Fundoplication at the time of paraesophageal hernia repair does not decrease the rate of hernia recurrence or postoperative reflux

Fundoplication at the time of paraesophageal hernia (PEH) repair is thought to help prevent the development or persistence of postoperative gastroesophageal reflux (GERD) and might also prevent hernia recurrence. However, the published data is not strong enough to definitively recommend this approach. This study was designed to evaluate the effectiveness and complications of a fundoplication at the time of paraesophageal hernia repair.

This was a retrospective cohort study of all patients who underwent a paraesophageal hernia repair at a single institution over a 14 year period from 2010 to 2023. Patients were divided into 2 cohorts, those who underwent fundoplication at the time of PEH repair and those who did not. Rates of PEH recurrence, rates of reoperation for a recurrent PEH, postoperative dysphagia rates, and postoperative GERD rates were then compared between the two cohorts.

There were 1,155 patients included in the study. There were 610 (53%) patients who underwent PEH repair with fundoplication and 545 (47%) who did not undergo a fundoplication. 113 (19%) of the patients who underwent fundoplication developed a hernia recurrence compared to 67 (12%) who had a PEH repair alone (p = 0.004). However, each cohort had similar rates of requiring reoperation (p = 0.4). Inclusion of a fundoplication did lead to higher rates of postoperative dysphagia > 30 days postoperatively, 12% vs 7% (p = 0.002), but did not lead to decreased rates of symptomatic GERD postoperatively, 7% with a fundoplication and 7% without (p = 0.93).

In this present study, fundoplication at the time of PEH repair did not prevent hernia recurrence, need for reoperation, or decrease postoperative GERD rates but does increase postoperative dysphagia. While there are definite indications for fundoplication at the time of PEH repair (i.e., type 1 hernia), these data do not support the routine use of fundoplication during PEH repair with a normal gastroesophageal flap valve intraoperatively.