Controversies in paraesophageal hernia repair; a review of literature

The value of "diaphragmatic relaxing incision" for the durability of the crural repair in patients with paraesophageal hernia: a double blind randomized clinical trial

Background

Surgical repair of paraesophageal hernias (PEHs) is burdened with high recurrence rates, and hitherto various techniques explored to enforce the traditional crural repair have not been successful. The hiatal reconstruction in PEH is exposed to significant tension, which may be minimized by adding a diaphragmatic relaxing incision to enhance the durability of the crural repair.

Patients and methods

All individuals undergoing elective laparoscopic repair of a large PEH, irrespective of age, were considered eligible. PEHs were classified into types II-IV. The preoperative work-up program included multidetector computed tomography and symptom assessment questionnaires, which will be repeated during the postoperative follow-up. Patients were randomly divided into a control group with crural repair alone and an intervention group with the addition of a left-sided diaphragmatic relaxing incision at the edge of the upper pole of the spleen. The diaphragmatic defect was then covered by a synthetic mesh.

Results

The primary endpoint of this trial was the rate of anatomical PEH recurrence at 1 year. Secondary endpoints included symptomatic gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular and pulmonary symptoms, and patient satisfaction in the immediate postoperative course (3 months) and at 1 year. Postoperative complications, morbidity, and disease burden were recorded for each patient. This was a double-blind study, meaning that the operation report was filed in a locked archive to keep the patient, staff, and clinical assessors blinded to the study group allocation. Blinding must not be broken during the follow-up unless required by any emergencies in the clinical management of the patient. Likewise, the patients must not be informed about the details of the operation.

Trial Registration

ClinicalTrials.gov, identification number NCT04179578.

Surgical Repair of Large Hiatal Hernias: Insight from a High-Volume Center

BACKGROUND

Laparoscopic-assisted hiatal hernia (HH) repair is safe and effective; however, it is unclear whether hernia size affects perioperative outcomes and whether a watch-and-wait strategy is appropriate for patients with asymptomatic large HHs. We aimed to investigate these issues.

METHODS

After IRB approval, we queried our prospectively maintained database for patients who underwent primary laparoscopic HH repair at our center between August 2016 and December 2019. All procedures were performed by a single surgeon (SKM). According to the intraoperative findings, HHs were divided into four groups: small (S-HH), medium (M-HH), large (L-HH), or giant (G-HH) when the percentage of herniated stomach was 0% (sliding), < 50%, 50-75%, or > 75%, respectively. Perioperative and mid-term outcomes were analyzed.

RESULTS

A total of 170 patients were grouped: S-HH (n = 46), M-HH (n = 69), L-HH (n = 20), and G-HH (n = 35) with mean age of 58.5.6 ± 11.0, 61.9 ± 11.3, 70.7 ± 10.3, and 72.6 ± 9.7 years (p < 0.001), respectively. Compared to M-HH patients, L-HH patients had significantly longer hospital stays (mean 2.8 ± 3.2 vs 1.4 ± 0.91 days; p = 0.001) and more postoperative complications (6/20 [30.0%] vs 3/69 [4.3%]; OR 6.9, 95% CI 5.4-8.4, p < 0.001). At a mean follow-up time of 43.1 ± 25.0 and 43.5 ± 21.6 months for the combined S/M-HH and L/G-HH groups, GERD-Health-Related Quality of Life scores were comparable (S/M-HH: 6.5 ± 10.9 vs L/G-HH: 7.1 ± 11.3; p = 0.63). There was no perioperative mortality.

CONCLUSIONS

HHs likely grow with age, reflecting their progressive nature. Laparoscopic L-HH repair was associated with higher morbidity than M-HH repair. Thus, patients with M-HH, even if less symptomatic, should be evaluated by a foregut surgeon. Regardless of HH size, good mid- and long-term quality of life outcomes can be achieved.

Robotic versus laparoscopic surgery for hiatal hernia repair: a systematic literature review and meta-analysis

The number of robotic hiatal hernia repairs (RHHR) is increasing. However, the superiority of this minimally invasive approach remains controversial. The aim of this study was to evaluate the available literature reporting on outcomes of RHHR compared with laparoscopic hiatal hernia repair (LHHR) in adult patients. The design of this systematic review was developed using the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Web of Science, PubMed, the Cochrane Library, and ClinicalTrials.gov databases were searched. Identified publications were reviewed independently by two authors. High heterogeneity was further explored through sensitivity analysis. The primary endpoint was the development of postoperative complications. Secondary endpoints included operation time, intraoperative complications, 30 day readmission rates and length of stay. The analysis was performed using Stata 17.0 software. A total of 7 studies totaling 10078 patients met the inclusion criteria. Five studies included postoperative complications. The postoperative complications rate was 4.25% (302/7111) in the LHHR group, and 3.49% (38/1088) in the RHHR group. Postoperative complications significantly decreased after RHHR compared with LHHR (OR 0.52; 95% CI 0.36 to 0.75, P = 0.000). Three studies involving 2176 patients reported length of hospital stay. In the three studies, the mean Length of hospital stay was 3.2 days in the RHHR group, and 4.2 days in the LHHR group. Length of hospital stay was decreased by a mean of 0.68 days for RHHR compared with LHHR (WMD, - 0.68 days; 95% CI - 1.32 to - 0.03, P = 0.02). There was no significant difference between the RHHR group and the LHHR group regarding operative time, intraoperative complications, and 30 day readmission (P > 0.05). Our research shows that RHHR may be the better option, as the approach decreases postoperative complications and length of hospital stay.

Robotic Hiatal Hernia Repair Associated with Higher Morbidity and Readmission Rates Compared to Laparoscopic Repair: 10-Year Analysis from the National Readmissions Database (NRD)

BACKGROUND

Laparoscopic techniques have been used for hiatal hernia repair. Robotic-assisted repairs have been increasingly used with unproven benefits. The aim of this study was to compare outcomes between laparoscopic and robotic-assisted hiatal hernia repair.

METHODS

The Nationwide Readmissions Database (NRD) was used to identify hospitalizations for laparoscopic or robotic hiatal hernia repair from 2010 to 2019. Primary outcomes included post-operative complications and 30- and 90-day readmission rates. Secondary outcomes included in-hospital death, length of stay, and inflation-adjusted hospital cost. Multivariable models were estimated for overall complication and readmission rates.

RESULTS

Approximately 517,864 hospitalizations met inclusion criteria with 11.3% including robotic repairs. Robotic repair was associated with a higher overall complication rate (9.2% vs. 6.8%, odds ratio [OR]: 1.4, 95% CI: 1.3-1.5, p < .001); however, the trend showed more similar complication rates across years. The higher overall complication rate remained after adjusting for patient and facility characteristics (adjusted OR [aOR]: 1.3, 95% CI: 1.2-1.4, p < .001). Robotic repairs were associated with higher 30-day (6.1% vs. 7.4%, aOR: 1.2, 95% CI: 1.2-1.3, p < .001) and 90-day readmission rates (9.4% vs. 11.2%, aOR: 1.2, 95% CI: 1.2-1.3, p < .001). In-hospital mortality and length of stay were similar, although, higher hospital costs were associated with robotic repairs. Both complications and readmission rates were lower as annual procedural volume increased.

CONCLUSION

Robotic repairs had higher unadjusted and adjusted complication and readmission rates. The overall complication rate has shown a trend towards improvement which may be a result of increasing experience with robotic surgery.

Minimally Invasive Abdominal Repair of a Giant Paraesophageal Hiatal Hernia with Occupation of the Right Thorax in a 53-Year-Old Man

Paraesophageal giant hiatal hernia is a rare condition associated with serious complications if not treated surgically. There are no reports of the minimally invasive abdominal repair of a giant hiatal hernia of the stomach almost entirely occupying the right thoracic cavity. The most common clinical presentation includes pathological gastroesophageal reflux, dysphagia, chest pain, or respiratory symptoms such as chronic cough or dyspnoea. Chest computed tomography, upper gastrointestinal endoscopy, and high-resolution oesophageal manometry are used to indicate the best treatment. This article reports the minimally invasive abdominal repair of a case of paraesophageal giant hiatal hernia occupying the right thoracic cavity.

Observational medical treatment or surgery for giant paraesophageal hiatal hernia in elderly patients

Giant paraesophageal hernias (GPHH) occur frequently in the elderly and account for about 5-10% of all hiatal hernias. Up to now controversy persists between expected medical treatment and surgical treatment. To assess if an indication for surgical repair of GPHH is possible in elderly patients. A prospective study that includes patients over 70 years of age hospitalized from January 2015 to December 2019 with GPHH. Patients were separated into Group A and Group B. Group A consisted of a cohort of 23 patients in whom observation and medical treatment were performed. Group B consisted of 44 patients submitted to elective laparoscopic hiatal hernia repair. Symptomatic patients were observed in both groups (20/23 in Group A and 38/44 in Group B). Charlson's score >6 and ASA II or III were more frequent in Group A. Patients in Group A presented symptoms many years before their hospitalization in comparison to Group B (21.8+7.8 vs. 6.2+3.5 years, respectively) (P=0.0001). Emergency hospitalization was observed exclusively in Group A. Acute complications were frequently observed and hospital stays were significantly longer in Group A, 14 patients were subjected to medical management and 6 to emergency surgery. In-hospital mortality occurred in 13/20 patients (65%) versus 1/38 patients (2.6%) in Group B (P=0.0001). Laparoscopic paraesophageal hiatal hernia repair can be done safely, effectively, and in a timely manner in elderly patients at specialized surgical teams. Advanced age alone should not be a limiting factor for the repair of paraesophageal hernias.

Surgical Interventions in Cases of Esophageal Hiatal Hernias among Older Japanese Adults: A Systematic Review

Background and Objectives: Given Japan's superaging population, an increasing number of older adults in the country need surgical treatment for esophageal hiatal hernias. Accordingly, this systematic review examines surgical interventions for symptomatic esophageal hiatal hernias in older Japanese patients and explores treatment outcomes. Materials and Methods: Articles on single operations for hiatal hernias published after 1991 were found on Google Scholar and Ichushi using specific keywords. Subsequently, articles fulfilling the predetermined inclusion criteria were considered in the study. Results: The mean patient age was 81.4 years, and the male-to-female ratio was 1:11.5. The main reasons for surgery were vomiting, dyspnea, and chest tightness. In terms of hernia classification, type IV was the most common (48%). Surgical modalities were laparoscopy in 15 cases, and laparotomy in 10 cases. Mean postoperative course was 26.47 days until hospital discharge, and there were no cases of perioperative death. Conclusions: Findings showed that multiple factors were involved in older adults' prognoses, and age was not the only biological factor. Therefore, aggressive surgical intervention should be considered for symptomatic older patients, even in the absence of surgery indicators.

When should we use mesh in laparoscopic hiatal hernia repair? A systematic review

The use of mesh in laparoscopic hiatal hernia repair (LHHR) remains controversial. The aim of this systematic review was to determine the usefulness of mesh in patients with large hiatal hernia (HH), obesity, recurrent HH, and complicated HH. We performed a systematic review of the current literature regarding the outcomes of LHHR with mesh reinforcement. All articles between 2000 and 2020 describing LHHR with primary suturing, mesh reinforcement, or those comparing both techniques were included. Symptom improvement, quality of life (QoL) improvement, and recurrence rates were evaluated in patients with large HH, obesity, recurrent HH, and complicated HH. Reported outcomes of the use of mesh in patients with large HH had wide variability and heterogeneity. Morbidly obese patients with HH should undergo a weight-loss procedure. However, the benefits of HH repair with mesh are unclear in these patients. Mesh reinforcement during redo LHHR may be beneficial in terms of QoL improvement and hernia recurrence. There is scarce evidence supporting the use of mesh in patients undergoing LHHR for complicated HH. Current data are heterogeneous and have failed to find significant differences when comparing primary suturing with mesh reinforcement. Further research is needed to determine in which patients undergoing LHHR mesh placement would be beneficial.

Paraesophageal hernia: to fundoplicate or not?

The need for an antireflux procedure during repair of a paraesophageal hernia (PEH) has been the subject of a long-standing controversy. With most centers now performing routine fundoplication during PEH repair, high-quality data on whether crural repair alone or using a mesh may provide adequate anti-reflux effect is still scarce. We sought to answer to the question: "Is fundoplication routinely needed during PEH repair?". Our endpoints were (I) rates of postoperative gastroesophageal reflux disease (GERD) (either symptomatic or objectively assessed), (II) rates of recurrence, and (III) rates of postoperative dysphagia. We searched the MEDLINE, Cochrane, PubMed, and Embase databases for papers published between 1995 and 2019, selecting comparative cohort studies and only including papers reporting the rationale for performing or not performing fundoplication. Overall, nine papers were included for review. While four of the included studies recommended selective or no fundoplication, most of these data come from earlier retrospective studies. Higher-quality data from recent prospective studies including two randomized controlled trials recommended routine fundoplication, mostly due to a significantly lower incidence of postoperative GERD. However, only a relatively short follow-up of 12 months was presented, which we recognize as an important limitation. Fundoplication did not seem to result in reduced recurrence rates when compared to primary repair alone.

Health-related quality of life after laparoscopic repair of giant paraesophageal hernia: how does recurrence in CT scan compare to clinical success?

Background

Computed tomography (CT) is widely used in the diagnosis of giant paraesophageal hernias (GPEH) but has not been utilised systematically for follow-up. We performed a cross-sectional observational study to assess mid-term outcomes of elective laparoscopic GPEH repair. The primary objective of the study was to evaluate the radiological hernia recurrence rate by CT and to determine its association with current symptoms and quality of life.

Methods

All non-emergent laparoscopic GPEH repairs between 2010 to 2015 were identified from hospital medical records. Each patient was offered non-contrast CT and sent questionnaires for disease-specific symptoms and health-related quality of life.

Results

The inclusion criteria were met by 165 patients (74% female, mean age 67 years). Total recurrence rate was 29.3%. Major recurrent hernia (> 5 cm) was revealed by CT in 4 patients (4.3%). Radiological findings did not correlate with symptom-related quality of life. Perioperative mortality occurred in 1 patient (0.6%). Complications were reported in 27 patients (16.4%).

Conclusions

Successful laparoscopic repair of GPEH requires both expertise and experience. It appears to lead to effective symptom relief with high patient satisfaction. However, small radiological recurrences are common but do not affect postoperative symptom-related patient wellbeing.

Safety and Efficacy of Crura Augmentation with Phasix ST Mesh for Large Hiatal Hernia: 3-Year Single-Center Experience

Background: Safety and effectiveness of absorbable meshes for laparoscopic hiatus hernia repair are still debated. This may be due to patient selection, technique of repair, type and shape of mesh, definition of recurrent hernia, and length of follow-up. The aim of this study was to assess safety, short-term efficacy, and quality of life after laparoscopic repair of hiatal hernia reinforced with a biosynthetic absorbable mesh. Materials and Methods: A single-center observational cohort study was conducted in patients with large type III-IV hiatal hernia who underwent laparoscopic crural repair reinforced with Phasix ST^®, a monofilament resorbable mesh (poly-4-hydroxybuterate) with a hydrogel barrier on one side. Patient data were extracted from hospital charts and a prospectively updated research database. Both generic Short Form-36 (SF-36) and disease-specific (Gastro-Esophageal Reflux Disease Health-Related Quality of Life [GERD-HRQL]) questionnaires were used to assess preoperative and postoperative quality of life. Results: From January 2017 to July 2019, 73 consecutive patients were implanted with Phasix ST mesh. The median follow-up was 17 (interquartile range 9-24) months. Recurrent hernia was found in 2 of 62 (3.2%) patients followed for more than 6 months after surgery, but none required reoperation. The overall postoperative morbidity rate was 8.2%. No mesh-related complications occurred. Compared to baseline, there was a statistically significant improvement of all items of the SF-36 questionnaire (P < .001) and of the median GERD-HRQL score (P < .001). Conclusion: The use of Phasix ST mesh to reinforce crural repair for large hiatus hernias is safe, is effective in the short-term follow-up, and is associated to improved quality of life.

The other explanation for dyspnea: giant paraesophageal hiatal hernia repair routinely improves pulmonary function

Paraesophageal hiatal hernias (PEHs) are most commonly associated with gastrointestinal symptoms; less widely appreciated is their potentially important influence on respiratory function. We hypothesize that surgical repair of PEH will significantly improve not only gastrointestinal symptoms, but also preoperative dyspnea and spirometry scores. A prospective Institutional Review Board-approved database was used to review all patients undergoing PEH repair from 2000 to 2016. Patients with pre- and postoperative pulmonary function tests assessed by spirometry were included. Postoperative changes in spirometry measurements were compared to PEH size as reflected by the percentage of intrathoracic stomach observed on preoperative contrast studies. Patients were stratified according to improvement in forced expiratory volume in 1 second (FEV1). Patients with >12% ('significant') improvement in FEV1 after surgery were compared to the remaining patient population. In total, 299 patients met the inclusion criteria. Symptomatic improvement in respiratory function was noted in all patients after PEH repair. Age, gender, BMI, presenting symptoms, Charlson comorbidity index as well as preoperative comorbidities did not significantly impact the functional outcome. Spirometry results improved in 80% of the patients, 21% of whom showed an improvement of >20% compared to the preoperative level. 'Significant' improvement in respiratory function was seen in 122 of 299 (41%) patients. Patients presenting with moderate and severe preoperative pulmonary obstruction demonstrated 'significant' improvement in FEV1 in 48% and 40% of cases, respectively. Large PEHs, characterized by a percentage of intrathoracic stomach >75%, was strongly associated with 'significant' improvement in FEV1 (P = 0.001). PEHs can impact subjective and objective respiratory status and surgical repair can result in a significant improvement in dyspnea and pulmonary function score that is independent of preoperative pulmonary disease. Gastric herniation of more than 75% was associated with higher possibility for improvement of pulmonary function tests. Patients with persistent and unexplained dyspnea and coexistent PEH should be assessed by an experienced surgeon for consideration of elective repair.

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)

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.

A Safe and Effective Technique of Paraesophageal Hernia Reduction Using Combined Laparoscopy and Nonsutured PEG Gastropexy in High-Risk Patients

BACKGROUND

Paraesophageal hernias (PHs) can cause significant morbidity and even mortality in untreated patients. While formal surgical repair remains the ideal treatment option, patients who are elderly and/or frail and who have with multiple comorbidities may be unsuitable candidates for a surgical repair. We present a case series of 5 patients treated with a combined laparoscopic reduction of PH and 2-point percutaneous endoscopic gastropexy (PEG).

METHODS

Data on the 5 patients were collated, and a review of the literature was performed to determine similar cases and outcomes.

RESULTS

Five elderly patients (mean age 80 y, range 71-89 y) with significant existing comorbidities (average ASA 3) presented acutely with large PH at our institution. All had abdominal pain, nausea/vomiting, symptoms of gastric outlet obstruction, and an element of hypoxia. Computed tomography examination results confirmed the diagnosis. Because the patients were elderly and frail, a formal surgical repair of the PHs was not feasible. A combined laparoscopy/PEG gastropexy was undertaken to reduce the PH, and a 2-point PEG fixation was performed. Four of the 5 patients returned to normal oral intake before discharge. A fifth patient was successfully fed via the PEG. There were no complications, and all were discharged to their usual place of residence.

CONCLUSION

A combination of laparoscopic reduction and nonsutured PEG gastropexy is a safe and effective alternative treatment for high-risk patients (with significant morbidity and mortality) with symptomatic PHs. Most patients (80%) returned to normal oral intake postprocedure and were discharged home within 3 d.

Role of fundoplication in treatment of patients with symptoms of hiatal hernia

Gastroesophageal reflux disease (GERD) is often associated with hiatal hernia (HH). However, the need for fundoplication during hiatal hernia repair (HHR) remains controversial. The objective of this study was to evaluate the effect of HHR with concomitant laparoscopic Nissen fundoplication (HHR-LNF) in HH patients. A total of 122 patients with symptomatic HH were randomized to receive either HHR (n = 61) or HHR-LNF (n = 61). The measures of evaluating outcomes included DeMeester scores (DMS), complications, Reflux Diagnostic Questionnaire and patients' satisfaction 24 months following surgery. Despite comparable values in both groups at randomization, the DMS, total numbers of reflux episodes and percentage of time with pH < 4 were significantly higher in HHR group than in HHR-LNF group (P = 0.017, P = 0.002 and P = 0.019, respectively) at 6 months after surgery. One months postoperatively, complications were higher in the HHR-LNF group than in the HHR group (all P < 0.001), and there was no difference between the two groups at 6 months. By the end of the 2-year follow-up, HHR-LNF group showed a significantly lower reflux syndrome frequency-intensity score and greater percentage of satisfaction compared with HHR group (all P < 0.001). Laparoscopic HHR should be combined with a fundoplication in GERD patients with HH. HHR-LNF is safe and effective, not only improve reflux-related symptom, but also reduce the incidence of complications.

Congenital paraesophageal hernia: Contemporary results and outcomes of laparoscopic approach to repair in symptomatic infants and children

BACKGROUND

Congenital paraesophageal hernia (CPEH) is a rare diaphragmatic anomaly for which repair has primarily been described by laparotomy, although, more recent case series describe laparoscopic repair. In reports with over five patients, the predominant approach has been with laparotomy. The purpose of our study was to review our recent institutional experience and results with exclusively laparoscopic repair of CPEH in infants and children.

METHODS

An IRB approved retrospective review of all patients with CPEH who underwent laparoscopic treatment at a tertiary children's hospital from 2010 to 2017 was performed. We included only those patients from our own institution with primary CPEH, or CPEH with prior repair (s) at other centers, with recurrence presenting for operation. Data including demographics, diagnostic studies, operative details, complications, outcomes, and follow up were analyzed. Age at diagnosis was 1 day to 25 years of age (mean 2.5 years).

RESULTS

A total 28 patients underwent 30 operations to treat CPEH. All operations were completed laparoscopically with no conversions to open. There were 6 Type II, 16 Type III, and 6 Type IV CPEH patients. Seventeen patients were less than one year of age (61%). Weight at time of repair was 10.3 kg (1.2-44 kg). Twelve patients were less than 5 kg (43%), eight patients (28.5%) were less than 10 kg, and 8 were more than 10 kg (28.5%). Operative time averaged 125 min (range 61-247 min). Three patients underwent initial CPEH repair (s) (open: 2 and laparoscopic: 1) at other institutions before laparoscopic revision was performed at our hospital (11%). Crural repair was performed in all patients, fundoplication in 26 (93%) and concomitant gastrostomy was performed in 14 patients (50%). Complications included two patients with recurrent hiatal hernias, which were redone laparoscopically (2/28 or 7% recurrence) and 1 capnothorax requiring pigtail drainage postoperatively. There were no deaths, no requirement for esophageal dilations, or esophageal lengthening. One patient required laparoscopic gastrostomy six weeks post initial repair for failure to thrive. Follow-up ranged from 4 months to 8 years (average 36 months).

CONCLUSION

Congenital paraesophageal hernia in infants and children is uncommon. Based on our experience, the laparoscopic approach to repair is feasible, even for neonates, with excellent results, acceptably low recurrence rate, and may even be considered for revisional operations.

STUDY TYPE

Clinical research paper.

LEVEL OF EVIDENCE

Type IV.

Perioperative Outcomes and Quality of Life after Repair of Recurrent Hiatal Hernia are Compromised Compared with Primary Repair

Paraesophageal hernia repair (PEHR) is burdened by high recurrence rates that frequently lead to redo PEHR. Revisional surgery, because of higher complexity, higher risk of injury, and the intrinsic risk of recurrence, has increased likelihood of higher complication rates and decreased quality of life (QOL) postoperatively. We aimed to compare perioperative outcomes and QOL after revisional and primary PEHR. A retrospective review of all patients who underwent PEHR for a recurrent hernia between January 2011 and July 2016 was completed. These were matched with a contemporary cohort of patients who underwent primary PEHR by age, gender, and BMI. Perioperative measures were compared. The patients were invited to complete the Gastrointestinal Quality of Life Index (GIQLI) to assess response to surgical intervention. There were 24 patients (group 1) who underwent revisional PEHR, and they were matched to 48 patients (group 2) who had a primary hernia repair. Thirteen patients in group 1 responded to the survey (54%), whereas 21 patients’ responses were received from group 2 (44%). Conversion rates, LOS, and mean Gastrointestinal Quality of Life Index scores were significantly different between the two groups. Reoperative procedures for paraesophageal and hiatal hernias are burdened by higher conversion rates and length of stay, with similar overall complication rates. Patients who are undergoing repair of a recurrent hernia should be preoperatively counseled, and should have realistic expectations of their GI QOL after surgery.

Evidence-Based Practice Guideline for Surgical Treatment of Gastroesophageal Reflux Disease 2018

The prevalence of gastroesophageal reflux disease (GERD) is increasing in Korea, and physicians, including surgeons, have been focusing on its treatment. Indeed, in Korea, medical treatment using a proton pump inhibitor is the mainstream treatment for GERD, while awareness of surgical treatment is limited. Accordingly, to promote the understanding of surgical treatment for GERD, the Korean Anti-Reflux Surgery Study Group published the Evidence-Based Practice Guideline for the Surgical Treatment of GERD. The guideline consists of 2 sections: fundamental information such as the definition, symptoms, and diagnostic tools of GERD and a recommendation statement about its surgical treatment. The recommendations presented 5 debates regarding fundoplication: 1) comparison of the effectiveness of medical and surgical treatments, 2) effectiveness of surgical treatment in cases of refractory GERD, 3) effectiveness of surgical treatment of extraesophageal symptoms, 4) comparison of effectiveness between total and partial fundoplication, and 5) effectiveness of fundoplication in cases of hiatal hernia. The present guideline is the first to demonstrate the efficacy of the surgical treatment GERD in Korea.

SURGICAL TACTICS FOR LARGE AND GIANT ESOPHAGEAL HIATAL HERNIA

The  OBJECTIVE  is to improve  the  results of surgical  treatment of patients with large  and  giant  EHH. MATERIAL AND METHODS.  We  present our  experience of surgical  treatment of 25  patients with large  and  giant  EHH, who  underwent laparoscopic  interventions according to  the  original  technique, which  consisted in the  method of plasty  of esophageal hiatus:   the   mesh  implant   was   installed   and   fixed  in  the   posterior  mediastinum  above  the   diaphragm.  RESULTS. Intraoperative  bleeding  was   noted   in  2  (8  %)  patients,  which  did  not  require   conversion.  In  the  near   postoperative period,   no  complications  were  noted.   In  the  long-term   periods from  1  to  5  years, there   was  no  recurrence of  EHH and  complications associated  with the  use   of mesh implant.  CONCLUSION.  Videoendosurgical  interventions  are  the operations  of  choice  in  the  treatment  of  patients  with  large  and  giant  EHH.  The  most  effective  method  of  plasty for  large  and  giant  EHH  is  the  combined plasty  of  the  esophageal hiatus   by  a  mesh implant  in  combination  with  a posterior  cruroraphy,  with  the  installation   and   fixation  of  the  mesh implant  in  the  posterior mediastinum above  the cruses of diaphragm.

Acute Paraesophageal Hernia: Laparoscopic Repair With Adjunct T-Fastener Gastropexy for the High Operative Risk Patient

BACKGROUND

In the emergent setting, most paraesophageal hernia (PEH) repairs are done by laparotomy with adjunct gastropexy or gastrostomy tube (GT) placement. This adjunct to the repair can be performed expeditiously by a laparoscopic approach by utilizing T-fasteners. We present our case series of patients with PEHs and acute gastric volvulus that were managed with laparoscopy and how patient characteristics can influence the repair technique.

METHODS

Patients with high operative risk who underwent laparoscopic hiatal hernia repair with adjunct T-fastener gastropexy in the emergent setting between July 2014 and July 2016 were included in this study.

RESULTS

Thirteen patients underwent successful PEH repair and all were classified as urgent/emergent upon admission. In total, 30.7% were performed laparoscopically. The median patient age was 84 years. A laparoscopic GT or gastropexy was performed for fixation of the stomach. Crural closure by an anterior cruroplasty was performed in all patients. There were no mortalities. One patient required conversion of gastropexy into a GT given symptoms of dysphagia. Prolonged length of stay was related to postdischarge institutionalization. All patients remained free of obstructive symptoms.

CONCLUSIONS

Laparoscopic PEH repair with adjunct gastropexy or GT placement should be considered in emergent cases for elderly patients with predominately obstructive symptoms. Laparoscopy for PEH repair is challenging and requires technical skills. T-fastener gastropexy or GT placement is safe, simple, and obviates the need for intracorporeal suturing. It also may be used to improve physician comfort with laparoscopy and to expedite the repair in this high-risk population.

Contribution of hiatal hernia to asthma in patients with gastroesophageal reflux disease

BACKGROUND

To determine the correlation between asthma and hiatal hernia (HH) in patients with gastroesophageal reflux disease (GERD)-related asthma requiring laparoscopic anti-reflux surgery.

METHODS

One hundred and thirty-six GERD patients with medically refractory asthma with (80 patients) or without HH (56 patients) were enrolled. Gastroesophageal reflux disease was assessed by endoscopy, esophageal manometry, reflux monitoring and symptom questionnaires, and treated with laparoscopic Nissen fundoplication (LNF) or LNF with concomitant hiatal hernia repair (LNF-HHR). The outcome measures included patients' satisfaction and drug independence.

RESULTS

The patients with HH had lower esophageal sphincters (P = .005) and higher DeMeester scores (P = .014) than those without HH. After an average follow-up of 24 months, symptom scores were significantly decreased from the preoperative values (P < .05). Compared to LNF, LNF-HHR showed a better improvement in both esophageal and asthmatic symptoms (P < .0001 and P = .016, respectively).

CONCLUSIONS

The patients with GERD with asthma have a high prevalence of HH. The presence of HH maybe correlated with asthma and severe GERD. Actively treating HH not only improved reflux, but also controlled asthma symptoms.

What are the differences in the outcome of laparoscopic axial (I) versus paraesophageal (II-IV) hiatal hernia repair?

INTRODUCTION

Comparison of elective laparoscopic repair of axial vs paraesophageal hiatal hernias reveals relevant differences in both the patient collectives and the complexity of the procedures.

MATERIALS AND METHODS

The present uni- and multivariable analysis of data from the Herniamed Registry compares the outcome for 2047 (67.3%) (type I) axial with 996 (32.7%) (types II-IV) paraesophageal primary hiatal hernias following laparoscopic repair.

RESULTS

Compared with the patients with axial hiatal hernias, patients with paraesophageal hiatal hernia were nine years older, had a higher ASA score (ASA III/IV: 34.8 vs 13.7%; p < 0.001), and more often at least one risk factor (38.8 vs 21.4%; p < 0.001). This led in the univariable analysis to significantly more general postoperative complications (6.0 vs 3.0%; p < 0.001). Reflecting the greater complexity of the procedures used for laparoscopic repair of paraesophageal hiatal hernias, significantly higher intraoperative organ injury rates (3.7 vs 2.3%; p = 0.033) and higher postoperative complication-related reoperation rates (2.1 vs 1.1%; p = 0.032) were identified. Univariable analysis did not reveal any significant differences in the recurrence and pain rates on one-year follow-up. Multivariable analysis did not find any evidence that the use of a mesh had a significant influence on the recurrence rate.

CONCLUSION

Surgical repair of paraesophageal hiatal hernia calls for an experienced surgeon as well as for corresponding intensive medicine competence because of the higher risks of general and surgical postoperative complications.

Treatment of giant paraesophageal hernia: pro laparoscopic approach

PURPOSE

Giant paraesophageal hernias (GPEH) are relatively uncommon and account for less than 5% of all primary hiatal hernias. Giant Secondary GPEH can be observed after surgery involving hiatal orifice opening, such as esophagectomy, antireflux surgery, and hiatal hernia repair. Surgical treatment is challenging, and there are still residual controversies regarding the laparoscopic approach, even though a reduced morbidity and mortality, as well as a shorter hospital stay have been demonstrated.

METHODS

A Pubmed electronic search of the literature including articles published between 1992 and 2016 was conducted using the following key words: hiatal hernia, paraesophageal hernias, mesh, laparoscopy, intrathoracic stomach, gastric volvulus, diaphragmatic hernia.

RESULTS

Given the risks of non-operative management, GPEH surgical repair is indicated in symptomatic patients. Technical steps for primary hernia repair include hernia reduction and sac excision, correct repositioning of the gastroesophageal junction, crural repair, and fundoplication. For secondary hernias, the surgical technique varies according to hernia type and components and according to the approach used during the first surgery. There is an ongoing debate regarding the best and safest method to close the hiatal orifice. The laparoscopic approach has demonstrated a lower postoperative morbidity and mortality, and a shorter hospital stay as compared to the open approach. A high recurrence rate has been reported for primary GPEH repair. However, recent studies suggest that recurrence does not reduce symptomatic outcomes.

CONCLUSIONS

The laparoscopic treatment of primary and secondary GPEH is safe and feasible in elective and emergency settings, especially in high-volume centers. The procedure is still challenging. The main steps are well defined. However, there is still room for improvement to lower the recurrence rate.

Long-term clinical outcomes after intrathoracic stomach surgery: a decade of longitudinal follow-up

BACKGROUND

A subset of patients with large paraesophageal hernias have more than 75% of the stomach herniated above the diaphragm; such cases are referred to as intrathoracic stomach (ITS). Herein, we report longitudinal symptomatic outcomes over a decade after surgical ITS repair in a large patient cohort.

METHODS

Patients who underwent surgical treatment for ITS from 01/2004 to 05/2016 were studied. Preoperative and follow-up data were prospectively collected. Patients completed a standardized symptom questionnaire 1 year postoperatively and at 2-year intervals thereafter.

RESULTS

In total, 235 patients were reviewed. The mean age was 70.0 ± 11.6 years; 174 patients (74.0%) were women. Surgical procedures included 7 transthoracic repairs and 228 transabdominal repairs (222 laparoscopic, 2 open, 4 laparoscopic-to-open conversions). Anti-reflux procedures were performed in 173 patients (73.6%). 33 patients (14.0%) had mesh reinforcement of hiatal closure; 11 (4.7%) underwent Collis gastroplasty. Follow-up symptom questionnaires at 1, 3, 5, 7, 9, and 11 years were available for 81, 48, 47, 30, 33, and 38% of patients, respectively. Significant and lasting symptom improvement was reported at all follow-up time points. Mean satisfaction scores of 9.3, 9.1, 9.3, 9.0, 9.5, and 9.8 on a 1-10 scale were recorded at the aforementioned intervals.

CONCLUSIONS

Long-term clinical outcomes confirm that laparoscopic ITS repair is safe and durable, and is associated with a high degree of patient satisfaction and symptom resolution.

A collective review of biological versus synthetic mesh-reinforced cruroplasty during laparoscopic Nissen fundoplication

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.

Modern diagnosis and treatment of hiatal hernias

PURPOSE

Hiatal hernias are a common finding on radiographic or endoscopic studies. Hiatal hernias may become symptomatic or, less frequently, can incarcerate or become a volvulus leading to organ ischemia. This review examines latest evidence on the diagnostic workup and management of hiatal hernias.

METHODS

A literature review of contemporary and latest studies with highest quality of evidence was completed. This information was examined and compiled in review format.

RESULTS

Asymptomatic hiatal and paraesophageal hernias become symptomatic and necessitate repair at a rate of 1% per year. Watchful waiting is appropriate for asymptomatic hernias. Symptomatic hiatal hernias and those with confirmed reflux disease require operative repair with an anti-reflux procedure. Key operative steps include the following: reduction and excision of hernia sac, 3 cm of intraabdominal esophageal length, crural closure with mesh reinforcement, and an anti-reflux procedure. Repairs not amenable to key steps may undergo gastropexy and gastrostomy placement as an alternative procedure.

CONCLUSIONS

Hiatal hernias are commonly incidental findings. When hernias become symptomatic or have reflux disease, an operative repair is required. A minimally invasive approach is safe and has improved outcomes.

Crura augmentation with Bio-A® mesh for laparoscopic repair of hiatal hernia: single-institution experience with 100 consecutive patients

BACKGROUND

The potential utility of both non-absorbable and absorbable meshes to reinforce the esophageal hiatus and prevent recurrent hernia has been investigated in observational studies and a few randomized clinical trials. Use of absorbable mesh has been associated with lesser side-effects, but the long-term safety and effectiveness are still debated. This rather scanty clinical evidence is due to heterogeneity and bias regarding the type of mesh and operation used, the modalities of follow-up, and the reporting of objective results.

OBJECTIVES

The aim of the study was to assess safety, quality of life, and recurrence-free probability after laparoscopic repair of hiatal hernia reinforced with a synthetic absorbable mesh.

METHODS

Observational, retrospective, single-center cohort study. All patients with hiatal hernia who underwent laparoscopic crura repair using a biosynthetic mesh (Gore Bio A^® tissue reinforcement, Flagstaff, AZ) were included. Pre- and post-operative symptoms were assessed with the GERD-HRQL questionnaire. Objective follow-up consisted of upper gastrointestinal endoscopy and barium swallow study.

RESULTS

From September 2011 to March 2016, a total of 100 patients underwent hiatal hernia repair using a Bio-A^® mesh. All surgical procedures were completed laparoscopically. Postoperative morbidity rate was 10%. All patients had a minimum follow-up of 6 months, and the median follow-up was 30 (IQR = 22) months. No mesh-related complications occurred. The incidence of recurrent hernia ≥2 cm was 9%, and eight of the nine patients had a preoperative type III hernia. The median GERD-HRQL score was significantly reduced after operation (p < 0.001). The recurrence-free probability at 1 and 5 years was, respectively, 0.99 (CI 0.97-1.00) and 0.84 (CI 0.74-0.97), and no reoperation was required. No association was found between age, BMI, hernia size, previously failed surgical repairs and hernia recurrence.

CONCLUSIONS

The use of a synthetic absorbable mesh to reinforce the esophageal hiatus is safe and appears to be effective and durable over a medium-term follow-up.

The Optimal Approach to Symptomatic Paraesophageal Hernia Repair: Important Technical Considerations

While the asymptomatic paraesophageal hernia (PEH) can be observed safely, surgery is indicated for symptomatic hernias. Laparoscopic repair is associated with decreased morbidity and mortality; however, it is associated with a higher rate of radiologic recurrence when compared with the open approach. Though a majority of patients experience good symptomatic relief from laparoscopic repair, strict adherence to good technique is critical to minimize recurrence. The fundamental steps of laparoscopic PEH repair include adequate mediastinal mobilization of the esophagus, tension-free approximation of the diaphragmatic crura, and gastric fundoplication. Collis gastroplasty, mesh reinforcement, use of relaxing incisions, and anterior gastropexy are just a few adjuncts to basic principles that can be utilized and have been widely studied in recent years. In this article, we present a comprehensive review of literature addressing key aspects and controversies regarding the optimal approach to repairing paraesophageal hernias laparoscopically.

Simultaneous thoraco-laparoscopic repair of giant hiatal hernias: an alternative approach

Laparoscopic repair of giant hiatal hernias with intrathoracic displacement of organs is recommended to relieve troublesome symptoms in patients. During this procedure, incomplete excision of the hernia sac from the mediastinum and omission of creating a 'non-tension-free position' of the cardio-esophageal junction into the abdominal cavity are associated with hiatal hernia recurrence. Giant hiatal hernias therefore often require a thoracotomy or thoracoscopy, to free dense adhesions higher up the chest. These procedures may increase the risk of perioperative morbidity due to lengthy operating times. We developed an operation procedure for giant hiatal hernia repair containing all the benefits of minimal invasive surgery, with overview of both thoracic and abdominal herniated structures. Three patients with a giant hiatal hernia were treated by a simultaneous thoraco-laparoscopic approach, which proved to be technically feasible and safe. Simultaneous thoraco-laparoscopic hernia repair can be considered a reasonable treatment option in selected cases such as type IV hernias, hernia recurrence or traumatic diaphragmatic herniation.

Gasless laparoscopic surgery plus abdominal wall lifting for giant hiatal hernia-our single-center experience

Giant hiatal hernia (GHH) comprises 5% of hiatal hernia and is associated with significant complications. The traditional operative procedure, no matter transthoracic or transabdomen repair of giant hiatal hernia, is characteristic of more invasion and more complications. Although laparoscopic repair as a minimally invasive surgery is accepted, a part of patients can not tolerate pneumoperitoneum because of combination with cardiopulmonary diseases or severe posterior mediastinal and neck emphesema during operation. The aim of this article was to analyze our experience in gasless laparoscopic repair with abdominal wall lifting to treat the giant hiatal hernia. We performed a retrospective review of patients undergoing gasless laparoscopic repair of GHH with abdominal wall lifting from 2012 to 2015 at our institution. The GHH was defined as greater than one-third of the stomach in the chest. Gasless laparoscopic repair of GHH with abdominal wall lifting was attempted in 27 patients. Mean age was 67 years. The results showed that there were no conversions to open surgery and no intraoperative deaths. The mean duration of operation was 100 min (range: 90-130 min). One-side pleura was injured in 4 cases (14.8%). The mean postoperative length of stay was 4 days (range: 3-7 days). Median follow- up was 26 months (range: 6-38 months). Transient dysphagia for solid food occurred in three patients (11.1%), and this symptom disappeared within three months. There was one patient with recurrent hiatal hernia who was reoperated on. Two patients still complained of heartburn three months after surgery. Neither reoperation nor endoscopic treatment due to signs of postoperative esophageal stenosis was required in any patient. Totally, satisfactory outcome was reported in 88.9% patients. It was concluded that the gasless laparoscopic approach with abdominal wall lifting to the repair of GHH is feasible, safe, and effective for the patients who cannot tolerate the pneumoperitoneum.

Subjective outcome after laparoscopic hiatal hernia repair for intrathoracic stomach

PURPOSE

For decades, an intrathoracic stomach (ITS) has been a definite indication for surgery due to the perceived risk of an acute volvulus with perforation, gangrene, or hemorrhage. At the present time, elective laparoscopic repair is the first choice for treatment of ITS. There is a lack of evidence in the long-term quality of life after a hiatal hernia repair for an intrathoracic stomach.

METHODS

A retrospective analysis was performed on all patients undergoing a hiatal hernia repair for an intrathoracic stomach between January 2004 and January 2015. Additionally, to a hiatal closure, the patients received an antireflux procedure. Outcome measures included patient characteristics, operative details, complications, and postoperative morbidity and mortality. All patients were sent a quality of life questionnaire to assess long-term quality of life and patient satisfaction. A higher quality of life score represents a better quality of life.

RESULTS

Eighty-six patients underwent laparoscopic repair for ITS, from which, one patient died during surgery. Eighty-five patients were contacted and 81 completed the questionnaire, resulting in a response rate of 95.3 %. At a median follow-up of 2.7 years (range 0.1-9.6), the mean quality of life score was 13.5 (standard deviation 2.8). The mean overall satisfaction was 8.4. There were four recurrences: three in the first 12 days after surgery and one in 2.4 years.

CONCLUSIONS

Very good results in patient satisfaction and symptom reduction were achieved after a median follow-up of 2.7 years in this laparoscopic repair of the intrathoracic stomach single center experience study. The symptomatic recurrence rate was very low.

Medium-term durability of giant hiatus hernia repair without mesh

Introduction This is the second report on objective review of 100 patients who underwent composite fundoplication-cardiopexy for repair of giant hiatus hernia (GHH) at a median of 24 months following surgery. Outcomes were objective follow-up by endoscopy and quality of life (QoL) by Gastrointestinal Quality of Life Index (GIQLI), modified Visick scores and dysphagia scores. The initial report for this cohort suggested a low objective recurrence rate (9%) and substantial improvements in QoL indices. Methods The rate of hernia recurrence was assessed with Kaplan-Meier analysis and covariates were analysed with the Cox proportional hazards model. Paired t-tests and related samples Wilcoxon signed-rank tests were used to compare QoL scores. Unpaired data were compared with the independent samples t-test and Mann-Whitney U test. Results Objective review was obtained in 97% of the patients. There were five recurrences of hernias that had a vertical height of >2cm from the diaphragmatic hiatus, with three patients requiring reoperation for severe dysphagia. Small recurrences (<2cm) occurred in 20 patients. The median time to recurrence was 40 months (95% confidence interval: 34-46 months). At two years, recurrence of any size had occurred in 24% of cases. At follow-up review (median: 27 months), the mean GIQLI score was 109 (p=0.279), the median modified Visick score was 2 (p=0.954) and the median dysphagia score was 41 (p=0.623). There was no evidence that the GIQLI score (p=0.089), the modified Visick score (p=0.339) or the dysphagia score (p=0.445) changed significantly after recurrence. Conclusions There was a sustained improvement in overall QoL and reflux scores after GHH repair. QoL scores showed persistent improvement in reflux and overall health, even in the subgroup with recurrence. The majority (80%) of recurrences were small and recurrent herniation did not appear to significantly change QoL. The rates of recurrence and QoL are comparable with those for other methods of repair.

Symptom Relief After Laparoscopic Paraesophageal Hernia Repair Without Mesh

BACKGROUND

Laparoscopic repair of paraesophageal hernia (LPEHR) is considered today the standard of care for this condition. While attention has been mostly focused on the incidence of postoperative radiologic recurrence of a hiatal hernia, few data are available about the effect of the operation on symptoms.

AIMS

In this study, we aim to determine the effect of primary LPEHR on postoperative symptoms.

PATIENTS AND METHODS

One hundred and sixty-two patients underwent LPEH repair in two academic tertiary care centers. Preoperative evaluation included barium swallow (100 %), endoscopy (80 %), manometry (81 %), and pH monitoring (25 %). Type III PEH was the most common (94 %), and it was associated with a gastric volvulus in 27 % of patients.

RESULTS

A fundoplication was performed in all patients: Nissen in 57 %, Dor in 36 %, and Toupet in 6 %. A Collis gastroplasty was added in 6 % of patients. There were no perioperative deaths. The intraoperative complication rate was 7 %. The operation was completed laparoscopically in 98 % of patients. Postoperative complications occurred in four patients, and three needed a second operation. Average follow-up was 24 months. Heartburn, regurgitation, chest pain, dysphagia, respiratory symptoms, and hoarseness improved as a result of the operation. Anemia fully resolved in all patients.

CONCLUSIONS

LPEH repair is safe and effective, and the need for reoperation is rare. Few patients experience postoperative symptoms, and these are easily controlled with acid-reducing medications.

Surgery for Type III-IV hiatal hernia: anatomical recurrence and global results after elective treatment of short oesophagus with open and minimally invasive surgery

OBJECTIVES

Type III-IV hiatal hernia (HH) is associated with a true short oesophagus in more than 50% of cases; dedicated treatment of this condition might be appropriate to reduce the recurrence rate after surgery. A case series of patients receiving surgery for Type III-IV hernia was examined for short oesophagus, and the results were analysed.

METHODS

From 1980 to 1994, 60 patients underwent an open surgical approach, and the position of the oesophago-gastric junction was visually localized; from 1995 to 2013, 48 patients underwent a minimally invasive approach, and the oesophago-gastric junction was objectively localized using a laparoscopic-endoscopic method. The patients underwent a timed clinical-instrumental follow-up that included symptoms assessment, barium swallow and endoscopy. The results were considered to be excellent in the absence of symptoms and oesophagitis; good, if symptoms occurred two to four times a month in the absence of oesophagitis; fair, if symptoms occurred two to four times a week in the presence of hyperaemia, oedema and/or microscopic oesophagitis; and poor, if symptoms occurred on a daily basis in the presence of any grade of endoscopic oesophagitis, HH of any size or type, or the need for antireflux medical therapy. The follow-up time was calculated from the time of surgery to the last complete follow-up.

RESULTS

Among the open surgery patients, 78% underwent abdominal fundoplication, 10% the Belsey Mark IV procedure, 8% laparotomic Collis-Nissen fundoplication and 3% the Pearson operation. Among the minimally invasive surgery patients, 44% underwent a laparoscopic floppy Nissen procedure and 56% a left thoracoscopic Collis-laparoscopic Nissen procedure. The postoperative mortality and complication rates were 1.6% (1/60) and 15% for open surgery and 4.1% (2/48) and 12.5% for minimally invasive surgery. A total of 105 patients were followed up for a median period of 96 months. Five relapses occurred after open surgery (5/59, 8%) and two after minimally invasive surgery (2/46, 4%). Among the 105 patients, excellent, good, fair and poor outcomes were observed in 38%, 44%, 9% and 9%, respectively.

CONCLUSIONS

These data suggested that the selective treatment of short oesophagus in association with a Type III-IV hernia reduced the anatomical recurrence rate and achieved satisfactory outcomes.

CLINICALTRIALSGOV ID

NCT01606449.

Paraesophageal hernia

The treatment of PEHs is challenging. They tend to occur in patients in their 60s and 70s with multiple medical problems and a variety of associated symptoms. Detailed preoperative evaluation is crucial to determining a safe and effective strategy for repair in the operating room. Laparoscopic PEH repair has shown to be advantageous compared with conventional open repair with regard to hospital stay, recovery time, and decreased complications. Although some results indicate there are higher recurrence rates in laparoscopic PEH repair, the clinical significance of these recurrences has not yet been determined. In order to maximize the efficacy of this procedure, modifications have emerged, such as performing a fundoplication and using an absorbable mesh onlay to reinforce the cruroplasty. Althoughmoreprospective, randomized studies are needed to support the superior results of these surgical adjuncts, laparoscopic PEH repair with an antireflux procedure and absorbable mesh should be the current standard of care.

Paraesophageal hernia repair in the emergency setting: is laparoscopy with the addition of a fundoplication the new gold standard?

BACKGROUND

Laparoscopic repair of paraesophageal hernia (PEH) with fundoplication is currently the preferred elective strategy, but emergent cases are often done open without an anti-reflux (AR) procedure. This study examined PEH repair in elective and urgent/emergent settings and investigated patient characteristic influence on the use of adjunctive techniques, such as AR procedures or gastrostomy tube (GT) placement.

METHODS

Utilizing the University HealthSystem Consortium Clinical Database Resource Manager, selected discharge data were retrieved using International Classification of Disease 9 diagnosis codes for PEH and procedure specific codes. Chi-squared and paired t tests were applied (α = 0.05).

RESULTS

Discharge data from October 2010 through June 2014 indicated 7950 patients (≥18 years) underwent PEH surgery, 84.7 % were performed laparoscopically and 15.3 % open. 24.6 % of cases were classified urgent/emergent upon admission, and almost 70 % of these were completed laparoscopically. Open paraesophageal hernia repairs (OHR) represented a higher proportion of urgent/emergent cases but were only 30 % of this total. Laparoscopic paraesophageal hernia repair (LHR) patients were more likely to receive an AR procedure in all situations (54.9 % LHR vs. 26.3 % OHR). Almost 90 % of elective PEH repairs in this cohort were laparoscopic. Elective cases were more commonly associated with AR procedures than emergent cases which frequently incorporated GT placement.

CONCLUSION

We demonstrate that laparoscopic PEH repair has become accepted in emergent cases. Open PEH repair is often reserved for emergent surgeries and less commonly includes an AR procedure. Laparoscopy with an AR procedure is clearly the standard of care in elective surgery. The decision to perform an open or laparoscopic surgery, with or without adjunctive techniques, may be based more on the physician's comfort with laparoscopic surgery and surgical practices than the patient's condition. Long-term follow-up studies are needed to determine the functional outcomes of these strategies.

Treatment and controversies in paraesophageal hernia repair

Background

Historically all paraesophageal hernias were repaired surgically, today intervention is reserved for symptomatic paraesophageal hernias. In this review, we describe the indications for repair and explore the controversies in paraesophageal hernia repair, which include a comparison of open to laparoscopic paraesophageal hernia repair, the necessity of complete sac excision, the routine performance of fundoplication, and the use of mesh for hernia repair.

Methods

We searched Pubmed for papers published between 1980 and 2015 using the following keywords: hiatal hernias, paraesophageal hernias, regurgitation, dysphagia, gastroesophageal reflux disease, aspiration, GERD, endoscopy, manometry, pH monitoring, proton pump inhibitors, anemia, iron-deficiency anemia, Nissen fundoplication, sac excision, mesh, and mesh repair.

Results

Indications for paraesophageal hernia repair have changed, and currently symptomatic paraesophageal hernias are recommended for repair. In addition, it is important not to overlook iron-deficiency anemia and pulmonary complaints, which tend to improve with repair. Current practice favors a laparoscopic approach, complete sac excision, primary crural repair with or without use of mesh, and a routine fundoplication.

New surgical approach for giant paraesophageal hernia repair: closure of the esophageal hiatus anteriorly using the left triangular ligament

BACKGROUND

Obtaining a tension-free repair for giant paraesophageal hernias (PEH) is often challenging. Many different techniques have been proposed, including laparoscopic posterior hiatoplasty with the use of prosthetic or biologic mesh as well as the use of autologous teres or falciform ligament flaps. In this report, we describe the use of the left triangular ligament as an onlay autologous vascularized flap to bridge the anterior residual defect after posterior cruroplasty.

METHODS

A novel technique of paraesophageal hiatal hernia repair is described. Posterior hiatoplasty is performed, including the approximation of the diaphragmatic crural fibers to the extent possible. The left triangular ligament is then mobilized and sutured to the right and left crural fibers lining the esophageal hiatus to seal the anterior residual diaphragmatic defect.

RESULTS

This technique has been performed in 4 patients with a mean age of 71 years and a 3:1 female to male ratio. The average hiatal defect size was 5.5 cm and the average length of operation was 122 min. There was no evidence of radiologic or clinical recurrence on follow-up.

CONCLUSION

The use of the left triangular ligament flap is feasible and may be a valuable tool for closure of an anterior diaphragmatic defect in giant PEHs. Additional studies to validate its long-term function are needed.

Contemporary management of paraesophaegeal hernias: establishing a European expert consensus

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.

Improved Patient Outcomes in Paraesophageal Hernia Repair Using a Laparoscopic Approach: A Study of the National Surgical Quality Improvement Program Data

A consensus on the optimal surgical approach for repair of a paraesophageal hernia has not been reached. The aim of this study was to examine the outcomes of open and laparoscopic paraesophageal hernia repairs (PHR), both with and without mesh. A review of the National Surgical Quality Improvement Program (NSQIP) database from 2007 to 2011 was conducted. Patients who underwent an open or laparoscopic PHR were included. The primary outcome was 30-day mortality. Secondary outcomes included infections, respiratory and cardiac complications, intraoperative or perioperative transfusions, sepsis, and septic shock. Statistical analyses using odds ratios were performed comparing the open and laparoscopic approaches. A total of 4470 patients were identified using NSQIP; 2834 patients had a laparoscopic repair and the remaining 1636 patients underwent an open PHR. Compared with the laparoscopic approach, the open repair group had significantly higher 30-day mortality (odds ratio, 4.75; 95% confidence interval, 2.67 to 8.47; P < 0.0001). The laparoscopic approach had a statistically significant decrease in infections, respiratory and cardiac events/complications, transfusion requirements, episodes of sepsis, and septic shock ( P < 0.05). Our data suggest increased perioperative morbidity associated with an open PHR compared with laparoscopic. There was no statistically significant difference in any of the primary or secondary outcomes in patients repaired with mesh compared with those without. The overall use of mesh in paraesophageal hernia repairs has increased. The NSQIP data show significantly increased 30-day mortality in open repair compared with laparoscopic as well as a significantly higher perioperative complication rate.

Novel combined VATS/laparoscopic approach for giant and complicated paraesophageal hernia repair: description of technique and early results

BACKGROUND

The laparoscopic approach for repair of giant and/or recurrent paraesophageal hernias (PEH) is challenging, due to limited access to the dissection of the hernia sac into the proximal mediastinum and esophageal mobilization through the diaphragmatic hiatus. An esophageal lengthening procedure is often necessary, due to the difficulty in obtaining adequate intra-abdominal esophageal length. We, therefore, developed a VATS and laparoscopic technique, which allows for safe and extensive thoracic dissection and intra-abdominal gastric fixation and cruroplasty, yet preserving the benefits of minimally invasive surgery.

METHODS

We use a standard VATS approach. The hernia sac, optimally visualized, is dissected posteriorly from the thoracic aorta, inferiorly from its diaphragmatic attachments, anteriorly from the pericardium, and laterally from the mediastinal pleura. The esophagus is completely mobilized up to the aortic arch, and the anterior vagus nerve is released from its bronchial branches. The hernia sac is then opened, dissected, and completely removed. The hernia content is then reduced into the abdomen laparoscopically, the short gastric vessels are divided and the gastric fundus is completely mobilized. The hiatus is closed with interrupted sutures, and the cruroplasty is buttressed with a biological mesh. A floppy Nissen or a partial fundoplication and a gastropexy are done for reflux control and gastric fixation.

RESULTS

From January 2012 to January 2014, we treated 18 patients (7 with type III PEH and 11 with type IV) with the above-described procedure. Six patients had previous history of antireflux surgery. We performed a planned laparotomy instead of laparoscopy in two patients, who needed concurrent repair of complex incisional hernias. We did not need esophageal lengthening procedures, nor experienced damages to thoracic structures in any patient.

CONCLUSIONS

Our newly developed surgical approach has proven to be safe and feasible. This technique represents a good option for treatment of giant and complicated PEH.

Thirty-day outcomes of paraesophageal hernia repair using the NSQIP database: should laparoscopy be the standard of care?

BACKGROUND

Although surgical repair is universally recognized as the gold standard for treatment of paraesophageal hernia (PEH), the optimal surgical approach is still the subject of debate. To determine which surgical technique is safest, we compared the outcomes of laparoscopic (lap), open transabdominal (TA), and open transthoracic (TT) PEH repair using the NSQIP database.

STUDY DESIGN

From 2005 to 2011, we identified 8,186 patients who underwent a PEH repair (78.4% lap, 19.2% TA, 2.4% TT). Primary outcome measured was 30-day mortality. Secondary outcomes included hospital length of stay, and NSQIP-measured postoperative complications. Multivariable analyses were performed to compare the odds of each outcome across procedure type (lap, TA, and TT) while adjusting for other factors.

RESULTS

Transabdominal patients had the highest 30-day mortality rate (2.6%), compared with 0.5% in the lap patients (p < 0.001) and 1.5% in TT patients. Mean length of stay was statistically significantly longer for TA and TT patients (7.8 days and 6.5 days, respectively) compared with lap patients (3.3 days). After adjusting for age, American Society of Anesthesiologists score, emergency cases, functional status, and steroid use, TA patients were nearly 3 times as likely as lap patients to experience 30-day mortality (odds ratio [OR], 2.97; 95% CI, 1.69 to 5.20; p < 0.001). Moreover, TA and TT patients had significantly increased odds of overall (OR 2.12; 95% CI 1.79 to 2.51; p < 0.001; OR 2.73; 95% CI 1.88 to 3.96; p < 0.001; respectively) and serious morbidity (OR 1.90; 95% CI 1.53 to 2.37, p < 0.001; OR 2.49; 95% CI 1.54 to 4.00; p < 0.001; respectively).

CONCLUSIONS

In the absence of published data indicating improved long-term outcomes after open TA or TT approach, our findings support the use of laparoscopy, whenever technically feasible, because it yields improved short-term outcomes.