Outcomes of surgical management of symptomatic large recurrent hiatus hernia

Determining the need for a thoracoscopic approach to treat a giant hiatal hernia when abdominal access is poor

BACKGROUND

Giant hernias present a significant challenge for digestive surgeons. The approach taken (laparoscopic vs thoracoscopic) depends largely on the preferences and skills of each surgeon, although in most cases today the laparoscopic approach is preferred.

AIM

To determine whether patients presenting inadequate laparoscopic access to the intrathoracic hernial sac obtain poorer postoperative results than those with no such problem, in order to assess the need for a thoracoscopic approach.

METHODS

For the retrospective series of patients treated in our hospital for hiatal hernia (n = 112), we calculated the laparoscopic field of view and the working area accessible to surgical instruments, by means of preoperative imaging tests, to assess the likely outcome for cases inaccessible to laparoscopy.

RESULTS

Patients with giant hiatal hernias for whom a preoperative calculation suggested that the laparoscopic route would not access all areas of the intrathoracic sac presented higher rates of perioperative complications and recurrence during follow-up than those for whom laparoscopy was unimpeded. The difference was statistically significant. Moreover, the insertion of mesh did not improve results for the non-accessible group.

CONCLUSION

For patients with giant hiatal hernias, it is essential to conduct a preoperative evaluation of the angle of vision and the working area for surgery. When parts of the intrathoracic sac are inaccessible laparoscopically, the thoracoscopic approach should be considered.

Anatomic Observation of Recurrent Hiatal Hernia: Recurrence or Disease Progression?

BACKGROUND

Recurrence after hiatal hernia repair is common. The causes are uncertain. Our observation is the site of recurrence is primarily the nonsutured or nonreinforced anterior-left lateral portion of the hiatus. Our aim was to assess the distribution of hiatal hernia recurrence location as a basis for developing a theory of recurrence.

METHODS

Consecutive patients who underwent repair of recurrent hiatal hernias from March 2012 to December 2019 were reviewed. Data collected included age, sex, date of operation, location of hiatal hernia recurrence, operative approach, method of hiatal hernia repair, fundoplication performed, need for gastrectomy, and additional procedures.

RESULTS

One hundred and eight consecutive patients were studied. The distribution of recurrence locations was as follows: anterior 67%, posterior 12%, and circumferential 21%. Foreshortened esophagus was a contributing factor in 12%. Median time from the original repair to recurrence was 1.5 years (interquartile range 0.9 to 3.75 years) for posterior recurrences, 2.75 years (interquartile range 1.15 to 8.5 years) for circumferential recurrences, and 3.25 years (interquartile range 1.38 to 10 years) for anterior recurrences. Recurrences were repaired in a variety of techniques, depending on the clinical circumstances.

CONCLUSIONS

Hiatal hernia recurrences due to failure of the crural closure were less common, but early, recurrences. The majority of recurrences were due to stretching of the hiatus anterior and to the left of the esophagus. We theorize that the pathophysiology of late hiatal hernia recurrence is widening of the anterior and left lateral portion of the hiatus secondary to repeated stress from differential pressures that eventually overcomes the tensile strength of the hiatus.

A retrospective multicenter analysis on redo-laparoscopic anti-reflux surgery: conservative or conversion fundoplication?

BACKGROUND

Nearly 20% of patients who undergo hiatal hernia (HH) repair and anti-reflux surgery (ARS) report recurrent HH at long-term follow-up and may be candidates for redo surgery. Current literature on redo-ARS has limitations due to small sample sizes or single center experiences. This type of redo surgery is challenging due to rare but severe complications. Furthermore, the optimal technique for redo-ARS remains debatable. The purpose of the current multicenter study was to review the outcomes of redo-fundoplication and to identify the best ARS repair technique for recurrent HH and gastroesophageal reflux disease (GERD).

METHODS

Data on 975 consecutive patients undergoing hiatal hernia and GERD repair were retrospectively collected in five European high-volume centers. Patient data included demographics, BMI, techniques of the first and redo surgeries (mesh/type of ARS), perioperative morbidity, perioperative complications, duration of hospitalization, time to recurrence, and follow-up. We analyzed the independent risk factors associated with recurrent symptoms and complications during the last ARS. Statistical analysis was performed using GraphPad Prism^® and R software^®.

RESULTS

Seventy-three (7.49%) patients underwent redo-ARS during the last decade; 71 (98%) of the surgeries were performed using a minimally invasive approach. Forty-two (57.5%) had conversion from Nissen to Toupet. In 17 (23.3%) patients, the initial Nissen fundoplication was conserved. The initial Toupet fundoplication was conserved in 9 (12.3%) patients, and 5 (6.9%) had conversion of Toupet to Nissen. Out of the 73 patients, 10 (13%) underwent more than one redo-ARS. At 8.5 (1-107) months of follow-up, patients who underwent reoperation with Toupet ARS were less symptomatic during the postoperative period compared to those who underwent Nissen fundoplication (p = 0.005, OR 0.038). Patients undergoing mesh repair during the redo-fundoplication (21%) were less symptomatic during the postoperative period (p = 0.020, OR 0.010). The overall rate of complications (Clavien-Dindo classification) after redo surgery was 11%. Multivariate analysis showed that the open approach (p = 0.036, OR 1.721), drain placement (p = 0.0388, OR 9.308), recurrence of dysphagia (p = 0.049, OR 8.411), and patient age (p = 0.0619, OR 1.111) were independent risk factors for complications during the last ARS.

CONCLUSIONS

Failure of ARS rarely occurs in the hands of experienced surgeons. Redo-ARS is feasible using a minimally invasive approach. According to our study, in terms of recurrence of symptoms, Toupet fundoplication is a superior ARS technique compared to Nissen for redo-fundoplication. Therefore, Toupet fundoplication should be considered in redo interventions for patients who initially underwent ARS with Nissen fundoplication. Furthermore, mesh repair in reoperations has a positive impact on reducing the recurrence of symptoms postoperatively.

Evaluation of resection of the gastroesophageal junction and jejunal interposition (Merendino procedure) as a rescue procedure in patients with a failed redo antireflux procedure. A single-center experience

Background

Primary antireflux surgery has high success rates but 5 to 20% of patients undergoing antireflux operations can experience recurrent reflux and dysphagia, requiring reoperation. Different surgical approaches after failed fundoplication have been described in the literature. The aim of this study was to evaluate resection of the gastroesophageal junction with jejunal interposition (Merendino procedure) as a rescue procedure after failed fundoplication.

Methods

All patients who underwent a Merendino procedure at the Karolinska University Hospital between 2004 and 2012 after a failed antireflux fundoplication were identified. Data regarding previous surgical history, preoperative workup, postoperative complications, subsequent investigations and re-interventions were collected retrospectively. The follow-up also included questionnaires regarding quality of life, gastrointestinal function and the dumping syndrome.

Results

Twelve patients had a Merendino reconstruction. Ten patients had undergone at least two previous fundoplications, of which one patient had four such procedures. The main indication for surgery was epigastric and radiating back pain, with or without dysphagia. Postoperative complications occurred in 8/12 patients (67%). During a median follow-up of 35 months (range 20–61), four (25%) patients had an additional redo procedure with conversion to a Roux-en-Y esophagojejunostomy within 12 months, mainly due to obstructive symptoms that could not be managed conservatively or with endoscopic techniques. Questionnaires scores were generally poor in all dimensions.

Conclusions

In our experience, the Merendino procedure seems to be an unsuitable surgical option for patients who require an alternative surgical reconstruction due to a failed fundoplication. However, the small number of patients included in this study as well as the small number of participants who completed the postoperative workout limits this study.

One More Time: Redo Paraesophageal Hernia Repair Results in Safe, Durable Outcomes Compared with Primary Repairs

The incidence and causes of failed paraesophageal hernia repairs (PEHR) remain poorly understood. Our study aimed to evaluate long-term clinical outcomes after reoperative fundoplication as compared with initial PEHR. A prospectively maintained institutional hernia-specific database was queried for PEHR between 2008 and 2017. Patients with prior history of PEHR were categorized as “redo” paraesophageal hernia (RPEH). Primary outcomes included postoperative morbidity, mortality, symptom resolution, and hernia recurrence. A total of 402 patients underwent minimally invasive PEHR (Initial PEH = 305, RPEH = 97). Redo PEHR had more prevalent preoperative nausea/vomiting (50.6% vs 34.1%, P < 0.007) and weight loss (24.1% vs 13.5%, P < 0.02). RPEH had had longer mean operative time (256.4 ± 91.2 vs 190.3 ± 59.9 minutes, P < 0.0001) and higher rate of conversion to open (10.3% vs 0.67%, P < 0.0001); however, no difference was noted in postoperative complications, hernia recurrence, or mortality between cohorts. Laparoscopic revision of prior PEHR in symptomatic patients can be safely performed with favorable outcomes compared with initial PEHR. Despite redo procedures seeming to be more technically demanding (as noted by longer operative time and higher conversion rates), outcomes are similar and overall resolution of symptoms is achieved in most patients.

Autologous Dermis Graft Implantation: A Novel Approach to Reinforcement in Giant Hiatal Hernias

Objectives

Nonreinforced tensile repair of giant hiatal hernias is susceptible to recurrence, and the role of mesh graft implantation remains controversial. Creating a new and viable choice without the use of high-cost biological allografts is desirable. This study presents the application of dermis graft reinforcement, a cost-efficient, easily adaptable alternative, in graft reinforcement of giant hiatal hernia repairs.

Methods

A 62-year-old female patient with recurrent giant hiatal hernia (9 × 11 cm) and upside down stomach, immediately following the Belsey repair done in another department, was selected for the pilot procedure. The standard three-stitch nonabsorbable reconstruction of diaphragmatic crura was undertaken via laparoscopic approach. A 12 × 6 cm dermis autograft was harvested from the loose abdominal skin. “U” figure onlay reinforcement of diaphragm closure was secured with titanium staples. The procedure was completed with a standard Dor fundoplication. One- and seven-month follow-ups were conducted.

Results

No short-term postoperative complications were observed. One-month follow-up showed normal anatomical location of abdominal viscera on computed tomography imaging. High-resolution manometry showed normal lower esophageal sphincter pressure. Preoperative abdominal complaints were resolved. Procedural costs were lower than the average cost following mesh graft reinforcement.

Conclusion

Dermis graft reinforcement is a cheap, easily adaptable procedure in the repair of giant hiatal hernias, even in the setting of laparoscopic reoperative procedure.

Primary and Redo Antireflux Surgery: Outcomes and Lessons Learned

INTRODUCTION

Some patients require one or more reoperative interventions after undergoing primary antireflux surgery (ARS). We compared outcomes after primary and reoperative ARS.

METHODS

We queried a prospectively maintained database to identify patients who underwent ARS from September 23, 2003 to May 28, 2016. Patients were categorized into four groups: A (primary ARS), B (first reoperative ARS), C (second reoperative ARS), or D (≥ third reoperative ARS). Patients completed follow-up foregut symptom surveys and satisfaction questionnaires at regular intervals.

RESULTS

In total, 940 patients were studied (A: n = 545, B: n = 302, C: n = 80, D: n = 13). Age, sex, and BMI were comparable across groups. Heartburn was the most common preoperative symptom in A, whereas dysphagia was more common in B-D. Open approach, mean operative time, and mean blood loss increased from A to D (P < 0.05), as did need for Roux-en-Y reconstruction. Vagal injury (2-19-33-54%; P < 0.05), visceral perforation (2-20-36-23%; P < 0.05), postoperative leak (0.2-2-6-8%; P < 0.05 A vs. all), and morbidity (2-10-14-39%; P < 0.05) also increased from A to D. At mean follow-up of 36 months, the proportion of patients who reported no significant symptoms, excellent satisfaction, and likeliness to recommend this surgery to a friend progressively declined with each successive reintervention (P < 0.05).

CONCLUSIONS

Complications and patient-reported outcomes worsen with each reoperative ARS.

Temporal patterns of hiatus hernia recurrence and hiatal failure: quality of life and recurrence after revision surgery

Antireflux and paraesophageal hernia repair surgery is increasingly performed and there is an increased requirement for revision hiatus hernia surgery. There are no reports on the changes in types of failures and/or the variations in location of crural defects over time following primary surgery and limited reports on the outcomes of revision surgery. The aim of this study is to report the changes in types of hernia recurrence and location of crural defects following primary surgery, to test our hypothesis of the temporal events leading to hiatal recurrence and aid prevention. Quality of life scores following revision surgery are also reported, in one of the largest and longest follow-up series in revision hiatus surgery. Review of a single-surgeon database of all revision hiatal surgery between 1992 and 2015. The type of recurrence and the location of crural defect were noted intraoperatively. Recurrence was diagnosed on gastroscopy and/or contrast study. Quality of life outcomes were measured using Visick, dysphagia, atypical reflux symptoms, satisfaction scores, and Gastrointestinal Quality of Life Index (GIQLI). Two-hundred eighty four patients (126 male, 158 female), median age 60.8(48.2-69.1), underwent revision hiatal surgery. Median follow-up following primary surgery was 122.8(75.3-180.3) and 91.6(40.5-152.5) months after revision surgery. The most common type of hernia recurrence in the early period after primary surgery was 'telescope'(42.9%), but overall, fundoplication apparatus transhiatal migration was consistently the predominant type of recurrence at 1-3 years (54.3%), 3-5 years (42.5%), 5-10 years (45.1%), and >10 years (44.1%). The location of crural defects changed over duration following primary surgery as anteroposterior defects was most common in the early period (45.5% in <1 year) but decreased over time (30.3% at 1-3 years) while anterior defects increased in the long term with 35.9%, 40%, and 42.2% at 3-5 years, 5-10 years, and >10 years, respectively. Revision surgery intraoperative morbidity was 19.7%, mainly gastric (9.5%) and esophageal (2.1%) perforation. There was a 75% follow-up rate and recurrence following revision surgery was 15.4%(44/284) in unscreened population and 21%(44/212) in screened population. There was no difference in recurrence rate based on size of hiatus hernia at primary surgery, or at revision surgery. There were significant improvements in the Visick score (3.3 vs. 2.4), the modified Dakkak score (23.2 vs. 15.4), the atypical reflux symptom score (23.7 vs. 15.4), and satisfaction scores (0.9 vs. 2.2), but no difference in the various domains (symptom, physical, social, and medical) of the GIQLI scores following revision surgery. Revision hiatal surgery has higher intraoperative morbidity but may achieve adequate long-term satisfaction and quality of life. The most common type of early recurrence following primary surgery is telescoping, and overall is wrap herniation. Anterior crural defects may be strong contributor to late hiatus hernia recurrence. Symptom-specific components of GIQLI, but not the overall GIQLI score, may be required to detect improvements in QOL.

Durability of giant hiatus hernia repair in 455 patients over 20 years

INTRODUCTION

The surgical management of symptomatic giant hiatus hernia (GHH) aims to improve quality of life (QoL) and reduce the risk of life threatening complications. Previous reports are predominantly those with small sample sizes and short follow-up periods. The present study sought to assess a large cohort of patients for recurrence and QoL over a longer time period.

METHODS

This was a follow-up study of a prospectively collected database of 455 consecutive patients. Primary repair of GHH was evaluated by endoscopy/barium meal for recurrence and a standardised symptom questionnaire for QoL. Recurrence was assessed for size, elapsed time, oesophagitis and symptoms.

RESULTS

Objective and subjective review was achieved in 91.9% and 68.6% of patients. The median age was 69 years (range: 15-93 years) and 64% were female. Laparoscopic repair was completed in 95% (mesh in 6% and Collis gastroplasty in 7%). The 30-day mortality rate was 0.9%. The proportion of patients alive at five and ten years were 90% and 75% respectively. Postoperative QoL scores improved from a mean of 95 to 111 (p<0.01) and were stable over time (112 at 10 years). The overall recurrence rate was 35.6% (149/418) at 42 months; this was 11.5% (48/418) for hernias >2cm and 24.2% (101/418) for <2cm. The rate of new recurrence at 0-1 years was 13.7% (>2cm = 3.4%, <2cm = 10.3%), at 1-5 years it was 30.8% (>2cm = 9.5%, <2cm = 21.3%), at 5-10 years it was 40.1% (>2cm = 13.8%, <2cm = 26.3%) and at over 10 years it was 50.0% (>2cm = 25.0%, <2cm = 25.0%). Recurrence was associated with oesophagitis but not decreased QoL. Revision surgery was required in 4.8% of cases (14.8% with recurrence). There were no interval major GHH complications.

CONCLUSIONS

Surgery has provided sustained QoL improvements irrespective of recurrence. Recurrence occurred progressively over ten years and may predispose to oesophagitis.

Current readings: Failed hiatal hernia repair

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.