Paraesophageal hernia repair - Chapter V: Quality of life

As explained in previous chapters, fundoplication is routinely performed during paraesophageal hernia repair to prevent postoperative gastroesophageal reflux and to reinforce the repair to prevent recurrence. However, the choice of the best fundoplication technique is still controversial, and a balance must be achieved between adequate reflux control and postoperative dysphagia.

Several studies have suggested that patients with paraesophageal hernia suffer from esophageal dysmotility, and, even though esophageal manometry was thought to be a useful tool in assessing esophagus contractility, its measurements are unreliable due to distorted anatomy and deranged intrathoracic pressures. Thus, decision making in the appropriate technique reconstruction of the lower esophageal sphincter becomes cumbersome. 

Nissen fundoplication (full 360-degree) is associated with the highest risk of postoperative dysphagia, compared to partial fundoplications. It should not be recommended in cases of preoperative diagnosis of esophageal dysmotility. Due to this, some authors advocate for a partial fundoplication in all patients.

Huerta et al published in 2018 their results on the treatment of type III and IV paraesophageal hernias with Nissen and Toupet fundoplications and reported no differences on heartburn, dysphagia, regurgitation or use of acid-reducing medications. Follow-up was 2.5 years for the Toupet group and 4.8 years for the Nissen group.

The McGill University group (Trepanier et al.) published their long-term outcomes (5 years) on the treatment of large paraesophageal hernias (> 50% of the stomach herniated) comparing Nissen fundoplication to Dor fundoplication. They concluded that Dor fundoplication was associated with less early postoperative dysphagia compared to Nissen fundoplication, but with no difference at 6 months.  In addition, there were no differences in the incidence of short-term and long-term self-reported symptoms of reflux or on the percentage of patients using proton pump inhibitors.

Although the debate is still ongoing, with advocates for the use of partial fundoplications over Nissen fundoplication due to the risk of dysphagia, most literature is based on retrospective studies. Well-designed trials should be conducted to obtain an answer on which is the best technique for treating patients with paraesophageal hernias.