Laparoscopic Hill Repair: 25-Year Follow-Up
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Surgical Endoscopy and Other Interventional Techniques https://doi.org/10.1007/s00464-018-6150-z Laparoscopic Hill repair: 25-year follow-up Yeseul Park1 · Ralph W. Aye1 · Jeffrey R. Watkins1 · Alex S. Farivar1 · Brian E. Louie1 Received: 29 July 2017 / Accepted: 21 March 2018 © Springer Science+Business Media, LLC, part of Springer Nature 2018 Abstract Background The open Hill repair for gastroesophageal reflux disease and hiatal hernia is remarkably durable, with a median 10-year reoperation rate of only 3% and satisfaction of 93%. No long-term data exist for the laparoscopic Hill repair (LHR). Methods Patients who underwent primary LHR at Swedish Medical Center for reflux and/or hiatal hernia at least 5 years earlier (1992–2010) were identified from an IRB-approved database. There were 727 patients who met inclusion criteria, including 648 undergoing repair for reflux and 79 for paraesophageal hernia. Two questionnaires were administered via mail to evaluate long-term quality of life using validated GERD-HRQL, Swallowing score, and global satisfaction score. Outcomes were defined by GERD-HRQL score, Swallowing score, resumption of proton pump inhibitor (PPI) therapy, need for reoperation, and global satisfaction with overall results. Results Two hundred forty-two patients completed and returned the survey (226 lost to follow-up, 90 deceased, 3 denied undergoing LHR, 166 non-responders), of which 52% were male. The average age at the time of surgery was 49.5 years. Median follow-up was 18.5 years (range 6.2–24.7). The average GERD-HRQL score (7.1) and the average Swallowing score (39.9) both indicated excellent symptomatic outcomes. 30% of patients are using daily PPIs. 24 patients (9.9%) required reoperation for failure during the follow-up period, 21 in the reflux group and 3 in the paraesophageal hernia group. Overall, 85% reported good to excellent results, and 76% would recommend the operation. Conclusion LHR shows excellent long-term durability and quality of life similar to the open Hill repair, with 85% good to excellent results at a median follow-up of 19 years and a reoperation rate under 10%. It is surmised that Hill suture fixation of the gastroesophageal junction to the preaortic fascia may confer unique structural integrity compared to other repairs. Keywords Hill · Laparoscopy · Long-term · Antireflux · Paraesophageal hernia · Fundoplication The Hill repair for gastroesophageal reflux disease (GERD) laparoscopic antireflux surgery are limited, and there are no re-establishes the gastroesophageal flap valve and anchors published long-term studies of the laparoscopic Hill repair the gastroesophageal junction (GEJ) to the preaortic fascia, (LHR). At a time of increasing concern for the long-term thus differentiating it from other antireflux operations, which use of proton pump inhibitors to treat reflux disease, it is are based on fundoplication. The open Hill repair for GERD incumbent on surgeons to know and report the long-term and hiatal hernia has been shown to be remarkably durable, results of antireflux surgery. We sought to assess outcomes with a 91% satisfaction rate and a reoperation rate of only of LHRs done at least 5 years previously. 2% at up to 25-year follow-up [1]. Moreover, Hill sutures, when added to laparoscopic Nissen fundoplication for parae- sophageal hernia, dramatically decrease long-term anatomic Materials and methods recurrence rates and may have independent structural advan- tages [10]. However, publications on long-term outcomes of A retrospective review of 822 patients undergoing LHR at Swedish Medical Center from 1992 to 2010 was per- formed. 95 patients were excluded: 14 underwent LHR as * Ralph W. Aye a second antireflux operation, 36 required conversion to [email protected] an open repair, and 45 had less than 5-year follow-up. The 1 Division of Thoracic Surgery, Swedish Cancer Institute remaining 727 patients underwent a primary LHR, with and Medical Center, 1101 Madison, Suite #900, Seattle, 648 (89.1%) having the repair for GERD and 79 (10.9%) for WA 98104, USA Vol.:(0123456789)1 3 Surgical Endoscopy paraesophageal hernia (PEH). The Swedish Medical Center of subgroups and various studies utilized the T test, with the Institutional Review Board approved this project. significance level set at ap < 0.05. The Hill repair was performed laparoscopically in all cases with a standardized technique which included com- plete mobilization of the hiatus, trimming of the hernia Results sac except along the lesser curvature, non-division of the short gastric vessels, closure of the hiatus, and placement Of the 727 patients who underwent a primary LHR, 90 were of four non-absorbable repair sutures each of which passed deceased and 3 denied (in error) ever having LHR. Of the sequentially through the anterior sling fibers of the lower remaining 634, 226 could not be contacted and were accord- esophageal sphincter, then the posterior sling fibers, then the ingly categorized as lost to follow-up, leaving 408 available preaortic fascia just superior to the celiac axis. The sutures for survey. With 166 declining to participate, the remaining were partially tied over a 45–48 Fr bougie and then adjusted 242 completed surveys for an overall follow-up of 38% and utilizing single-port water perfused manometrics. a survey response rate of 59% of those available (Fig. 1). All patients received the same structured survey via mail. These 242 responders were the basis of further analysis. Patient consent was obtained before administering ques- Two hundred thirteen (88%) of 242 participants under- tionnaires. A staff member (YP) contacted and interviewed went LHR for reflux and 29 (12%) for PEH. On aver- each of the non-responders using a scripted format over tel- age, PEH patients were older (55.2 years) than GERD ephone. If requested by the patient, the interviewer sent the (47.4 years) at the time of surgery (p < 0.01). Additionally, survey via email. the PEH patients had a significantly shorter median follow- Two questionnaires were implemented to appraise long- up of 12.3 years relative to the 18.6-year median of the reflux term quality of life after LHR. The first investigated the patients (p = 0.03, Table 2). During the follow-up period, patient’s symptoms of heartburn, dysphagia, odynophagia, 16% underwent endoscopic dilation. 24 patients (9.9%; 21 and bloating as well as antireflux medication interfering GERD, 3 PEH) underwent reoperative repair for failure, giv- with daily life using a six-point validated Gastroesophageal ing a reoperation rate of 9.9% for the GERD subgroup and Reflux Disease-Health Related Quality of Life (GERD- 10.3% for the PEH subgroup. A significantly higher propor- HRQL) scale (range 0–50, 0 = best) [2]. It included a sat- tion of women than men underwent reoperation (p = 0.01, isfaction score with regard to current condition (e.g., satis- Table 1). Recurrences requiring reoperation were considered fied, neutral, or dissatisfied), type and frequency of reflux failures (see separate analysis). remedies taken more than once a week (antacids, H 2 block- The median follow-up for the remaining 218 was ers, and/or proton pump inhibitors [PPIs]), and any further 18.5 years (range 6.2–24.7), with 113 (52%) males and a esophageal procedures undertaken following LHR (dilations mean age of 49.5 years at surgery. Participants obtained and reoperations). Two five-point Likert scales evaluated an average 7.1 GERD-HRQL score (range 0–50, 0 = best). global assessment and the likelihood of recommending LHR More than 24% of patients attained the best possible score to family members with a similar condition. of zero, e.g., complete absence of heartburn, dysphagia, The second survey utilized a Swallowing score (range odynophagia, bloating, or medical therapy. The average 0–45, 45 = best) described by Dakkak and Bennett [3]. Swallowing score was 39.9 (range 0–45). 61% reported the Patients ranked difficulty with swallowing nine specified maximum score of 45. More than half of the participants food consistencies. Foods not eaten out of preference were conveyed little to no avoidance of food due to dysphagia, treated as problematic, unless they specifically mentioned necessity to eat slower relative to others, or regurgitation. no issues with foods of identical consistency. Three sup- One hundred eighteen patients (46%) reported utilizing plementary questions addressed avoidance of food due to antireflux medication more than once a week (21 antacids, dysphagia, the need to eat slower than others, and regurgi- 21 H2 blockers, 76 PPIs, 13 multiple), but only 66 (30%) tation using five-point Likert scales, ranging from “absent” are on daily PPIs (Fig. 2). As a whole, 85% reported good to “occurs daily.” to excellent outcomes (Fig. 3), and 76% would recommend Surveys were administered independent of current use or the operation to a family member with a similar condition non-use of medication, e.g., those who had resumed medi- (Fig. 4). On a three-point scale, the majority of respondents cation were instructed to answer according to their current (67%) felt satisfied with their current condition, 17% felt condition on medication. We compared our data with short- neutral, and 16% felt dissatisfied. term results of LHR and long-term results of open Hill repair Responders who underwent LHR for GERD versus PEH and to published reports of other laparoscopic antireflux indicated similar quality of life results (Table 2). operations with long-term follow-up. Comparing the primary group to those