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Montcusí B, Jaume-Bottcher S, Álvarez I, Ramón JM, Sánchez-Parrilla J, Grande L, Pera M. 5-Year Collis-Nissen Gastroplasty Outcomes for Type III-IV Hiatal Hernia with Short Esophagus: A Prospective Observational Study. J Am Coll Surg 2023; 237:596-604. [PMID: 37326320 DOI: 10.1097/xcs.0000000000000785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND To assess the 5-year outcomes of patients undergoing Collis-Nissen gastroplasty for type III-IV hiatal hernia with short esophagus. STUDY DESIGN From a prospective observational cohort of patients who underwent antireflux surgery for type III-IV hiatal hernia between 2009 and 2020, those with short esophagus (abdominal length <2.5 cm) in whom a Collis-Nissen procedure was performed and reached at least 5 years of follow-up were identified. Hernia recurrence, patients' symptoms, and quality of life were assessed annually by barium meal x-ray, upper endoscopy, and validated symptoms and Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaires. RESULTS Of the 114 patients with Collis-Nissen gastroplasty, 80 patients who completed a 5-year follow-up were included (mean age 71 years). There were no postoperative leaks or deaths. Recurrent hiatal hernia (any size) was identified in 7 patients (8.8%). Heartburn, regurgitation, chest pain, and cough were significantly improved at each follow-up interval (p < 0.05). Preoperative dysphagia disappeared or improved in 26 of 30 patients, while new-onset dysphagia occurred in 6. Mean postoperative QOLRAD scores significantly improved at all dimensions (p < 0.05). CONCLUSIONS Collis gastroplasty combined with Nissen fundoplication provides low hernia recurrence, good control of symptoms, and improved quality of life in patients with large hiatal hernia and short esophagus.
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Affiliation(s)
- Blanca Montcusí
- From the Section of Upper Gastrointestinal Surgery, Department of Surgery, Hospital del Mar Medical Research Institute Universitat Autònoma de Barcelona (Montcusí, Jaume-Bottcher, Álvarez, Ramón, Grande, Pera), Barcelona, Spain
| | - Sofia Jaume-Bottcher
- From the Section of Upper Gastrointestinal Surgery, Department of Surgery, Hospital del Mar Medical Research Institute Universitat Autònoma de Barcelona (Montcusí, Jaume-Bottcher, Álvarez, Ramón, Grande, Pera), Barcelona, Spain
| | - Idoia Álvarez
- From the Section of Upper Gastrointestinal Surgery, Department of Surgery, Hospital del Mar Medical Research Institute Universitat Autònoma de Barcelona (Montcusí, Jaume-Bottcher, Álvarez, Ramón, Grande, Pera), Barcelona, Spain
| | - José M Ramón
- From the Section of Upper Gastrointestinal Surgery, Department of Surgery, Hospital del Mar Medical Research Institute Universitat Autònoma de Barcelona (Montcusí, Jaume-Bottcher, Álvarez, Ramón, Grande, Pera), Barcelona, Spain
| | - Juan Sánchez-Parrilla
- the Department of Radiology, Hospital del Mar, Universitat Pompeu Fabra (Sánchez-Parrilla), Barcelona, Spain
| | - Luis Grande
- From the Section of Upper Gastrointestinal Surgery, Department of Surgery, Hospital del Mar Medical Research Institute Universitat Autònoma de Barcelona (Montcusí, Jaume-Bottcher, Álvarez, Ramón, Grande, Pera), Barcelona, Spain
| | - Manuel Pera
- From the Section of Upper Gastrointestinal Surgery, Department of Surgery, Hospital del Mar Medical Research Institute Universitat Autònoma de Barcelona (Montcusí, Jaume-Bottcher, Álvarez, Ramón, Grande, Pera), Barcelona, Spain
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Cocco AM, Chai V, Read M, Ward S, Johnson MA, Chong L, Gillespie C, Hii MW. Percentage of intrathoracic stomach predicts operative and post-operative morbidity, persistent reflux and PPI requirement following laparoscopic hiatus hernia repair and fundoplication. Surg Endosc 2023; 37:1994-2002. [PMID: 36278994 PMCID: PMC10017603 DOI: 10.1007/s00464-022-09701-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 10/02/2022] [Indexed: 10/31/2022]
Abstract
PURPOSE Large hiatus hernias are relatively common and can be associated with adverse symptoms and serious complications. Operative repair is indicated in this patient group for symptom management and the prevention of morbidity. This study aimed to identify predictors of poor outcomes following laparoscopic hiatus hernia repair and fundoplication (LHHRaF) to aid in counselling potential surgical candidates. METHODOLOGY A retrospective analysis was performed from a prospectively maintained, multicentre database of patients who underwent LHHRaF between 2014 and 2020. Revision procedures were excluded. Hernia size was defined as the intraoperative percentage of intrathoracic stomach, estimated by the surgeon to the nearest 10%. Predictors of outcomes were determined using a prespecified multivariate logistic regression model. RESULTS 625 patients underwent LHHRaF between 2014 and 2020 with 443 patients included. Median age was 65 years, 62.9% were female and 42.7% of patients had ≥ 50% intrathoracic stomach. In a multivariate regression model, intrathoracic stomach percentage was predictive of operative complications (P = 0.014, OR 1.05), post-operative complications (P = 0.026, OR 1.01) and higher comprehensive complication index score (P = 0.023, OR 1.04). At 12 months it was predictive of failure to improve symptomatic reflux (P = 0.008, OR 1.02) and persistent PPI requirement (P = 0.047, OR 1.02). Operative duration and blood loss were predicted by BMI (P = 0.004 and < 0.001), Type III/IV hernias (P = 0.045 and P = 0.005) and intrathoracic stomach percentage (P = 0.009 and P < 0.001). Post-operative length of stay was predicted by age (P < 0.001) and emergency presentation (P = 0.003). CONCLUSION In a multivariate regression model, intrathoracic stomach percentage was predictive of operative and post-operative morbidity, PPI use, and failure to improve reflux symptoms at 12 months.
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Affiliation(s)
- A M Cocco
- The Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, Australia.
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia.
| | - V Chai
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - M Read
- The Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - S Ward
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, Eastern Health, Melbourne, Australia
| | - M A Johnson
- The Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, Eastern Health, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, The Royal Melbourne Hospital, Melbourne, Australia
| | - L Chong
- The Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - C Gillespie
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - M W Hii
- The Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, Eastern Health, Melbourne, Australia
- Upper GI and Hepatobiliary Surgical Unit, The Royal Melbourne Hospital, Melbourne, Australia
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Siow SL, Chuah JS, Mahendran HA. Laparoscopic repair of paraesophageal hernia with organo-axial intrathoracic gastric volvulus. Asian J Endosc Surg 2020; 13:437-440. [PMID: 31338969 DOI: 10.1111/ases.12740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/05/2019] [Indexed: 10/26/2022]
Abstract
Intrathoracic organo-axial gastric volvulus is a rare clinical entity associated with paraesophageal hernia. It is characterized by migration of the stomach into the thoracic cavity through an enlarged hiatal defect and rotation around its long axis connecting the cardia and the pylorus. A 72-year-old woman presented with epigastric pain that radiated to the left scapula for 1 week prior to presentation. Computed tomography scan of her thorax and abdomen demonstrated paraoesophageal hernia with organo-axial intrathoracic gastric volvulus. Laparoscopically, the stomach was returned to its abdominal position, the mediastinal sac was excised and after adequate intra-abdominal length of the esophagus was attained, the hiatal defect was closed primarily and reinforced with a composite mesh. An anterior 180° partial fundoplication was performed as both an anti-reflux procedure and also as a form of gastropexy. She had an uneventful recovery and remains well after 2 years.
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Affiliation(s)
- Sze Li Siow
- Department of General Surgery, Sarawak General Hospital, Ministry of Health Malaysia, Kuching, Malaysia.,Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Kuching, Malaysia
| | - Jun Sen Chuah
- Department of General Surgery, Sarawak General Hospital, Ministry of Health Malaysia, Kuching, Malaysia
| | - Hans Alexander Mahendran
- Department of General Surgery, Hospital Sultanah Aminah, Ministry of Health Malaysia, Johor Bahru, Malaysia
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Laparoscopic treatment of giant hiatal hernia with or without mesh reinforcement: A systematic review and meta-analysis. Int J Surg 2020; 77:97-104. [DOI: 10.1016/j.ijsu.2020.02.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/10/2020] [Accepted: 02/24/2020] [Indexed: 12/12/2022]
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Pauwels A, Boecxstaens V, Andrews CN, Attwood SE, Berrisford R, Bisschops R, Boeckxstaens GE, Bor S, Bredenoord AJ, Cicala M, Corsetti M, Fornari F, Gyawali CP, Hatlebakk J, Johnson SB, Lerut T, Lundell L, Mattioli S, Miwa H, Nafteux P, Omari T, Pandolfino J, Penagini R, Rice TW, Roelandt P, Rommel N, Savarino V, Sifrim D, Suzuki H, Tutuian R, Vanuytsel T, Vela MF, Watson DI, Zerbib F, Tack J. How to select patients for antireflux surgery? The ICARUS guidelines (international consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for antireflux surgery). Gut 2019; 68:1928-1941. [PMID: 31375601 DOI: 10.1136/gutjnl-2019-318260] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 05/28/2019] [Accepted: 05/29/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Antireflux surgery can be proposed in patients with GORD, especially when proton pump inhibitor (PPI) use leads to incomplete symptom improvement. However, to date, international consensus guidelines on the clinical criteria and additional technical examinations used in patient selection for antireflux surgery are lacking. We aimed at generating key recommendations in the selection of patients for antireflux surgery. DESIGN We included 35 international experts (gastroenterologists, surgeons and physiologists) in a Delphi process and developed 37 statements that were revised by the Consensus Group, to start the Delphi process. Three voting rounds followed where each statement was presented with the evidence summary. The panel indicated the degree of agreement for the statement. When 80% of the Consensus Group agreed (A+/A) with a statement, this was defined as consensus. All votes were mutually anonymous. RESULTS Patients with heartburn with a satisfactory response to PPIs, patients with a hiatal hernia (HH), patients with oesophagitis Los Angeles (LA) grade B or higher and patients with Barrett's oesophagus are good candidates for antireflux surgery. An endoscopy prior to antireflux surgery is mandatory and a barium swallow should be performed in patients with suspicion of a HH or short oesophagus. Oesophageal manometry is mandatory to rule out major motility disorders. Finally, oesophageal pH (±impedance) monitoring of PPI is mandatory to select patients for antireflux surgery, if endoscopy is negative for unequivocal reflux oesophagitis. CONCLUSION With the ICARUS guidelines, we generated key recommendations for selection of patients for antireflux surgery.
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Affiliation(s)
- Ans Pauwels
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Veerle Boecxstaens
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Department of Surgical Oncology, Oncological and Vascular Access Surgery, Leuven, Belgium.,Department of Oncology, KU Leuven, Leuven, Belgium
| | | | | | - Richard Berrisford
- Peninsula Oesophago-gastric Surgery Unit, Derriford Hospital, Plymouth, Plymouth, UK
| | - Raf Bisschops
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Gastroenterology and Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Guy E Boeckxstaens
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - Serhat Bor
- Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Albert J Bredenoord
- Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, Netherlands
| | - Michele Cicala
- Digestive Diseases, Universita Campus Bio Medico, Roma, Italy
| | - Maura Corsetti
- Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
| | - Fernando Fornari
- Programa de Pós-Graduação: Ciências em Gastroenterologia e Hepatologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Chandra Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jan Hatlebakk
- Gastroenterology, Haukeland Sykehus, University of Bergen, Bergen, Norway
| | - Scott B Johnson
- Department of Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, USA
| | - Toni Lerut
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Lars Lundell
- Department of Surgery, Karolinska, Stockholm, Sweden
| | - Sandro Mattioli
- Department of Medical and Surgical Sciences, Universita degli Studi di Bologna, Bologna, Emilia-Romagna, Italy
| | - Hiroto Miwa
- Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Philippe Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Taher Omari
- Department of Gastroenterology, Flinders University, Adelaide, Australia
| | - John Pandolfino
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Roberto Penagini
- Department of Pathophysiology and Transplantation, Ospedale Maggiore Policlinico, Milano, Lombardia, Italy
| | - Thomas W Rice
- Thoracic Surgery, Emeritus Staff Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, USA
| | - Philip Roelandt
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Gastroenterology and Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Nathalie Rommel
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Neurosciences, KU Leuven, Leuven, Belgium
| | - Vincenzo Savarino
- Internal Medicine and Medical Specialties, Universita di Genoa, Genoa, Italy
| | - Daniel Sifrim
- Barts and The London School of Medicine and Dentistry, Queen Mary University London, London, UK
| | - Hidekazu Suzuki
- Gastroenterology and Hepatology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Radu Tutuian
- Gastroenteroloy, Tiefenauspital Bern, Bern, Switzerland
| | - Tim Vanuytsel
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Gastroenterology and Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
| | | | - David I Watson
- Department of Surgery, Flinders Medical Centre, Flinders University, Adelaide, South Australia, Australia
| | - Frank Zerbib
- Department of Gastroenterology, Bordeaux University Hospital, Université de Bordeaux, Bordeaux, France
| | - Jan Tack
- Department of Chronic Diseases, Metabolism and Ageing, Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium.,Gastroenterology and Hepatology, University Hospital Gasthuisberg, Leuven, Belgium
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Castelijns PSS, van de Poll MCG, Smulders JF. A Modified Technique to Create a Standardized Floppy Nissen Fundoplication Without a Bougie. J Laparoendosc Adv Surg Tech A 2018; 28:853-858. [PMID: 29466120 DOI: 10.1089/lap.2017.0734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Nissen fundoplication is frequently applied in the surgical treatment of patients with gastroesophageal reflux disease (GERD). When the gastroesophageal junction remains too large or becomes too narrow, persistent GERD or dysphagia may occur. To assure a correct size of the gastroesophageal junction, the fundoplication can be created over a bougie. However, this increases the risk of esophageal perforation. Therefore, we have modified a previously described technique to create a standardized fundoplication without the use of a bougie. In this article, we describe this technique and demonstrate the initial results. MATERIALS AND METHODS We describe a technique to create a standardized Nissen fundoplication. After suture repair of the hiatal hernia, three marking sutures were placed on the gastric fundus, based on an equilateral triangle. The size of this triangle determines the final diameter of the fundoplication. With these measurements, we assure sufficient patency, minimize rotation, and create a more reproducible fundoplication that may reduce postoperative dysphagia. RESULTS We have operated 15 patients according to this technique. Mean operative time was 69.5 (SD 8.4) minutes, no complications occurred. There was no early dysphagia and the mean length of stay was 1.3 days (1-2). Quality of life after 1 year was excellent. CONCLUSIONS This modified method for standardized Nissen fundoplication is safe and might reduce postoperative dysphagia. Quality of life after 1 year is excellent. The effect on postoperative dysphagia and the reproducibility of this technique should be established in a large prospective study.
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Affiliation(s)
- Petrus S S Castelijns
- 1 Department of Surgery, Maastricht University Medical Centre , Maastricht, The Netherlands
| | - Marcel C G van de Poll
- 1 Department of Surgery, Maastricht University Medical Centre , Maastricht, The Netherlands .,2 Department of Intensive Care Medicine, Maastricht University Medical Centre , Maastricht, The Netherlands .,3 School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University , Maastricht, The Netherlands
| | - Johannes F Smulders
- 4 Department of Surgery, Catharina Hospital Eindhoven , Eindhoven, The Netherlands
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Castelijns PSS, Ponten JEH, van de Poll MCG, Nienhuijs SW, Smulders JF. A collective review of biological versus synthetic mesh-reinforced cruroplasty during laparoscopic Nissen fundoplication. J Minim Access Surg 2017; 14:87-94. [PMID: 28928334 PMCID: PMC5869985 DOI: 10.4103/jmas.jmas_91_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: Laparoscopic cruroplasty and fundoplication have become the gold standard in the treatment of hiatal hernia and gastro-oesophageal reflux disease (GERD). The use of a mesh-reinforcement of the cruroplasty has been proven effective; although, there is a lack of evidence considering which type of mesh is superior. The aim of this study was to compare recurrence rates after mesh reinforced cruroplasty using biological versus synthetic meshes. Methods: We performed a systematic review of all clinical trials published between January 2004 and September 2015 describing the application of a mesh in the hiatal hernia repair during Nissen fundoplication for both GERD and hiatal hernia. The primary outcome was the recurrence rate, and secondary outcomes were complication rate, mortality and symptomatic outcome. Results: We included 16 studies and extracted data regarding 1089 mesh operated patients of whom 385 received a biological mesh and 704 a synthetic mesh. The mean follow-up was 53.4 months. The recurrence rate in the synthetic mesh group was 6.8% compared to 16.1% in the biological mesh group (P < 0.05). The complication rate was 5.1% and 4.6% (P = 0.694), respectively, and there were 12 mesh-related complications. No mesh-related mortality was reported. Conclusion: Mesh reinforcement of hiatal hernia repair seems safe in the short-term follow-up. The available literature suggests no clear advantage of biological over synthetic meshes. Regarding cost-efficiency and short-term results, the use of synthetic nonabsorbable meshes might be advocated.
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Affiliation(s)
- P S S Castelijns
- Department of Surgery, Catharina Hospital Eindhoven, 5623 EJ Eindhoven, The Netherlands
| | - J E H Ponten
- Department of Surgery, Catharina Hospital Eindhoven, 5623 EJ Eindhoven, The Netherlands
| | - M C G van de Poll
- Department of Surgery and Intensive Care Medicine, MUMC+, 6229 HX Maastricht, The Netherlands
| | - S W Nienhuijs
- Department of Surgery, Catharina Hospital Eindhoven, 5623 EJ Eindhoven, The Netherlands
| | - J F Smulders
- Department of Surgery, Catharina Hospital Eindhoven, 5623 EJ Eindhoven, The Netherlands
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Bonrath EM, Grantcharov TP. Contemporary management of paraesophaegeal hernias: establishing a European expert consensus. Surg Endosc 2014; 29:2180-95. [PMID: 25361649 DOI: 10.1007/s00464-014-3918-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 09/22/2014] [Indexed: 01/24/2023]
Abstract
BACKGROUND The surgical treatment of paraesophageal hernias remains a challenge due to the lack of consensus regarding principles of operative treatment. The objectives of this study were to achieve consensus on key topics through expert opinion using a Delphi methodology. METHODS A Delphi survey combined with a face-to-face meeting was conducted. A panel of European experts in foregut surgery from high-volume centres generated items in the first survey round. In subsequent rounds, the panel rated agreement with statements on a 5-point Likert-type scale. Internal consistency (consensus) was predefined as Cronbach's α > .80. Items that >70 % of the panel either rated as irrelevant/unimportant, or relevant/important were selected as consensus items, while topics that did not reach this cut-off were termed "undecided/controversial". RESULTS Three survey rounds were completed: 19 experts from 10 countries completed round one, 18 continued through rounds two and three. Internal consistency was high in rounds two and three (α > .90). Fifty-eight additional/revised items derived from comments and free-text entries were included in round three. In total, 118 items were rated; consensus agreement was achieved for 70 of these. Examples of consensus topics are the relevance of the disease profile for assessing surgical urgency and complexity, the role of clinical history as the mainstay of patient follow-up, indications for revision surgery, and training and credentialing recommendations. Topics with the most "undecided/controversial" items were follow-up, postoperative care and surgical technique. CONCLUSIONS This Delphi study achieved expert consensus on key topics in the operative management of paraesophageal hernias, providing an overview of the current opinion among European foregut surgeons. Moreover, areas with substantial variability in opinions were identified reflecting the current lack of empirical evidence and opportunities for future research.
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Affiliation(s)
- E M Bonrath
- University of Toronto, 30 Bond Street, Toronto, ON, M5B1W8, Canada,
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9
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Daigle CR, Funch-Jensen P, Calatayud D, Rask P, Jacobsen B, Grantcharov TP. Laparoscopic repair of paraesophageal hernia with anterior gastropexy: a multicenter study. Surg Endosc 2014; 29:1856-61. [DOI: 10.1007/s00464-014-3877-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 09/02/2014] [Indexed: 12/18/2022]
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Postoperative Dysphagia in laparoscopic paraesophageal hernia repair: the effect of distal esophageal angulation. Surg Laparosc Endosc Percutan Tech 2014; 23:449-52. [PMID: 24105284 DOI: 10.1097/sle.0b013e31829ce60a] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Dysphagia following laparoscopic paraesophageal hernia repair is an uncommon but difficult problem that may be due to technical factors. We looked for an association between esophageal angulation after posterior crural repair and postoperative dysphagia. MATERIALS AND METHODS Patients undergoing paraesophageal hiatus hernia repair were identified from a prospectively maintained dedicated database. All patients underwent a standardized laparoscopic repair. Essentially the hernia sac was dissected from the mediastinum, a posterior hiatal repair was carried out with interrupted polyester sutures, and augmented with mesh on lay. A partial posterior fundoplication was then carried out. We used the number of posterior sutures as a proxy for anterior esophageal angulation. Quality-of-life data and dysphagia scores were recorded preoperatively, at 6 weeks postoperatively and 12 months postoperatively using validated instruments. RESULTS Between November 2004 and September 2010, 114 consecutive patients underwent paraesophageal hiatus hernia repair. There was 1 postoperative death in the series. Median age was 67 years (interquartile range, 59 to 77 y) and 90 (79%) were female. Median hospital stay was 3 days (interquartile range, 2 to 5 y). Follow-up data were available in 87 (76%) of patients at 6 weeks and 94 (82%) of patients at 12 months postoperation. Overall, there was a significant improvement in quality of life that was sustained out to 12 months (P<0.001). Dakkak dysphagia scores were significantly improved postoperatively. Improvement was sustained out to 12 months (P<0.001). Three patients underwent endoscopic esophageal dilation for dysphagia following surgery. There was no significant correlation between the number of posterior sutures used and dysphagia outcome. Specifically there was no association with overall Dakkak scores or change in Dakkak score. CONCLUSIONS Anterior angulation due to posterior hiatal repair does not result in worsening dysphagia, even in patients with large hiatal defects. A posterior repair should therefore remain the standard approach for hiatal closure.
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11
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Mittal SK, Shah P. Current readings: Failed hiatal hernia repair. Semin Thorac Cardiovasc Surg 2014; 26:331-4. [PMID: 25837548 DOI: 10.1053/j.semtcvs.2015.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2015] [Indexed: 11/11/2022]
Abstract
Recurrent hiatal hernia is noted in up to 70% of patients undergoing reoperative antireflux procedure. Role of short esophagus vis-à-vis a need for Collis gastroplasty, mesh reinforcement of hiatus, and access of surgery (thoracotomy vs laparotomy) have been debated. The aim of this article is to review selected recent publications that address these issues.
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Affiliation(s)
- Sumeet K Mittal
- Department of Surgery, Creighton University, Omaha, Nebraska.
| | - Parth Shah
- Department of Surgery, Creighton University, Omaha, Nebraska
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12
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The choice of primary repair or mesh repair for paraesophageal hernia: a decision analysis based on utility scores. Ann Surg 2013; 257:655-64. [PMID: 23364700 DOI: 10.1097/sla.0b013e3182822c8c] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Controversy exists on the use of mesh in the repair of paraesophageal hernias (PEH). This debate centers around the type of mesh used, its value in preventing recurrence, its short- and long-term complications, and the consequences of those complications compared with primary repair. Decision analysis is a method to account for the important aspects of a clinical decision. The purpose of this study was to determine whether or not the addition of mesh would be superior in PEH repair. METHODS A decision analysis model of the choice between primary repair and mesh repair of a PEH was constructed. The essential features of the decision were the rate of perioperative complications, PEH recurrence rate, reoperation rate after recurrence, rate of symptomatic recurrence, and type of outcome after reoperation. The literature was reviewed to obtain data for the decision analysis and the average rates used in the baseline analysis. A utility score was used as the outcome measure, with a perfect outcome receiving a score of 100 and death 0. Sensitivity analysis was used to determine if changing the rates of recurrence or reoperation changed the dominant treatment. RESULTS Using the baseline analysis, mesh repair was slightly superior to primary repair (utility score 99.59 vs 99.12, respectively). However, if recurrence rates were similar, primary repair would be slightly superior; whereas if reoperation rates were similar, mesh repair would be superior. Using sensitivity analysis, there are combinations of recurrence rates and reoperation rates that would make one repair superior to the other. However, these differences are relatively small. CONCLUSIONS Depending on what the decision-maker accepts as the recurrence and reoperation rates for these types of repair, either mesh or primary repair may be the treatment of choice. However, the differences between the two are small, and, perhaps, clinically inconsequential.
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Hirota M, Nakajima K, Souma Y, Mikata S, Iwase K, Demura K, Takahashi T, Yamasaki M, Miyata H, Kurokawa Y, Takiguchi S, Mori M, Doki Y. Assistive esophagoscopy during laparoscopic surgery for intra-thoracic stomach. Esophagus 2013. [DOI: 10.1007/s10388-013-0367-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
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