Paraesophageal hiatal hernia: is an antireflux procedure necessary?

Between January 1970 and October 1992, 119 patients underwent 126 repairs of a paraesophageal hiatal hernia at the Lahey Clinic. Seven patients with a recurrent hernia required reoperation. Of the procedures, 19 (15%) included an antireflux procedure because of severe reflux symptoms and objective evidence of reflux demonstrated by grade 2 esophagitis on endoscopy, manometric evidence of a hypotensive lower esophageal sphincter pressure (< or = 10 mm Hg), positive results on 24-hour pH monitoring, or all three methods. Follow-up ranged from 6 months to 18 years with a median of 61.5 months, and the results of 115 operations were analyzed. Symptomatic results were good to excellent after 96 (83.5%) of these 115 operations. Thirteen symptomatic paraesophageal hernias recurred in 12 patients (one recurrence per 58 patient-years of follow-up). Severe reflux symptoms accompanied by endoscopic evidence of esophagitis developed in 2 patients who had not undergone an antireflux procedure at the time of repair of the hernia. We conclude that an antireflux procedure is rarely required in patients undergoing repair of a paraesophageal hiatal hernia and should be employed only when objective evidence of reflux is seen preoperatively.