Long-term Outcomes and Factors Associated With Failure After Paraesophageal Hernia Repair

Abstract

Introduction: Fundoplication with or without Collis gastroplasty is frequently performed for the repair of complex hiatal hernia. However, symptoms or hernia can recur in some patients requiring re-do fundoplication. Factors associated with failed fundoplication surgery remain unclear. The aim of this study was to assess the factors associated with failed fundoplication surgery. Methods: Patients who underwent PEH repairby a single thoracic surgeon (TWR) at our institution between Jan 1, 2006 and Dec 31, 2013 was performed. Patients who presented for redo fundoplication were excluded. Failed fundoplication was defined as presence of symptoms (heartburn, chest pain and/or reflux) with either post-op abnormal pH testing (based on total time pH5.5%) or recurrence of hiatal hernia on endoscopy or barium swallow. Results: A total of 339 patients (mean age 59.6±13.3 years and 242 (71.4%) female) underwent PEH repair during the study period with a median follow up of 12.8 months (25th and 75th percentile 2.6, 47.7). Sixty patients were referred for redo fundoplication and were excluded. Of the 279 patients, 18 patients met criteria for failed fundoplication during follow-up. Median time to failure was 2.4 months [2.3, 7.2]. Fifteen patients had symptoms and abnormal pH study, 2 had symptoms and recurrence of hiatal hernia and 1 had all three (symptoms, abnormal pH study and hiatal hernia). Table 1 presents the analysis of factors associated with failed fundoplication surgery. On multivariable analysis, presence of pre-fundoplication reflux symptoms (HR: 3.7, 95% CI 1.06-12.6, P-value: 0.041) and preoperative esophageal motility disorder (HR: 2.8, 95% CI 1.1-7.2, P-value 0.028) were associated with failed fundoplication. Figure 1 presents the time-to-event analysis for failed fundoplication. Nearly all of the fundoplication failures occurred within 24 months after surgery.Figure: Time-to-event analysis of failed fundoplication.Table: Table. Analysis of Factors Associated with Failed FundoplicationConclusion: In patients undergoing PEH repair, pre-fundoplication regurgitation and esophageal motility disorder were associated with increased risk for failed fundoplication. PEH repair failure beyond 24 months after surgery is rare.