LETTERS
Early Hiatal Hernia Recurrence Rates
Laparoscopic Paraesophageal Hernia Repair
Gregory L Falk, MD Sydney, NSW, Australia
In Reply to Falk Steven R DeMeester, Los Angeles, CA
Although Alicuben and colleagues1 may be commended for their technical approach to a difficult problem, this article should not be considered an assessment of results of adjunct therapies for repair of the hiatus but more a technical feasibility study. As rightly pointed out by the authors, paraesophageal hernia has a high recurrence rate and many different techniques have been used in an attempt to reduce these rates, and recurrence seems to occur progressively over time. With a median follow-up of 5 months, this series is barely convalescent. It is hard to ascertain what percentage of patients have had objective assessment for reherniation, but the reported 4% recurrence at median 5 months seems no different from that in other series. Pleural incision helps diaphragmatic closure as reported, but there is no discussion of relaxation of retraction or reduction in laparoscopic pressures to aid the hiatus closure, often giving an appearance of tension that is not real.2 Although it indicates the technical feasibility of releasing incision in 10 patients, this article does not give any support to this approach. Selection for supplemental mesh repair by an appreciation of tension requires a randomized approach for validation; however, in our work the awareness of “tension” was a risk factor for recurrence.3 It is a fine theoretical view to avoid recurrence after surgery, but it appears not to affect the quality of life of this patient group. Perhaps the extensive and technically adroit approach is clinically insignificant?
MD, FACS
We thank Gregory Falk for his comments and agree completely that long-term objective follow-up will be critical to fully assess the impact of various technical modifications for laparoscopic paraesophageal hernia repair to show improvement in the high objective recurrence rates. Although our median follow-up was short, 22% of the patients had 1 year of follow-up. In the 69 patients with objective follow-up, there were 3 hernia recurrences, and only 1 of these was found in the group with 1 year of follow-up. Therefore, we believe that our low recurrence rate of 4% compares favorably with that in other reports of these patients. We agree that tension is the bane of any hernia repair, including those at the hiatus. We also agree that reduction of insufflation pressure can allow crural closure, but when that isn’t enough, we favor a relaxing incision to allow primary crural closure with a minimum of tension. In addition, although controversial at the hiatus, mesh use has been proven to reduce recurrences at all other hernia sites. It is unlikely that mesh alone will salvage a repair under tension, but we believe that the right mesh and the right repair technique will lead to improved outcomes. Not all recurrences will require a reoperation, but some do, and I suspect that many surgeons, like myself, are seeing a steady stream of redo patients. I would caution against a laissez-faire attitude toward hernia recurrence when the primary goal of the operation in patients with a paraesophageal hernia is to repair the hernia. Disclosure Information: Nothing to disclose.
REFERENCES
American Academy of Emergency Medicine Response to “Optimal Resources for Children’s Surgical Care in the United States”
1. Alicuben ET, Worrell SG, DeMeester SR. Impact of crural relaxing incisions, Collis gastroplasty, and nonecross-linked human dermal mesh crural reinforcement on early hiatal hernia recurrence rates. J Am Coll Surg 2014;219:988e992. 2. D’Netto TJ, Falk GL. A technique for the laparoscopic repair of paraoesophageal hernia without mesh. J Gastrointest Surg 2014; 18:851e857. 3. Le Page P, Furtado R, Hayward M, et al. Durability of giant hiatus hernia repair - 455 patients over 20 years. Ann R Coll Surg Engl 2014 (in press).
Mark Reiter, MD, MBA, FAAEM American Academy of Emergency Medicine, Milwaukee, WI
Disclosure Information: Nothing to disclose.
ª 2015 by the American College of Surgeons Published by Elsevier Inc.
968
http://dx.doi.org/10.1016/j.jamcollsurg.2014.12.021 ISSN 1072-7515/15
Early Hiatal Hernia Recurrence Rates
Laparoscopic Paraesophageal Hernia Repair
Gregory L Falk, MD Sydney, NSW, Australia
In Reply to Falk Steven R DeMeester, Los Angeles, CA
Although Alicuben and colleagues1 may be commended for their technical approach to a difficult problem, this article should not be considered an assessment of results of adjunct therapies for repair of the hiatus but more a technical feasibility study. As rightly pointed out by the authors, paraesophageal hernia has a high recurrence rate and many different techniques have been used in an attempt to reduce these rates, and recurrence seems to occur progressively over time. With a median follow-up of 5 months, this series is barely convalescent. It is hard to ascertain what percentage of patients have had objective assessment for reherniation, but the reported 4% recurrence at median 5 months seems no different from that in other series. Pleural incision helps diaphragmatic closure as reported, but there is no discussion of relaxation of retraction or reduction in laparoscopic pressures to aid the hiatus closure, often giving an appearance of tension that is not real.2 Although it indicates the technical feasibility of releasing incision in 10 patients, this article does not give any support to this approach. Selection for supplemental mesh repair by an appreciation of tension requires a randomized approach for validation; however, in our work the awareness of “tension” was a risk factor for recurrence.3 It is a fine theoretical view to avoid recurrence after surgery, but it appears not to affect the quality of life of this patient group. Perhaps the extensive and technically adroit approach is clinically insignificant?
MD, FACS
We thank Gregory Falk for his comments and agree completely that long-term objective follow-up will be critical to fully assess the impact of various technical modifications for laparoscopic paraesophageal hernia repair to show improvement in the high objective recurrence rates. Although our median follow-up was short, 22% of the patients had 1 year of follow-up. In the 69 patients with objective follow-up, there were 3 hernia recurrences, and only 1 of these was found in the group with 1 year of follow-up. Therefore, we believe that our low recurrence rate of 4% compares favorably with that in other reports of these patients. We agree that tension is the bane of any hernia repair, including those at the hiatus. We also agree that reduction of insufflation pressure can allow crural closure, but when that isn’t enough, we favor a relaxing incision to allow primary crural closure with a minimum of tension. In addition, although controversial at the hiatus, mesh use has been proven to reduce recurrences at all other hernia sites. It is unlikely that mesh alone will salvage a repair under tension, but we believe that the right mesh and the right repair technique will lead to improved outcomes. Not all recurrences will require a reoperation, but some do, and I suspect that many surgeons, like myself, are seeing a steady stream of redo patients. I would caution against a laissez-faire attitude toward hernia recurrence when the primary goal of the operation in patients with a paraesophageal hernia is to repair the hernia. Disclosure Information: Nothing to disclose.
REFERENCES
American Academy of Emergency Medicine Response to “Optimal Resources for Children’s Surgical Care in the United States”
1. Alicuben ET, Worrell SG, DeMeester SR. Impact of crural relaxing incisions, Collis gastroplasty, and nonecross-linked human dermal mesh crural reinforcement on early hiatal hernia recurrence rates. J Am Coll Surg 2014;219:988e992. 2. D’Netto TJ, Falk GL. A technique for the laparoscopic repair of paraoesophageal hernia without mesh. J Gastrointest Surg 2014; 18:851e857. 3. Le Page P, Furtado R, Hayward M, et al. Durability of giant hiatus hernia repair - 455 patients over 20 years. Ann R Coll Surg Engl 2014 (in press).
Mark Reiter, MD, MBA, FAAEM American Academy of Emergency Medicine, Milwaukee, WI
Disclosure Information: Nothing to disclose.
ª 2015 by the American College of Surgeons Published by Elsevier Inc.
968
http://dx.doi.org/10.1016/j.jamcollsurg.2014.12.021 ISSN 1072-7515/15
