Hiatal hernia repair with or without esophageal lengthening: is there a difference?

OBJECTIVE

The need for esophageal lengthening (EL) as part of hiatal hernia (HH) repair is perceived to elevate perioperative risk and provide functionally inferior outcomes. Our objectives were to determine the risk factors of undergoing EL and to compare outcomes between operations with and without EL. We hypothesized that operative and functional outcomes for HH repair were similar in patients whether they required EL or not.

METHODS

We reviewed institutional experience with EL as part of HH repair. The patients underwent symptom evaluation before and after surgery using a validated tool.

RESULTS

Between 1999 and 2009, a total of 375 patients underwent HH repair. The operative approach was thoracotomy, 153 (41%); laparotomy, 18 (5%); laparoscopy, 167 (44%); or combined, 37 (10%). Of these, 168 (45%) required EL. There was a higher need for thoracotomy in the patients undergoing EL (79/168 vs 74/207, χ = 4.88, P = 0.034). The incidence of perioperative complications (leak, pneumonia, ileus, respiratory failure, and bleeding) was similar between the groups. Sixty-five selected patients undergoing EL were compared with 63 patients with comparable demographics not requiring EL. In a well-validated questionnaire that assessed symptoms before and after surgery, the patients undergoing EL showed significant improvement in their heartburn (76.8%), dysphagia (67.6%), regurgitation (71.7%), chest pain (91.9%), and nausea (86.5%) (P < 0.05). The patients not undergoing EL also showed significant improvement in their heartburn (81.1%), dysphagia (71.1%), regurgitation (64.4%), chest pain (64.1%), and nausea (61.0%) (P < 0.05). Improvement in symptoms, the continued use of antacid medications, and overall surgery satisfaction score were statistically similar between the two groups.

CONCLUSIONS

Operative and functional outcomes for HH repair with or without EL are acceptable and comparable. Thoracic surgeons should use EL without reservations for appropriate indications.