Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia.
Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia.
Hernia. 2023 Dec;27(6):1543-1553. doi: 10.1007/s10029-023-02873-1. Epub 2023 Aug 31.
Laparoscopic giant hiatus hernia repair is technically difficult with ongoing debate regarding the most effective surgical technique. Repair of small hernia has been well described but data for giant hernia is variable. This study evaluated trends in outcomes of laparoscopic non-mesh repair of giant paraesophageal hernia (PEH) over 30 years.
Retrospective analysis of a single-surgeon prospective database. Laparoscopic non-mesh repairs for giant PEH between 1991 and 2021 included. Three-hundred-sixty-degree fundoplication was performed routinely, evolving into "composite repair" (esophagopexy and cardiopexy to the right crus). Cases were chronologically divided into tertiles based on operation date (Group 1, 1991-2002; Group 2, 2003-2012; Group 3, 2012-2021) with trends in casemix, operative factors and outcomes evaluated. Hernia recurrence was plotted using weighted moving average and cumulative sum (CUSUM) analysis.
862 giant PEH repairs met selection criteria. There was an increasing proportion of "composite repair" after the first decade (Group 1, 2.7%; Group 2, 81.9%; Group 3, 100%; p < 0.001). There were less anatomical hernia recurrence (Group 1, 36.6%; Group 2, 22.9%; Group 3, 22.7%; p < 0.001) and symptomatic recurrence (Group 1, 34.2%; Group 2, 21.9%; Group 3, 7%; p < 0.001) over time. The incidence of anatomical recurrence declined over time, decreasing from 30.8% and plateauing below 17.6% near the study's end. Median followup (months) in the first decade was higher but followup between the latter two decades comparable (Group 1, 49 [IQR 20, 81]; Group 2, 30 [IQR 15, 65]; Group 3, 24 [14, 56]; p < 0.001). There were 10 (1.2%) Clavien-Dindo grade ≥ III complications including two perioperative deaths (0.2%).
Hernia recurrence rates decreased with increasing case volume. This coincided with the increasing adoption of "composite repair", supporting the possible improvement in recurrence rates with this approach.
腹腔镜巨大食管裂孔疝修补术技术难度大，目前仍在争论最有效的手术技术。小型疝的修补已有很好的描述，但关于巨大疝的数据则各不相同。本研究评估了 30 多年来腹腔镜非网片修补巨大食管旁疝（PEH）的结果趋势。
对单外科医生前瞻性数据库进行回顾性分析。纳入 1991 年至 2021 年间行腹腔镜非网片修补的巨大 PEH。常规行 360 度胃底折叠术，逐渐演变为“复合修补”（食管裂孔旁和右膈脚的食管固定术）。根据手术日期将病例分为三组（第 1 组，1991-2002 年；第 2 组，2003-2012 年；第 3 组，2012-2021 年），评估病例组合、手术因素和结果的变化趋势。采用加权移动平均和累积和（CUSUM）分析绘制疝复发情况。
862 例巨大 PEH 修复符合入选标准。在第一个十年后，“复合修补”的比例逐渐增加（第 1 组，2.7%；第 2 组，81.9%；第 3 组，100%；p<0.001）。解剖学疝复发（第 1 组，36.6%；第 2 组，22.9%；第 3 组，22.7%；p<0.001）和症状性复发（第 1 组，34.2%；第 2 组，21.9%；第 3 组，7%；p<0.001）随时间减少。解剖学复发的发生率随时间下降，接近研究结束时降至 17.6%以下。第一个十年的中位随访时间（月）较高，但后两个十年的随访时间相当（第 1 组，49[IQR 20, 81]；第 2 组，30[IQR 15, 65]；第 3 组，24[14, 56]；p<0.001）。有 10 例（1.2%）Clavien-Dindo 分级≥III 级并发症，包括 2 例围手术期死亡（0.2%）。
疝复发率随手术例数的增加而降低。这与“复合修补”的应用越来越多相吻合，支持该方法可能提高复发率。
