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Minimally Invasive Surgery For Paraesophageal Hernia Is 'Revolutionary' -- But There's Still Controversy

Tue, 10/29/2013 - 10:17am

Minimally invasive surgical techniques have revolutionized the treatment paraesophageal hernia—but there's continued controversy over some key technical aspects of the procedure. To inform the debate, leading surgical specialists outline their approaches to laparoscopic paraesophageal hernia repair in the October issue of Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.

Five nationally recognized leaders in foregut surgery "systematically and point-by-point" outline their approach to this effective but technically challenging procedure. The special feature section provides "a fascinating picture in which all authors agree that the basic principles of the operation should be respected," according to an introductory article by Dr. Piero Marco Fisichella of Loyola University Chicago. "However, [the experts] achieve all these steps in very different ways, arguing that technical details might influence outcomes or make the operation easier."

Laparoscopic Hernia Repair Provides Good Outcomes with Faster Recovery

Paraesophgeal hernia is a common condition in which part of the stomach becomes herniated through the diaphragm and into the chest—higher than the junction between the esophagus and stomach. In addition to heartburn and difficulty swallowing, patients may experience chest pain, especially after meals, and shortness of breath. When other treatments can't relieve symptoms, surgery is recommended.

In the past, surgery was performed through an open incision in the abdomen or chest. But over the past decade, minimally invasive laparoscopic approaches have revolutionized the treatment of paraesophageal hernia. Laparoscopic surgery provides excellent results with a low rate of recurrent hernia, less pain, and faster recovery.

But the laparoscopic procedure is technically challenging, with a "long learning curve" for surgeons, and is best performed by experienced specialists at referral medical centers. And even among the experts, there is ongoing debate regarding key areas of surgical technique.

Five Expert Teams Describe Their Surgical Techniques

In the special feature section, specialist from five leading surgical centers outline their approach to laparoscopic paraesophageal hernia repair. The lead authors are Dr. Marco Ettore Allaix of University of Chicago; Dr. Steven R. DeMeester of The University of Southern California, Los Angeles; Dr. Zeljka Jutric of Swedish Medical Center, Seattle; Dr. Ellen Morrow of University of Washington, Seattle; and Dr. Nathaniel J. Soper of Northwestern University Feinberg School of Medicine, Chicago.

There are even uncertainties as to which patients should undergo the procedure—many affected patients are older adults with multiple medical problems. But the experts generally agree that even very elderly patients can undergo the procedure, as long as they are fit for surgery. They also agree that morbidly obese patients should have gastric bypass surgery at the same time, or should lose weight before undergoing hernia repair.

Much of the controversy centers on key technical details that may affect the long-term success of the procedure. For example, the experts agree that a "tension-free repair" is essential to reduce the risk of recurrent hernia—but they have differing views on how best to achieve this goal. In addition to detailing their preferred approach to this and other areas of controversy, the teams describe the rationale behind their individual techniques.

"Given this high level of variability among the experts in performing the critical steps of the operation, the reader will realize that understanding all the nuances used by the different authors is important," Dr. Fisichella writes. "[O]nly by comprehending the minute details of this operation one can critically understand the literature and the results on outcomes."

Dr. Fisichella adds that defining the issues and alternatives will help in developing to promote "well thought out" clinical trials to optimize the surgical approach. The editors of Surgical Laparoscopy, Endoscopy & Percutaneous Techniques hope that, by sharing and comparing techniques of laparoscopic paraesophageal hernia repair, their special feature section will help in achieving the best surgical results for patients undergoing this important and still-evolving procedure.

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