Routine Esophagograms Following Hiatus Hernia Repair Minimizes Reoperative Morbidity: A Multicenter Comparative Cohort Study

OBJECTIVE: Determine the utility of routine esophagograms following hiatus hernia repair and its impact on patient outcomes. BACKGROUND: Hiatus hernia repairs are common. Early complications such as re-herniation, esophageal obstruction and perforation, although infrequent, incur significant morbidity. Whether routine postoperative esophagograms enable early recognition of these complications, expedite surgical management, reduce reoperative morbidity, and improve functional outcomes are unclear. METHODS: Analysis of a prospectively-maintained database of hiatus hernia repairs in 14 hospitals, and review of esophagograms in this cohort. RESULTS: 1829 hiatus hernias were repaired. Of these, 1571 (85.9%) patients underwent a postoperative esophagogram. Overall, 1 in 48 esophagograms resulted in an early (<14 days) reoperation, which was undertaken in 44 (2.4%) patients. Compared to those without an esophagogram, patients who received this test prior to reoperation (n = 37) had a shorter time to diagnosis (2.4 vs. 3.9 days, p = 0.041) and treatment (2.4 vs. 4.3 days, p = 0.037) of their complications. This was associated with lower rates of open surgery (10.8% vs. 42.9%, p = 0.034), gastric resection (0.0% vs. 28.6%, p = 0.022), postoperative morbidity (13.5% vs. 85.7%, p < 0.001), unplanned intensive care admission (16.2% vs. 85.7%, p < 0.001), and decreased length-of-stay (7.3 vs. 18.3 days, p = 0.009). Furthermore, we identified less intraoperative and postoperative complications, as well as superior functional outcomes at one-year follow-up in patients who underwent early reoperations for an esophagogram-detected asymptomatic re-herniation than those who needed surgery for late symptomatic recurrences.