Duke Masters of Minimally Invasive Thoracic Surgery Orlando…€¦ · · 2017-09-19Duke Masters of Minimally Invasive Thoracic Surgery Orlando, FL September 17, 2016 Session V:

Duke Masters of Minimally Invasive Thoracic Surgery

Orlando, FL

September 17, 2016

Session V: Minimally Invasive Esophageal Surgery

Giant Paraesophageal Hernia

James D. Luketich MD, FACS

Henry T. Bahnson Professor and Chairman,

Department of Cardiothoracic Surgery

University of Pittsburgh Medical Center

Overview

• Hiatal Hernia Overview and Clinical Presentation

• Review important principles learned from the

open surgical repair of giant paraesophageal hiatal

hernias

• Discuss results of open surgical series of GPEH

• UPMC Results of laparoscopic series of GPEH

Background: Giant

Paraesophageal Hiatal Hernia

• GERD is frequently associated with a simple Type I hiatus

hernia, surgical approach is generally laparoscopic

• Giant Paraesophageal Hernias are less common and

probably represent a progression of Type I hernia to a

Type III

• Most type IIIs are symptomatic and a small percent lethal

• These giant hiatal hernias are more complex to repair, lead

to more recurrences and have been traditionally managed

by open surgery

Typical Esophagram of Giant

PEH Intra-thoracic

Stomach

The Essential Steps to Successful Repair of

Giant Paraesophageal Hiatal Hernia-1

• Open surgical results of GPEH are good in the hands of experienced esophageal surgeons

• Results depend upon important operative steps:

– Identification of the plane between the hiatal hernia sac and mediastinal pleura and meticulous dissection of the hernia sac

– Mobilization of the crura, maintaining the peritoneal lining and the integrity of the crural muscle

– Tension-free approximation of intact crura, if either of these conditions cannot be met, consider mesh cruroplasty

• Mobilization of the esophagus, maintianing vagal nerve viabiity to deliver a tension free, 2-3 cm segment of intra-abbdominal esophagus

• If this cannot be achieved, continue mediastinal mobilization, if this still cannot be achieved, consider an esophageal lengthening procedure or an aggressive pexy following as much mobilization as possible

• Perform an anti-reflux procedure, preferably a floppy, 2 stitch Nissen

• If these principles are followed meticulously using an open or laparoscopic approach, good long-term outcomes can be achieved



Controversies

• Open vs. minimally invasive

• Primary crural repair vs. buttressed with

mesh

• Short esophagus: ? Incidence, what to do if

present?

• Learning curve series vs extensive

longitudinal experience

• Elective Vs. Emergent

Open Series of PEH Repair

Series Ellis Maziak Schauer

1986 1998 1998

no. cases 55 94 25

Hospital stay 9.5 NR 10.3

Mortality (%) 1.8 2 0

Recurrences* 1.8 2 8

* recurrences requiring re-operations

Open Repair of Giant PEH with

Collis Gastroplasty and Belsey:

Maziak and Pearson • 94 patients with intra-thoracic stomach (type III) operated

upon over a 20 year period

• Operative approach

– Left thoracotomy

– sac excision

– Collis lengthening procedure for shortened esophagus

– no deaths, 1% leak rate

• 91% with good results, 9% with fair results

• At a mean follow-up of 10 years only 2 re-operations required

• JTCVS 1998

Surgical Outcomes: Concerns Over

Increased Morbidity and Recurrences

Associated with Laparoscopic Repair of

Giant Hiatal Hernias

• Laparoscopic report from the Mayo Clinic: 30-day

mortality 5.4%

– Recurrence rate in short-term follow-up: 13%

– First 37 cases

• Similar experience elsewhere in first 50 cases

Deschamps, et al. Ann Thorac Surg. October 2001.

Recurrence Rate of Following

Laparoscopic Repair of Giant Hiatal

Hernia (USC Initial experience)

42

15

0

5

10

15

20

25

30

35

40

45

%

Recurrence

Laparoscopic

Open

• Hashemi et al USC

J Am Coll Surg 2000

Prevalence of a recurrent hernia in the 41

patients (21 open and 20 laparoscopic) that had annual

videoesophagrams

for a minimum of 3 years.

DeMeester et al ; American College of Surgeons 2010, JACS 2011

Role of Mesh in GPEH:

Randomized Trial

• Randomized trial of Surgisis mesh for repair of GPEH

• Median follow-up 6 months interim results closed the trial

– Mesh are 9% recurrence

– Non-mesh arm 16% recurrence

• Their conclusion: Mesh must be used

• Other Conclusions:

– Recurrence rate concerning in either arm, surgical experience not stated to enroll patients

– Results DO NOT depend on a single variable!

Oelschlager et al. American Surgical Association 2006, Ann Surg 2006

Role of Mesh in GPEH

Randomized Trial: Long term Follow-up

• Randomized trial of Surgisis mesh for repair of GPEH

• Median follow-up of 58 months (range 42 to 78 mo)

• 72 completed clinical follow-up and60 repeated a UGI (Primary repair n= 34; Mesh n=26).

• There were 20 patients (59%) with recurrent HH in the Primary repair group – 20 (59%) with recurrent hernia vs. 14 patients (54%) with recurrent HH in the mesh group (p0.7).

• There was no statistically significant difference in relevant symptoms or QOL between patients

Oelschlager et al. J Am Coll Surg 2011

GPEH: Principles of Repair

• Hernia reduction

• Sac resection

• Crural repair

• Fundoplication

• Tension free intra-abdominal repair

• Liberal use of esophageal lengthening

GPEH: Principles of Repair

• Sac dissection (removal from the mediastinum, not necessarily

removal from the body)

• Hernia reduction (occurs by itself if you do the above step

completely)

• Crural repair (primary repair is possible with careful crural

preservation)

• Strive to achieve a tension-free segment of intra-abdominal

esophagus

• If not present, go back to mediastinum and keep working on

mobilization

• If still not present, go back to mediastinum and keep working on

mobilization

• If still not present, consider esophageal lengthening procedure

• Floppy, Nissen fundoplication

• 94 patients ; Massive incarcerated hiatal

hernia

• Transthoracic Repair with Belsey

Fundoplication

• Collis Gastroplasty in 80% of patients

Giant Paraesophageal Hernia:

Open Repair

Maziak, Todd, Pearson JTCVS 1998

What is the incidence of short

esophagus?

Series Year Incidence (%) N

Legacy 1996 14 238

USC 1999 15.6 236

Pittsburgh 2000 27 100

(PEH)

Emory 2001 2.9 1000

Toronto 1998 80 94

Pittsburgh 2002 56 200

(PEH)

Hill Career 0 Career

Emory 2003 4.3 1579

Conditions Associated With

Higher Incidence of Short

Esophagus

•Long standing, severe disease

•Re-do cases

•Stricture

•Non-reducible large hiatal hernia

(>5cm)

•Barrett’s esophagus

•Paraesophageal hernia (type III)

Factors Contributing to Laparoscopic

Failure to Recognize Short Esophagus

• Failure to dissect fat pad and identify esophago-cardia junction

• Failure to recognize a relatively tubularized gastric cardia

• Caudal tension on penrose drain

• Caudal migration with rigid Bougie

• Cephalad migration of diaphragm with pneumoperitoneum pressure

• Failure to have a plan if you do encounter it: “If all you have is a hammer, everything looks like a nail!”

• 94 patients ; Massive incarcerated hiatal

hernia

• Transthoracic Repair with Belsey

Fundoplication

• Collis Gastroplasty in 80% of patients

Giant Paraesophageal Hernia:

Open Repair

Maziak, Todd, Pearson JTCVS 1998

• Follow up : Mean 94 months

• 24 patients followed more than 10 years

• Standard Questionnaire : Every year for 5

years, then 2 year intervals

• Routine Ba Swallow: 1, 5, 10 years

• Follow-up Manometry, pH testing done

selectively

Results : Open GPEH Repair

• Excellent to good results in 94% of patients

• Recurrence in 2 patients (both symptomatic)

• Reoperations in 2 patients (both had Collis

Gastroplasty done during the reoperation)

Results: Open GPEH Repair

Key Elements: Sac Dissection

Key Elements: Sac Dissection

Video

Assessment of Esophageal Length

Cardia location

Key Elements: Maintaining the

Crural Integrity (Video)

What to do if you encounter a

short esophagus?

• Look for it!

• Keep working to gain length !

• Have a plan!

• Open if necessary!

• Laparoscopic Collis in selected cases

Endo-GIA Application to Create Collis Segment

Collis Segment Created with EEA and Endo-GIA

Neo-esophagus

Laparoscopic Wedge Gastroplasty

Maddaus, Luketich. In Pearson Esophageal Surgery





Laparoscopic Wedge

Gastroplasty (Video)

Overview of Completed gastroplasty


Factors Contributing to Laparoscopic

Failure to Recognize Short Esophagus

• Failure to dissect fat pad and identify esophago-cardia junction

• Failure to recognize a relatively tubularized gastric cardia

• Caudal tension on penrose drain

• Caudal migration with rigid Bougie

• Cephalad migration of diaphragm with pneumoperitoneum pressure

• Failure of surgeon to have experience with a laparoscopic method of lengthening

Collis Gastroplasty and Reinforced

Crural Repair (Maddaus Series)

• University of Minnesota Series:

• 61 patients underwent Giant Para esophageal Hernia Repair with Collis Gastroplasty, complete fat pad dissection, hernia sac excision with reinforced crural repair, NO Mesh

• Complications: Esophageal leak 1, Pneumonia 1, Death 1

• Mean GERD QOL Score was 1.15 (0=asymptomatic; 45= severe symptoms)

• Ba Esophagram obtained at median of 323 days (4-1080 days)

• Ba Swallow Data available in 54 ( 89%) of patients.

• No short term recurrence; 1 (1. 9%) small asymptomatic recurrence Whitson et al. Presented at the AATS 2006, JTCVS

“Shoe Shine” of Wrap

Laparoscopic Repair of Diaphragm

• 662 patients had attempted non-emergent

laparoscopic repair

• 75% female

• Median age 70 years (IQR 19-92)

• 15% had a BMI ≥35

• 49% had an age-adjusted Charlson

Comorbidity Index score ≥ 3

UPMC Series:

Laparoscopic Repair GPEH

UPMC Series:

Laparoscopic Repair GPEH • 662 patients had attempted non-emergent

laparoscopic repair; 652 (98.5%) completed

laparoscopically

• 63% required Collis gastroplasty

• 13% mesh cruroplasty

• 98% fundoplication (647/662)

– Floppy Nissen 79% (512/647)

– Partial fundoplication 21% (135/647)

• LOS median 3 days

Luketich et al, AATS, JTCVS 2010

Results – Perioperative Outcomes

• Overall rates of major morbidity and

mortality low

– Mortality 1.7% (11/662)

– Pneumonia 4% (29/653)

– Post-operative leak 2.5% (16/653)

Summary of Findings

• Symptomatic improvement is excellent

– 89% of patients express satisfaction with surgery

– 90% report good to excellent GERD-related

quality of life

• Median follow-up: 25 months

• 3.2% of patients underwent reoperation in

subsequent follow-up

UPMC Experience : Long Term Results

• 1997 – 2003 -187 patients with laparoscopic

approach

• Fundoplication in 183/187 (98%), Collis

Gastroplasty in 160/187 (86%) of patients

• Mesh Cruroplasty in 30/187 (16%)

• Median clinical follow up - 77 months

• QOL questionnaire (GERD – HRQOL ; SF

-36)

• Follow up Ba Swallow

Nason K, Luketich et al. Presented at DDW 2008, J Gastr Intest Surg

Long Term Results

• Reoperations in 7 patients (4.4%)

• Ba Swallow – 154 patients

• Median time to Ba swallow: 50 months

• Radiographic Recurrence in 23 patients

(15%)

– 7 (4.4%) chose reoperation

– 16 on medical treatment with variable success

– Crural Mesh reinforcement was not associated

with a reduced risk of radiographic recurrence

UPMC Experience : Long Term

Results

Quality of Life (Obtained at median of 77

months after repair):

GERD HRQOL (0-45) (Fair to excellent in 90%)

• Excellent : 78%

• Good : 8%

• Fair : 4%

• Poor : 9%

SF – 36 (Preserved)

• Physical component score : 52

• Mental component score : 53

Successful Repair of Giant Paraesophageal

Hiatal Hernia?

• No single step is “The Key Step”, Several Important Steps

• Identification of the plane between the hiatal hernia sac and mediastinal pleura and meticulous dissection of the hernia sac

• Mobilization of the crura, maintaining the peritoneal lining and the integrity of the crural muscle

• Tension-free approximation of intact crura, if either of these conditions cannot be met, consider mesh cruroplasty (needed infrequently in our experience)

• Mobilization of the esophagus, maintaining vagal nerve viability to deliver a tension free, 2-3 cm segment of intra-abdominal esophagus

• If this cannot be achieved, continue mediastinal mobilization, if this still cannot be achieved, consider an esophageal lengthening procedure or an aggressive pexy following as much mobilization as possible

• Perform an anti-reflux procedure, preferably a floppy, 2 stitch Nissen

• If these principles are followed meticulously using an open or laparoscopic approach, good long-term outcomes can be achieved



Conclusions • Complex giant hiatal hernias can be managed successfully

by the laparoscopic approach in selected, experienced centers – Our long term data 4% operative recurrence rate (6 years plus)

– 12-14% radiographic recurrence rate, some asymptomatic, most small and not at risk of torsion

• Higher recurrence rates reported from less experienced centers

• Failure to recognize and treat a short esophagus contributes to recurrences, mesh in some cases

• Failure to accomplish complete mediastinal sac dissection and maintain crural integrity

• Other factors involved, including the size of the hiatal defect and open and/or laparoscopic operative experience

Thank You

Duke Masters of Minimally Invasive Thoracic Surgery Orlando…€¦ · · 2017-09-19Duke Masters of Minimally Invasive Thoracic Surgery Orlando, FL September 17, 2016 Session V:

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