Defining recurrence after paraesophageal hernia repair: Correlating symptoms and radiographic findings

Defining recurrence after paraesophageal hernia repair: Correlating symptoms and radiographic findings Anne O. Lidor, MD, MPH,a Qingwen Kawaji, BS,b Miloslawa Stem, MS,a Richard M. Fleming, MD,c Michael A. Schweitzer, MD,a Kimberley E. Steele, MD,a and Michael R. Marohn, DO,a Baltimore, MD

Background. Laparoscopic repair of paraesophageal hernia (PEH) has been shown to result in excellent relief of symptoms and improved quality of life (QOL) despite a high radiographically identified recurrence rate. Because there is no uniform definition of PEH recurrence, it is difficult to compare studies reporting on this. This study attempts to introduce consistency to the definition of PEH recurrence based on correlation of symptoms and radiographic findings. Methods. This is an analysis of data derived from an ongoing prospective study. From April 2009 to December 2012, we enrolled 101 patients who underwent elective laparoscopic PEH repair with bioprosthesis buttressed over a primary cruroplasty. A validated gastroesophageal reflux disease-specific QOL tool was administered to patients before, and at 2 and 12 months postoperatively. Upper gastrointestinal barium contrast examination (UGI) was performed at 1 year. Results. Of 101 patients, 13 were not available for follow-up, 58 reached the 1-year milestone for interval UGI, and 1 patient required reoperation for symptomatic recurrent PEH. There was no relationship between total QOL score and radiographic recurrent hernia (RRH); however, significant deterioration in many symptoms was seen in RRH > 2 cm. Based on these findings, we defined recurrence as RRH > 2 cm and calculated our recurrence rate as 28% (n = 16). Conclusion. Our analysis of symptom scores after laparoscopic PEH repair suggests that significant worsening occurs with RRH > 2 cm. Given that there is no consistent description of recurrent PEH, we suggest this as a possible standardized definition. Overall, patients with recurrent PEHs continue to experience excellent QOL and rarely require reoperation. (Surgery 2013;154:171-8.) From the Department of Surgery,a Johns Hopkins University School of Medicine, the Department of Biochemistry and Molecular Biology,b Johns Hopkins Bloomberg School of Public Health, and the Department of Radiology,c Johns Hopkins University School of Medicine, Baltimore, MD

PARAESOPHAGEAL HERNIA (PEH) repair is a technically challenging operation that continues to be associated with a high recurrence rate. Currently, most PEH are repaired laparoscopically,1 and the role of mesh (either prosthetic or biologic) in reducing the rate of recurrence remains a source of controversy. Many reports have confirmed that Mr. Edwin Lewis provided generous support of Dr Lidor’s Department of Surgery Research Fund. Presented at the 8th Annual Academic Surgical Congress, February 6, 2013, New Orleans, LA. Accepted for publication March 28, 2013. Reprint requests: Anne O. Lidor, MD, MPH, Associate Professor of Surgery, Johns Hopkins Hospital, 600 N. Wolfe Street, Blalock 618, Baltimore, MD 21287. E-mail: [email protected]. 0039-6060/$ - see front matter Ó 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2013.03.015

laparoscopic repair of PEH, with or without crural mesh reinforcement, yield excellent relief of symptoms and improved quality of life (QOL), despite a high rate of radiographically identified recurrence. Unfortunately, because there is no universally agreed upon definition of PEH recurrence, it is difficult to compare studies reporting on this. Most large series of laparoscopic PEH repair have relied on barium esophagography or, less frequently, endoscopy or esophageal manometry to document recurrence. Although the specific technique for repair varies by institution and surgeon (eg, use of gastropexy, Colles gastroplasty, mesh reinforcement), reported radiographic recurrence rates in contemporary series continue to be quite high, between 16 and 66%.2-6 Notwithstanding this high rate of cruroplasty failure, these studies uniformly demonstrate that symptom relief SURGERY 171

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and QOL are significantly improved.7-9 Moreover, reoperation for symptomatic recurrence has been reported as infrequently as in 3–3.5% of cases,2,4,10 calling into question the clinical relevance of radiographic recurrence. Confounding things further is the lack of a standardized definition of precisely what constitutes PEH recurrence. This has resulted in a wide variability of definitions employed throughout many different series, severely hampering analysis and limiting meaningful comparisons among studies. We analyzed data from an ongoing, prospective trial of patients undergoing laparoscopic PEH repair at our institution. This study attempts to introduce consistency to the definition of PEH recurrence based on correlation of symptoms and radiographic findings. METHODS From April 2009 to December 2012, we enrolled 101 adult patients who underwent elective laparoscopic PEH repair with a biologic mesh (Veritas collagen matrix, Synovis, St. Paul MN) buttressed over a primary cruroplasty (Fig). All patients underwent Nissen fundoplication with or without anterior gastropexy. Consent of study participation was signed by all patients. Patients with simple sliding hiatal hernias were not included in this study, because type I hiatal hernias are not true PEH. To maintain as much consistency as possible in our cohort, we also excluded patients with type IV PEHs. Additional exclusion criteria included any patients on chronic immunosuppression and/or steroids, patients scheduled for planned open surgery, and patients with prior antireflux surgery. All data were prospectively collected on a standardized collection form and maintained in an electronic database. Patient demographic status, preoperative notes (patients history, signs, symptoms, and comorbidities), operative information (complications, reoperation), postoperative course of care (complication outcomes, duration of hospital stay), and postoperative clinic visits, including radiology screenings, were collected. This study was reviewed and approved by the Johns Hopkins Medicine Institutional Review Board. Symptom assessment. A modified version of a validated gastroesophageal reflux disease-specific QOL tool11 was administered to patients by a dedicated research team (either in person or by phone) before and at 2 and 12 months postoperatively. Patients were asked 11 questions about the following symptoms: Acid reflux (after meals and its severity), postprandial chest pain, early satiety,

Fig. Paraesophageal hernia (PEH) study and follow-up.

nausea, vomiting, difficulty and pain with swallowing, bloating/gas, shortness of breath, and overall condition satisfaction. The 2 acid reflux questions were combined into one for analysis. All questions were rated on a 6-point scale (0 [no symptoms] to 5 [symptoms are incapacitating, unable to do daily activities]). Higher scores represent greater severity of symptoms. Radiographic methods. Upper gastrointestinal barium contrast examination (UGI) was performed at 1 year at the Johns Hopkins Hospital. Patients who expressed difficulty in coming back to Baltimore had their UGI performed at outside radiology imagining centers and mailed their disks to the study coordinator. A single radiologist blinded to patient information read all studies. Measurement for recurrent hernia was recorded as the greatest vertical extension of gastric mucosa above the wrap, measured from the top of the wrap. Statistical methods. We looked at and compared overall QOL, individual symptom scores, as well as symptom score changes between 2-month and 1-year QOLs. Overall and individual symptom comparison between baseline, 2 months, and 1 year was performed for all patients as well as

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Table I. Baseline demographics and clinical characteristics for all enrolled paraesophageal hernia patients Total (n = 101) Age, mean (median) Female, n (%) Race, n (%) White Black Other QOL score, mean ± SD Preoperatively 2 months postoperatively 12 months postoperatively Duration of stay (d), median Reoperation, n (%)

61.2 (61) 65 (64) 83 (82) 15 (15) 3 (3) 28.3 ± 11.4 10.3 ± 7.6 10.3 ± 8.9 2 4 (3.9)

QOL, Quality of life.

stratified by recurrence using Wilcoxon signedrank test. Correlation between radiographic findings and mean symptom score change (defined as mean 1-year symptom score minus mean 2-month symptom score) was performed using Wilcoxon rank sum test and Kruskal-Wallis nonparametric analysis of variance, stratified by increasing size (0, #2, and >2 cm) of radiographic recurrent hernia (RRH). Pearson Chi-square and Fisher’s exact tests for categorical variables were used to determine significance between groups when appropriate. Medians were compared using the median test. All statistical analyses were performed using STATA/MP, version 11.2 (Stata Corp, College Station, TX). RESULTS Baseline demographic and clinical characteristics. Of 101 patients, 13 were unavailable for follow-up: 11 patients either voluntarily withdrew from the study or were lost to contact and 2 died from unrelated causes. Fifty-eight patients reached the 1-year milestone for interval UGI by December 2012 (Fig). For all patients, the median age was 61 years (range, 24–89) with 64.4% being women and 82.2% being white (Table I). There was a significant difference among the mean preoperative, 2-month, and 12-month QOL scores (P = .00). Four patients required reoperation, of whom only one was for symptomatic recurrent PEH manifested by obstructive symptoms. One patient underwent reoperation on postoperative day 2 for intrathoracic wrap migration and the 2 additional patients underwent reoperation for complaints of chest pain and dysphagia without recurrent PEH identified.

QOL and individual symptom assessment postoperatively. Overall, patients complained most frequently about acid reflux after meals and its severity, bloating/gas, early satiety, and overall condition satisfaction before undergoing surgery. However, they reported significant improvements in all symptoms and overall condition satisfaction at 2 and 12 months postoperative (Table II). Among the 58 patients with UGI, there was no difference between 2-month and 1-year overall QOL and individual symptom scores. However, comparison of mean score change (between 1 year and 2 months) stratified by increasing hernia size, revealed significant deterioration in individual symptom scores for acid reflux and shortness of breath, with additional trend toward significance for pain with swallowing in the HH >2 cm group compared with the other 2 HH groups (Table III). Using a preliminary definition of recurrence as RRH > 2 cm, we compared preoperative, 2-month, and 12-month symptom scores for the nonrecurrent and recurrent groups (Table IV). Symptoms such as early satiety, difficulty and pain with swallowing, and bloating/gas were not improved at 2 or 12 months postoperative for the recurrent patients. Additionally, postprandial chest pain and shortness of breath became problematic at 12 month postoperative compared with preoperative scores among the recurrent group. Recurrence of PEH. Based on these findings, we defined recurrence as RRH > 2 cm and calculated our recurrence rate as 27.6% at mean follow-up of 420 days (range, 234–802). The average postoperative hernia size was 0.34 ± 0.58 and 3.61 ± 0.99 cm for the nonrecurrent and recurrent groups, respectively. These 2 groups were similar in terms of their baseline demographic and clinical characteristics. There was no relationship found between overall mean QOL scores and RRH (Table V). DISCUSSION Although controversy persists regarding the optimal method for PEH repair, the absence of a uniform definition of recurrence severely impedes comparison among various series. This study is the first to attempt to define recurrence after PEH repair by correlating radiographic findings with symptoms. In this prospective study following patients after laparoscopic repair of PEH, we found that there was a significant worsening in symptoms once a hiatal hernia was noted to be >2 cm by barium esophagram. Nevertheless, despite a recurrence rate of 28% in our study, the overall symptom response and patient

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Table II. Comparison of mean preoperative, 2-month, and 12-month symptom scores for all paraesophageal hernia patients Symptoms (mean ± SD) Total Acid refluxz Postprandial chest pain Early satiety Nausea Vomiting Difficulty with swallowing Pain with swallowing Bloating/gas Shortness of breath Condition satisfaction

QOL1 (preoperative; n = 94) 28.32 6.88 2.26 3.18 1.71 1.46 1.77 1.05 3.20 2.22 4.60

± ± ± ± ± ± ± ± ± ± ±

QOL2 (2 months; n = 86)

11.38 3.20 1.90 1.88 1.62 1.73 1.75 1.50 1.71 1.83 1.10

10.31 1.31 0.50 2.01 0.73 0.49 0.78 0.24 2.66 0.81 0.83

± ± ± ± ± ± ± ± ± ± ±

P* value <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 .01 <.001 <.001

7.59 2.40 1.00 1.58 1.31 1.26 1.14 0.65 1.66 1.35 1.62

QOL3 (12 months; n = 65) 10.25 1.66 0.46 2.03 0.80 0.32 0.72 0.25 2.15 1.08 0.80

± ± ± ± ± ± ± ± ± ± ±

8.88 2.47 1.02 1.74 1.35 0.89 1.24 0.79 1.67 1.55 1.60

Py value <.001 <.001 <.001 <.01 <.001 <.001 <.001 <.001 <.01 <.001 <.001

*Preoperative vs 2-month QOL. yPreoperative vs 12-month QOL. zAcid reflux after meals and its severity (2 questions combined into one). Wilcoxon signed rank test. QOL, Quality of life.

Table III. Comparison of mean symptom score change* with increasing hernia size Symptoms (mean ± SD) Total Acid reflux Shortness of breath Pain with swallowing Nausea Vomiting Bloating/gas Early satiety Postprandial chest pain Difficulty with swallowing Condition satisfaction

HH 0 cm (n = 30; 51.7%) 0.88 0.56 0.12 0.16 0.28 0.04 0.12 0.17 0.08 0.16 0.20

± ± ± ± ± ± ± ± ± ± ±

0 < HH < 2 cm (n = 12; 20.7%)

3.64 1.61y,z 1.24z 0.75 0.98 0.45 1.81 1.79 1.04 1.11 1.12

1.09 0.91 0.18 0.18 0.45 0.09 0.64 0.09 0.18 0.09 0.45

± ± ± ± ± ± ± ± ± ± ±

4.25 1.81y 1.08 0.40x 1.13 0.70 1.69 1.22 1.33 0.70 1.04

HH >2 cm (n = 16; 27.6%) 1.50 1.19 0.81 0.33 0.63 0.44 0.81 0.47 0.00 0.40 0.25

± ± ± ± ± ± ± ± ± ± ±

10.80 2.59z 1.72z 0.90x 2.00 1.71 2.17 2.23 1.51 1.45 2.59

P value .03y .01z .047z .05x .15 .53 .61 .62 .60 .64 .83

*Symptom score change = 1year symptom score  2-month symptom score. y0 vs 0.1–2 cm. z0 vs >2 cm. x0.1–2 vs >2 cm. Kruskal-Wallis nonparametric analysis of variance and Wilcoxon rank-sum test. HH, Hiatal hernia; SD, standard deviation.

satisfaction after surgery was excellent and only 1 patient required reoperation for recurrent PEH. Laparoscopy for PEH repair has come to be considered the standard of care in the modern era as a result of the superior short-term outcomes demonstrated in many series.12-16 An early report comparing recurrence rates after open versus laparoscopic PEH repair reported a significantly higher rate of recurrence in the laparoscopic group.17 Recurrence rates after open repair have, indeed, been reported as low as 2% in the surgical literature,18 far lower than that reported in any modern laparoscopic series. Irrespective of the approach used, long-term recurrence remains a

major unresolved issue related to a variety of factors, including the unrelenting motion of the diaphragm, crural tension when large defects are repaired, and frequent inability to gain adequate intra-abdominal esophageal length. Only 3 randomized studies regarding PEH repair exist in the literature, each of which compares laparoscopic repair with and without mesh. In one of these studies,19 100 patients were followed for 1 year after hiatal hernia repair with Nissen fundoplication, some of whom also underwent PEH. Although follow-up was complete for all enrolled patients, the authors did not report on the relationship between symptomatic results

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Table IV. Comparison of mean preoperative, 2-month, and 12-month symptom scores for nonrecurrent and recurrent patients Symptoms (mean ± SD)

QOL1 (preoperative; n = 57)

Total Nonrecurrent 26.41 Recurrent 25.75 Condition satisfaction Nonrecurrent 4.48 Recurrent 4.44 Acid refluxz Nonrecurrent 6.27 Recurrent 7.06 Vomiting Nonrecurrent 1.24 Recurrent 1.63 Bloating/gas Nonrecurrent 2.85 Recurrent 3.06 Difficulty with swallowing Nonrecurrent 1.73 Recurrent 1.13 Pain with swallowing Nonrecurrent 0.90 Recurrent 0.50 Early satiety Nonrecurrent 3.20 Recurrent 2.50 Postprandial chest pain Nonrecurrent 2.15 Recurrent 1.44 Shortness of breath Nonrecurrent 2.22 Recurrent 2.06 Nausea Nonrecurrent 1.49 Recurrent 1.94

QOL2 (2 month; n = 56)

P* value

QOL3 (12 month; n = 53)

Py value

± 11.77 ± 8.93

9.95 ± 6.48 8.44 ± 6.99

<.001 <.001

8.59 ± 6.53 9.94 ± 9.06

<.001 <.001

± 1.40 ± 1.36

0.63 ± 1.43 0.63 ± 1.71

<.001 <.001

0.73 ± 1.59 0.88 ± 1.63

<.001 <.01

± 3.28 ± 3.00

1.30 ± 2.30 0.88 ± 1.59

<.001 <.001

0.92 ± 1.50 2.06 ± 2.32

<.001 <.01

± 1.64 ± 1.75

0.30 ± 1.04 0.63 ± 1.45

<.01 .04

0.22 ± 0.67 0.19 ± 0.75

<.01 <.01

± 1.67 ± 1.69

2.73 ± 1.43 2.50 ± 1.67

.71 .11

2.30 ± 1.47 1.69 ± 1.82

.13 .05

± 1.75 ± 1.54

0.90 ± 1.26 0.27 ± 0.59

.02 .05

0.78 ± 1.25 0.63 ± 1.45

.02 .34

± 1.37 ± 1.10

0.23 ± 0.53 0.00 ± 0.00

.01 .05

0.08 ± 0.36 0.31 ± 0.87

<.01 .47

± 1.90 ± 1.90

1.95 ± 2.00 2.00 ± 1.60

<.001 .26

1.67 ± 1.57 2.31 ± 1.85

<.01 .71

± 1.88 ± 1.55

0.60 ± 1.08 0.44 ± 1.09

<.001 .02

0.38 ± 0.86 0.44 ± 1.21

<.001 .05

± .1.80 ± 1.61

0.90 ± 1.45 0.25 ± 0.58

<.001 <.01

0.92 ± 1.16 1.06 ± 1.77

<.01 .06

± 1.55 ± 1.57

0.45 ± 0.93 1.00 ± 1.71

<.001 .18

0.65 ± 1.16 0.38 ± 0.89

<.01 <.01

*Preoperative vs 2-month QOL. yPreoperative vs 12-month QOL. zAcid reflux after meals and its severity (2 questions combined into one). Wilcoxon signed-rank test. QOL, Quality of life; SD, standard deviation.

and the presence or absence of PEH recurrence. Their overall recurrence rate was lower than in our study (17% vs 28%); however, only half of their patients had a PEH. Additionally, these authors do not define what constitutes hernia recurrence, and no detail is provided regarding reoperation rate. A second study20 followed 72 patients with laparoscopic PEH repair for a median of 2.5 years, reporting a 22% recurrence rate, with 5 patients (7%) requiring reoperation. Although their recurrence rate is comparable with what we present herein, these authors, too, failed to provide a definition of hernia recurrence. Barium esophagography was performed in symptomatic patients only, raising the possibility of significant

under-reporting of recurrence, given our finding that most of our recurrences were asymptomatic. The last study is much more complete and bears further discussion. The most complete randomized, multi-institutional study in the literature to date was recently published by Oelschlager et al.7 These authors report results after laparoscopic PEH repair in 108 patients with median follow-up of 58 months. Using a definition of radiographic recurrence as greatest vertical height of stomach $2 cm above the diaphragm, they reported a 57% recurrence rate. This definition of recurrence was determined a priori in their study, but it is also the threshold that we arrived at in our study. However, whereas Oelschlager et al only found a significant

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Table V. Baseline demographics and clinical characteristics for paraesophageal hernia patients who reached their milestone for interval upper gastrointestinal barium contrast examination stratified by radiologic hernia recurrence Nonrecurrent (HH # 2 cm; n = 42) Age, mean (median) Female, n (%) Race White Black Other QOL score, mean ± SD Preoperatively 2 months postoperatively 12 months postoperatively Mean follow-up time (d)* Length of stay (d), median Reoperation, n (%)

61.7 (62) 26 (62)

Recurrent (HH > 2 cm; n = 16) 62.5 (60) 12 (75)

35 (83.33) 6 (14.29) 1 (2.38)

14 (87.50) 2 (12.50) 0 (0)

26.41 ± 11.77 9.95 ± 6.48 8.59 ± 6.53 410.2 2 2 (4.76)

25.75 ± 8.93 8.44 ± 6.99 9.94 ± 9.06 446.1 2 1 (6.25)

P value .84 .35 .81

.84 .44 .55 .84 .84 .99

*Mean follow-up to 1-year upper gastrointestinal barium contrast examination. HH, Hiatal hernia; QOL, quality of life; SD, standard deviation.

correlation in symptom severity between recurrent and nonrecurrent patients with respect to heartburn, we found significant correlations for a variety of symptoms, including acid reflux, dysphagia, and shortness of breath. Despite this difference, the authors observed, as we did, that most patients with recurrence remain asymptomatic and the need for reoperation for recurrent hernia is very low. There is a paucity of studies reporting long-term outcomes after PEH repair. Unfortunately, most studies on this subject that have been published are retrospective21-24 and, as such, are highly subject to bias. One prospective, cohort study with up to 5-year follow-up25 reported no difference in symptoms (heartburn, regurgitation, dysphagia, chest pain, or satisfaction) between patients with and without recurrence. However, their definition of recurrence is not clearly stated in the paper, and postoperative symptom scores were not compared with preoperative scores. Moreover, only 4 patients were identified to have hernia recurrence, and complete follow-up was available in only half of the patients (36 out of 71) at 3 years. Another study, by Poncet et al,26 reported a 24% recurrence rate at up to 112 months postoperatively. These authors defined recurrence as any amount of esophagogastric junction migrating back into the mediastinum. Most of the recurrent patients had reflux symptoms and, unlike in our study, over half (57%) of the recurrences required reoperation. The 2 studies with the longest follow-up also followed patients prospectively for recurrence and clinical outcomes after laparoscopic PEH repair. Dallemagne et al3 reported long-term results

(median follow-up, >9 years) after laparoscopic PEH repair. As in our study, these authors observed excellent relief in individual symptoms as well as in overall Gastrointestinal Quality of Life Index scores27; however, the low numbers of patients at long-term follow-up precluded any correlation of symptoms with radiographic recurrence. Moreover, their definition of radiographic recurrence was more liberal than ours or that of Oelschlager et al, resulting in the highest reported recurrence rate (66%). Luketich et al2 have the largest published series of laparoscopic PEH repair. In their series of 662 patients, there were no differences reported in rates of symptoms between patients with and without radiographic recurrences or in patient-reported satisfaction. Their definition of recurrence was very similar to ours; however, their recurrence rate is much lower (16%); the reoperation rate for recurrence (3%) is similar to ours and that reported in other series. In a subgroup analysis of 187 of these patients at mean follow-up of 77 months,8 the authors did find significantly increased odds of chest pain and regurgitation, but not heartburn, in patients found to have a radiographic recurrence. Although it is impossible to discern the reason for these subtle differences from our findings, their results support ours in agreeing on the definition of recurrence. This study has several limitations. Although this was a prospective study with a dedicated team calling patients regularly to administer the QOL tool and to schedule both clinical and radiologic follow-up appointments, we nevertheless lost 13% of our patients to follow-up. The reasons for this

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included deaths owing to unrelated causes, patient relocation and/or change in phone number, and patient requests to withdraw from the study. Although this is higher than we would have liked, it is still much lower than similar cohort studies, many of which report attrition rates of >30%.13,25,26,28,29 Oelschlager et al7 compared the baseline demographics of their original cohort of patients undergoing laparoscopic PEH repair with that of their long-term follow-up cohort and found no difference between them, suggesting that our own attrition rate is also unlikely to skew our findings. Because many of our patients are referred here for surgery from well outside the Baltimore area and prefer to return to their local physicians to resume their medical care, this significantly hampered our ability to follow up with them in person. Ideally, we would have liked to include information best obtained during visits scheduled at our facilities, such as proton pump inhibitor use, endoscopy findings (esophagitis, Barrett’s esophagus, or need for additional procedures like dilatations), or postoperative manometry. Because we were precluded from reliably collecting such data in the clinical setting, we utilized only the information from the QOL survey to calculate our definition of recurrence. Because the QOL survey is a validated tool, and each patient is being compared with himself at baseline (serving as an internal control), this seems to us to be a valid methodology. Finally, approximately 30 of our original cohort have not yet completed their 1-year UGI. Although it is possible that the additional data provided by these patients may impact our results as they become available, this seems unlikely in view of the fact that our data have thus far been fairly consistent in the recurrent and nonrecurrent groups. In conclusion, our study confirms that laparoscopic PEH repair results in excellent QOL, the benefit of which realized even in the presence of hernia recurrence. However, despite this overall QOL improvement, we observed a significant worsening of many symptoms with RRH > 2 cm. We believe that RRH > 2 cm represents a clinically useful, and readily discernible, objective criterion for identifying significant recurrence of PEH after repair. We suggest this as a possible standardized definition as this would provide a reproducible means of comparing reports on PEH surgery and would introduce a uniform standard for assessing the results of PEH repair. We hope the findings from this study helps clinicians in informing patients about recurrence after PEH repair. Based

on our data, we would consider using UGI selectively in patients based on symptoms, although routine use of radiographic studies would be acceptable as a means to document potential progression of disease. The authors acknowledge Mr Edwin Lewis for his generous support of Dr Lidor’s Department of Surgery Research Fund.

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