Repair of symptomatic paraesophageal hernias in elderly (>70 years) patients results in sustained quality of life at 5 years and beyond.

BACKGROUND: Paraesophageal hernias (PEHs) involve herniation of stomach and/or other viscera into the mediastinum. These commonly occur in the elderly and can severely limit quality of life. Short term outcomes of repaired PEH demonstrated low morbidity and significant improvement in quality of life, but long-term data for all patients, especially the elderly, are lacking. METHODS: Retrospective chart review of a prospectively collected database of patients aged 70 or greater with a symptomatic PEH repaired 5+ years ago. Quality of life data were assessed preoperatively, at 12-24 months, and at 5+ years using QOLRAD, GERD-HRQL, and DSS. RESULTS: We identified 137 patients who met the age criteria, with 69 patients undergoing surgery 5+ years ago. With ten patients were lost to follow-up, 59 patients were analyzed, including 24 males and 35 females. Median age at repair was 77 years. There were two 90-day mortalities, with one occurring within 30 days of surgery. Patients alive at evaluation had a median age of 74 years and were followed a median 7.4 years. From baseline, QOLRAD improved from 4 to 6.5, GERD-HRQL improved from 11 to 5, and swallowing improved from 11 to 38. During follow-up, 21 patients died. Deceased patients lived a median of 4 years after repair, with a median age at repair of 80 years. At a median time follow-up of 2 years, this group's QOLRAD improved from 5.1 to 7, GERD-HRQL improved from 16 to 4, and swallowing improved from 14.5 to 35. CONCLUSIONS: In elderly patients with symptomatic PEH undergoing surgical repair more than 5 years ago, there was sustained improvement in quality of life. This justifies surgical repair of symptomatic PEH in elderly patients.

Robotic Resection of 3 cm and Larger Thymomas Is Associated With Low Perioperative Morbidity and Mortality.

OBJECTIVE: The approach to thymoma resection has usually been determined by tumor size, although established guidelines do not exist. Minimally invasive approaches have been limited to tumors smaller than 5 cm, although 3 cm has been the suggested cutoff for performing an adequate oncologic procedure. No study has compared the perioperative outcomes of patients with 3 cm or larger tumors resected robotically versus sternotomy. METHODS: We reviewed patients who underwent resection of 3 cm or larger thymomas from 2004 to 2014. Patients were divided based on approach: robotic and open thymectomy/thymomectomy. RESULTS: Forty patients with tumors ranging from 3 to 13 cm were evaluated, 23 robotic and 17 open. Patient and tumor characteristics were similar. An R0 resection was primarily achieved: robotic, 91% (21/23); and open, 88% (15/17); P = 0.832. Adjuvant radiation rates were statistically equivalent: robotic, 17% (4/23) versus open, 41% (7/17); P = 0.191. Major postoperative complications were comparable: robotic, 4% (1/23) versus open, 29% (4/17); P = 0.184. Median chest tube duration was shorter for robotic (1 day) versus open (3 days); P = 0.001. The robotic approach had a shorter median intensive care unit stay compared to open (0 days vs 1 day); P = 0.024. The median hospital stay was shorter for robotic (2 days) versus open (5 days); P < 0.001. CONCLUSIONS: In 3 cm or larger thymomas, robotic thymectomy is feasible based on the ability to achieve a complete resection with similar adjuvant radiation therapy rates. Perioperatively, robotic thymectomy is associated with lower morbidity; and shorter chest tube duration, intensive care unit stay, and hospital stay compared to open. However, oncologic outcomes are immature and require prolonged surveillance.

Clinical Outcomes of Reoperation for Failed Antireflux Operations.

BACKGROUND: Up to 18% of patients undergoing antireflux operations will require reoperation. Authors caution that with each additional reoperation, fewer patients achieve satisfaction. The quality of life in patients who underwent revision operations was compared with patients who underwent primary antireflux operations to determine the effectiveness of revision operations. METHODS: We retrospectively reviewed patients who underwent revision after failed antireflux operations from 2004 to 2014. Patients were divided into two groups: first reoperation (Reop[1]) and more than one reoperation (Reop[>1]). For comparison, a control group of patients who underwent primary antireflux operations was included. Patients underwent quality of life assessment preoperatively and postoperatively. RESULTS: We identified 105 reoperative patients: 94 Reop(1), 11 Reop(>1), and 112 controls. The primary reason for failure was combined fundoplication herniation and slippage. Morbidity, mortality, and readmission rates were similar in all groups. Postoperative outcomes were improved in all groups but to a lesser degree in subsequent reoperations. Gastroesophageal Reflux Disease Health-Related Quality of Life: controls, 20.0 to 2.0; Reop(1), 26.5 to 4.0; and Reop(>1), 13.0 to 2.0. Quality of Life in Reflux and Dyspepsia: controls, 4.5 to 7.0; Reop(1), 3.7 to 6.7; and Reop(>1), 3.5 to 5.8. Dysphagia Severity Score: controls, 44.0 to 45.0; Reop(1), 36.0 to 45.0; and Reop(>1), 30.8 to 45.0. CONCLUSIONS: Patients undergoing revision antireflux operations have improved quality of life, relatively normal swallowing, and primary symptom resolution at a median of 20 months postoperatively. However, patients who undergo more than one reoperation have lower quality of life scores and less improvement in dysphagia, suggesting that other procedures such as Roux-en-Y or short colon interposition, should be considered after a failed initial reoperation.

Short-term outcomes using magnetic sphincter augmentation versus Nissen fundoplication for medically resistant gastroesophageal reflux disease.

BACKGROUND: In 2012 the United States Food and Drug Administration approved implantation of a magnetic sphincter to augment the native reflux barrier based on single-series data. We sought to compare our initial experience with magnetic sphincter augmentation (MSA) with laparoscopic Nissen fundoplication (LNF). METHODS: A retrospective case-control study was performed of consecutive patients undergoing either procedure who had chronic gastrointestinal esophageal disease (GERD) and a hiatal hernia of less than 3 cm. RESULTS: Sixty-six patients underwent operations (34 MSA and 32 LNF). The groups were similar in reflux characteristics and hernia size. Operative time was longer for LNF (118 vs 73 min) and resulted in 1 return to the operating room and 1 readmission. Preoperative symptoms were abolished in both groups. At 6 months or longer postoperatively, scores on the Gastroesophageal Reflux Disease Health Related Quality of Life scale improved from 20.6 to 5.0 for MSA vs 22.8 to 5.1 for LNF. Postoperative DeMeester scores (14.2 vs 5.1, p=0.0001) and the percentage of time pH was less than 4 (4.6 vs 1.1; p=0.0001) were normalized in both groups but statistically different. MSA resulted in improved gassy and bloated feelings (1.32 vs 2.36; p=0.59) and enabled belching in 67% compared with none of the LNFs. CONCLUSIONS: MSA results in similar objective control of GERD, symptom resolution, and improved quality of life compared with LNF. MSA seems to restore a more physiologic sphincter that allows physiologic reflux, facilitates belching, and creates less bloating and flatulence. This device has the potential to allow individualized treatment of patients with GERD and increase the surgical treatment of GERD.