 4.5 days (range, 3 to 12 days). Postoperative complications occurred in 17 of 72 patients (23.6%), but no patient sustained intraoperative or postoperative visceral injuries. In-hospital and 30-day mortality was zero. Heartburn and dysphagia symptom scores demonstrated significant improvement (p < 0.001). Postoperative SF-36 scores demonstrated levels better than the general population (six of eight categories) and better than the age-matched population (eight of eight categories). Objective follow-up demonstrated recurrent hernias in 11 patients (18%). Most of these recurrences (73%) were less than 2-cm sliding hernias, and no patients required revisional surgery. Conclusions. The results of open repair of PEH have continued to evolve in the same time that has seen the introduction of laparoscopic PEH repairs. Results with the open approach in the modern era can provide excellent outcomes, which are comparable to and in some measures exceed those obtained with the laparoscopic approach. (c) 2005 by The Society of Thoracic Surgeons.