Restoration of Normal Anatomy Without Fundoplication for Very Elderly Patients with Giant Paraesophageal Hernia (GPEH) with Predominantly Obstructive Symptoms

E. Tatsuya. Alicuben¹, J. Luketich², C. Kelsom³, G. Lloyd³, R. Levy⁴, T. Witek⁵, N. Baker⁶, I. Sarkaria⁷, S. Liang⁸, A. Pennathur⁹, O. Awais^10
1University of Pittsburgh Medical Center, OAKMONT, Pennsylvania ²UPMC Presbyterian, Pittsburgh, Pennsylvania ³University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania ⁴UPMC, Pittsburgh, Pennsylvania ⁵University of Pittsburgh, Baden, Pennsylvania ⁶UPMC, Mount Clare, West Virginia ⁷Univ. of Pittsburgh Medical Center - Dept. of CT Surgery, Dallas, Texas ⁸Rochester Regional Health, Rochester, New York ⁹University of Pittsburgh Medical Center - Department of Cardiothoraci, Pittsburgh, Pennsylvania ¹⁰UPMC Mercy Hospital, Pittsburgh, Pennsylvania

Purpose: We have reported on the efficacy and safety of giant paraesophageal hernia repair with restoration of normal anatomy without fundoplication1. Outcomes in the elderly, who may be less likely to tolerate the morbidity of fundoplication, are unknown. We therefore sought to report our results with this strategy.

Methods: Patients >80 years old who underwent primary GPEH repair from 2013 through 2022 were included. GPEH was defined as >40% of the stomach herniated into the chest. After careful evaluation, those without significant reflux (heartburn, regurgitation, pulmonary symptoms) were selected for operation. Urgent procedures were defined as patients presenting to the hospital for acute symptoms. Through minimally invasive approaches, hernia reduction and extensive mediastinal dissection with vagal and crural lining preservation were performed. Mobilization continued until the stomach and gastroesophageal junction were intraabdominal and tension-free. The crura were closed with non-absorbable sutures. The short gastric line was sutured to the left hemidiaphragm to restore normal gastric anatomy2. Follow up included symptom evaluation and antireflux medication use at clinic visits and objective follow up via endoscopy, barium esophagram or CT scan.

Results: There were 178 patients (characteristics in Table). The median age was 84.9 years (range 80-99.6 years). There were 103 elective and 75 urgent procedures. The median operative time was 242 minutes. The median hospital stay was 6 days (range 1-32 days). Discharge disposition was to home in 131/178 (74%) patients and skilled nursing or rehabilitation facility in 44/178 (25%) patients. There were 2 perioperative deaths, one related to myocardial infarction and one due to necrotizing pneumonia with respiratory failure. One patient suffered a cerebrovascular event and was discharged to hospice care.

Objective follow up was available in 170 patients at a median follow up of 14 months. There was a recurrent hernia in 21.7% (37/170) of patients: 30 small ( < 2 cm), 4 medium (3-4 cm), and 3 large. There were 8 patients with esophagitis which was successfully controlled with antisecretory medications.

At a median symptomatic follow up of 20 months, 17 patients reported any degree of heartburn. Of these patients, 12 required antireflux medications for symptom management. No patient has required reoperation for poorly controlled reflux.

Conclusion: GPEH repair with restoration of normal anatomy without fundoplication is effective and safe in the elderly population. While small recurrent hernias were common, most were associated with minimal to no symptoms. This approach can provide an alternative to and therefore avoid the morbidity of fundoplication in carefully selected patients.

Identify the source of the funding for this research project: N/A