Long-term outcomes following surgical repair of giant paraoesophageal hiatus hernia

Elective Laparoscopic Paraesophageal Hernia Repair Leads to an Increase in Life Expectancy Over Watchful Waiting in Asymptomatic Patients: An Updated Markov Analysis

OBJECTIVE

The aim of this study was to perform an updated Markov analysis to determine the optimal management strategy for patients with an asymptomatic paraesophageal hernia (PEH): elective laparoscopic hernia repair (ELHR) versus watchful waiting (WW).

BACKGROUND

Currently, it is recommended that patients with an asymptomatic PEH not undergo repair based on a 20-year-old Markov analysis. The current recommendation might lead to preventable hospitalizations for acute PEH-related complications and compromised survival.

METHODS

A Markov model with updated variables was used to compare life-years (L-Ys) gained with ELHR versus WW in patients with a PEH. One-way sensitivity analyses evaluated the robustness of the analysis to alternative data inputs, while probabilistic sensitivity analysis quantified the level of confidence in the results in relation to the uncertainty across all model inputs.

RESULTS

At age 40 to 90, ELHR led to greater life expectancy than WW, particularly in women. The gain in L-Ys (2.6) was greatest in a 40-year-old woman and diminished with increasing age. Sensitivity analysis showed that alternative values resulted in modest changes in the difference in L-Ys, but ELHR remained the preferred strategy. Probabilistic analysis showed that ELHR was the preferred strategy in 100% of 10,000 simulations for age 65, 98% for age 80, 90% for age 85, and 59% of simulations in 90-year-old women.

CONCLUSIONS

This updated analysis showed that ELHR leads to an increase in L-Ys over WW in healthy patients aged 40 to 90 years with an asymptomatic PEH. In this new paradigm, all patients with a PEH, regardless of symptoms, should be referred for the consideration of elective repair to maximize their life expectancy.

Recurrence in Paraesophageal Hernia: Patient Factors and Composite Surgical Repair in 862 Cases

BACKGROUND

Repair of giant paraesophageal hernia (PEH) is associated with a considerable hernia recurrence rate by objective measures. This study analyzed a large series of laparoscopic giant PEH repair to determine factors associated with anatomical recurrence.

METHOD

Data was extracted from a single-surgeon prospective database of laparoscopic repair of giant PEH from 1991 to 2021. Upper endoscopy was performed within 12 months postoperatively and selectively thereafter. Any supra-diaphragmatic stomach was defined as anatomical recurrence. Patient and hernia characteristics and technical operative factors, including "composite repair" (360° fundoplication with esophagopexy and cardiopexy to right crus), were evaluated with univariate and multivariate analysis.

RESULTS

Laparoscopic primary repair was performed in 862 patients. The anatomical recurrence rate was 27.3% with median follow-up of 33 months (IQR 16, 68). Recurrence was symptomatic in 45% of cases and 29% of these underwent a revision operation. Hernia recurrence was associated with younger age, adversely affected quality of life, and were associated with non-composite repair. Multivariate analysis identified age < 70 years, presence of Barrett's esophagus, absence of "composite repair", and hiatus closure under tension as independent factors associated with recurrence (HR 1.27, 95%CI 0.88-1.82, p = 0.01; HR 1.58, 95%CI 1.12-2.23, p = 0.009; HR 1.72, 95%CI 1.2-2.44, p = 0.002; HR 2.05, 95%CI 1.33-3.17, p = 0.001, respectively).

CONCLUSION

Repair of giant PEH is associated with substantial anatomical recurrence associated with patient and technique factors. Patient factors included age < 70 years, Barrett's esophagus, and hiatus tension. "Composite repair" was associated with lower recurrence rate.

Trends in outcomes of 862 giant hiatus hernia repairs over 30 years

PURPOSE

Laparoscopic giant hiatus hernia repair is technically difficult with ongoing debate regarding the most effective surgical technique. Repair of small hernia has been well described but data for giant hernia is variable. This study evaluated trends in outcomes of laparoscopic non-mesh repair of giant paraesophageal hernia (PEH) over 30 years.

METHODS

Retrospective analysis of a single-surgeon prospective database. Laparoscopic non-mesh repairs for giant PEH between 1991 and 2021 included. Three-hundred-sixty-degree fundoplication was performed routinely, evolving into "composite repair" (esophagopexy and cardiopexy to the right crus). Cases were chronologically divided into tertiles based on operation date (Group 1, 1991-2002; Group 2, 2003-2012; Group 3, 2012-2021) with trends in casemix, operative factors and outcomes evaluated. Hernia recurrence was plotted using weighted moving average and cumulative sum (CUSUM) analysis.

RESULTS

862 giant PEH repairs met selection criteria. There was an increasing proportion of "composite repair" after the first decade (Group 1, 2.7%; Group 2, 81.9%; Group 3, 100%; p < 0.001). There were less anatomical hernia recurrence (Group 1, 36.6%; Group 2, 22.9%; Group 3, 22.7%; p < 0.001) and symptomatic recurrence (Group 1, 34.2%; Group 2, 21.9%; Group 3, 7%; p < 0.001) over time. The incidence of anatomical recurrence declined over time, decreasing from 30.8% and plateauing below 17.6% near the study's end. Median followup (months) in the first decade was higher but followup between the latter two decades comparable (Group 1, 49 [IQR 20, 81]; Group 2, 30 [IQR 15, 65]; Group 3, 24 [14, 56]; p < 0.001). There were 10 (1.2%) Clavien-Dindo grade ≥ III complications including two perioperative deaths (0.2%).

CONCLUSION

Hernia recurrence rates decreased with increasing case volume. This coincided with the increasing adoption of "composite repair", supporting the possible improvement in recurrence rates with this approach.

Impact of laparoscopic repair on type III/IV giant paraesophageal hernias: a single-center experience

PURPOSE

Giant paraesophageal hernia (GPEH) is a challenging problem for surgeons because of its high recurrence rate. This study was conducted to compare the outcomes in type IV vs. type III GPEHs after laparoscopic repair. Other outcomes included peri-operative morbidity and long-term quality of life.

METHODS

A retrospective analysis of 130 GPEH patients in a period between 2010 and 2019 underwent a tailored laparoscopic repair in our tertiary center with a minimum follow-up of 48 months. Operative steps included hernial sac excision, crural repair, relaxing incisions, and mesh cruroplasty with special indications.

RESULTS

The study enrolled 90 patients with type III and 40 patients with type IV GPEH. Type IV GPEH patients were older, more fragile, and scored worse on ASA classification, aside from having a more challenging surgical technique (wider crura, weaker muscles, increased need for release incisions, and mesh cruroplasty).Type IV GPEHs had a prolonged operative durations, and a higher conversion rate. Additionally, the same group showed increased morbidity, mortality, and re-operation rates. With a mean follow-up of 65 months (range 48-150 months), the incidence of recurrence was 20.7%, with an increased incidence in type IV GPEH (37.5% vs. 13.33% in type III GPEH). Type IV GPEH, low pre-operative albumin, larger crural defect, and low surgeon experience were significant risk factors for recurrence after laparoscopic repair of GPEH.

CONCLUSION

Type IV GPEH has a higher peri-operative morbidity and recurrence rate; so, a more tailored laparoscopic repair with a high surgeon experience is needed.

Emergency surgery for hiatus hernias: does technique affect outcomes? A single-centre experience

BACKGROUND

Emergency surgery for a hiatus hernia is usually a high-risk procedure in acutely unwell patients. Common surgical techniques include reduction of the hernia, cruropexy then either fundoplication or gastropexy with a gastrostomy. This is an observational study in a tertiary referral centre for complicated hiatus hernias to compare recurrence rates between these two techniques.

METHODS

Eighty patients are included in this study, from October 2012 to November 2020. This is a retrospective review and analysis of their management and follow-up. Recurrence of the hiatus hernia that mandates surgical repair was the primary outcome of this study. Secondary outcomes include morbidity and mortality.

RESULTS

In total, 38% of the patients included in the study had fundoplication procedures, 53% had gastropexy, 6% had complete or partial resection of the stomach, 3% had fundoplication and gastropexy and one patient had neither (n = 30, 42, 5, 2,1, respectively). Eight patients had symptomatic recurrence of the hernia which required surgical repair. Three of these patients had acute recurrence and 5 after discharge. 50% had undergone fundoplication, 38% underwent gastropexy and 13% underwent a resection (n = 4, 3, 1) (p value = 0.5). 38% of patient had no complications and 30-day mortality was 7.5% CONCLUSION: To our knowledge, this is the largest single centre review of outcomes following emergency hiatus hernia repairs. Our results show that either fundoplication or gastropexy can be used safely to reduce the risk of recurrence in the emergency setting. Therefore, surgical technique can be tailored based on the patient characteristics and surgeon experience, without compromising the risk of recurrence or post-operative complications. Mortality and morbidity rates were in keeping with previous studies, which is lower than historically documented, with respiratory complications most prevalent. This study shows that emergency repair of hiatus hernias is a safe operation which is often a lifesaving procedure in elderly comorbid patients.

Is fundoplication necessary after paraesophageal hernia repair? A meta-analysis and systematic review

INTRODUCTION

Paraesophageal hernias are often asymptomatic, but when symptomatic they should be fixed laparoscopically. A cruroplasty of the diaphragmatic pillars is performed and a fundoplication is usually performed at the time. However, there are times, especially in emergency cases, where it is not always possible to perform a fundoplication. We hypothesized there would be no difference in outcomes whether or not a fundoplication is performed as part of a paraesophageal hernia repair.

METHODS

A literature review of available clinical databases was performed using PubMed, Clinical Key and Google Scholar. Our search terms were: "paraesophageal hernia" "paraesophageal hernia repair" "fundoplication" "emergency surgery" "no fundoplication" We excluded studies that were in languages other than English, abstracts and small case series.

RESULTS

Our search criteria yielded a total of 22 studies published between 1997 and 2020. There were a total of 8600 subjects enrolled into this study. The overall pooled prevalence of fundoplication were estimated as 69% (95% CI: 59%-78%). In patients who underwent fundoplication, the risk of gastroesophageal reflux disease (GERD) was reduced as compared to patients who did not undergo fundoplication (RR: 0.64, 95% CI: 0.40-1.04, p = 0.069, I2 = 47.2%). A similar trend was also observed in recurrence (RR: 0.53, 95% CI: 0.27-1.03, p = 0.061, I2 = 0.0%) and reoperations (RR: 0.25, 95% CI: 0.02-2.69, p = 0.25, I2 = 56.7%). However, patients who underwent fundoplication had an increased risk of dysphagia (RR: 1.68, 95% CI: 0.59-4.81, p = 0.83, I2 = 42%).

CONCLUSIONS

There is a higher rate of recurrence of gastroesophageal reflux disease, recurrence of hernia and reoperation when no fundoplication is performed during a paraesophageal hernia repair but a lower risk of dysphagia, but none of these reached statistical significance.(Comment 1) Paraesophageal hernia repair with fundoplication should be performed, but it is acceptable to not do it in certain situations.

Laparoscopic fundoplication for para-oesophageal hernia repair improves respiratory function in patients with dyspnoea: a prospective cohort study

Background

Dyspnoea in patients with a para-oesophageal hernia (PEH) occurs in 7% to 32% of cases and is very disabling, especially in elderly patients, and its origin is not well defined. The present study aims to assess the impact of PEH repair on dyspnoea and respiratory function.

Methods

From January 2019 to May 2021, all consecutive patients scheduled for PEH repair presenting with a modified Medical Research Council (mMRC) score ≥ 2 for dyspnoea were included. Before and 2 months after surgery, dyspnoea was assessed by both the dyspnoea visual analogue scale (DVAS) and the mMRC scale, as well as pulmonary function tests (PFTs) by plethysmography.

Results

All 43 patients that were included had pre- and postoperative dyspnoea assessments and PFTs. Median age was 70 years (range 63–73.5 years), 37 (86%) participants were women, median percentage of the intrathoracic stomach was 59.9% (range 44.2–83.0%), and median length of hospital stay was 3 days (range 3–4 days). After surgery, the DVAS decreased statistically significant (5.6 [4.7–6.7] vs. 3.0 [2.3–4.4], p < 0.001), and 37 (86%) patients had a clinically significant decrease in mMRC score. Absolute forced expiratory volume in one second (FEV1), total lung capacity, and forced vital capacity also statistically significantly increased after surgery by an average of 11.2% (SD 17.9), 5.0% (SD 13.9), and 10.7% (SD 14.6), respectively. Furthermore, from the subgroup analysis, it was identified that patients with a lower preoperative FEV1 were more likely to have improvement in it after surgery. No correlation was found between improvement in dyspnoea and FEV1. There was no correlation between the percentage of intrathoracic stomach and dyspnoea or improvement in PFT parameters.

Conclusion

PEH repair improves dyspnoea and FEV1 in a statistically significant manner in a population of patients presenting with dyspnoea. Patients with a low preoperative FEV1 are more likely to have improvement in it after surgery.

Do Poor Functional Outcomes and Higher Morbidity Following Emergency Repair of Giant Hiatus Hernia Warrant Elective Surgery in Asymptomatic Patients?

Background: Patients with a giant hiatus hernia may present with acute symptoms caused by obstruction, strangulation, perforation and uncontrolled bleeding. Emergency surgical repair has been associated with significant mortality and even greater morbidity. The aim of this study is to investigate the short-term outcomes following emergency repair of giant hiatus hernias.

Methods: Data were retrospectively collected for all patients who underwent emergency surgical repair of giant hiatus hernia in a university teaching hospital between 2009 and 2019. Outcomes were short-term morbidity and mortality. We also assessed the association of clinical predictor covariates, including age, ASA class and time to surgery, with risk for major morbidity.

Results: Thirty-seven patients with a median age of 68 years were identified. Following surgery, 9 patients (24.3%) developed organ dysfunction that required admission to the intensive care unit. Two patients (5.4%) underwent revision surgery and 3 (8.1%) developed pneumothorax that necessitated chest drain insertion. The commonest complication was pneumonia, which occurred in 13 patients (35.1%). Two deaths (5.4%) occurred within 30 days from surgery.

Conclusions: Emergency repair of giant hiatus hernia is associated with high rates of major morbidity, which includes poor functional status, further interventions, repeat surgery, and admission to the intensive care unit. Larger studies are warranted for long-term follow-up to assess post-operative quality of life is needed for asymptomatic patients and for those undergoing emergency surgery.

Does composite repair of giant paraoesophageal hernia improve patient outcomes?

BACKGROUND

Paraoesophageal hernia (PEH) is often symptomatic and reduces patients' quality of life (QoL). There is ongoing debate regarding the most effective surgical technique to repair giant PEH. This study aimed to see if an elective laparoscopic non-mesh composite technique of giant PEH repair offered an advantage in symptom control, hernia recurrence, QoL, morbidity and mortality.

METHODS

Data were extracted from a prospectively maintained database of patients undergoing hiatal hernia repair. Composite hernia repairs from inception for giant PEH between March 2009 and December 2015 were included. Perioperative mortality, complications, hernia recurrence rates, prevalence, recurrence of symptoms and QoL were included in analysis.

RESULTS

Inclusion criteria were met by 218 patients. Mean age was 70 (49-93). The average hernia size was 62% (range 30-100%; SD 21). There was one perioperative death and three significant complications (Clavien-Dindo grade III and IV). Recurrence rate was 24.8%. Without recurrence, QoL improved significantly across all domains. Recurrence of hiatus hernia reduced QoL. Surgery resulted in resolution of symptoms other than dysphagia which was incompletely improved. Patients' overall satisfaction with surgery was high.

CONCLUSION

Composite repair of giant PEH is safe with overall good outcomes. Majority of hernia recurrence are small and asymptomatic. Hernia recurrence negatively affected long-term QoL scores.

Non-elective paraesophageal hernia repair: surgical approaches and short-term outcomes

BACKGROUND

The majority of laparoscopic paraesophageal hernia (PEH) repairs are performed electively. We aimed to investigate the frequency of non-elective laparoscopic (MIS) PEH repair and compare 30-day outcomes to elective MIS repairs and non-elective open repairs. We hypothesized that an increasing percentage of non-elective PEH repairs would be performed laparoscopically and that this population would have improved outcomes compared to non-elective open PEH counterparts.

METHODS

The 2011-2016 NSQIP PUFs were used to identify patients who underwent PEH repair. Case status was classified as open vs. MIS and elective versus non-elective. Preoperative patient characteristics, operative details, discharge destination, and 30-day postoperative complication rates were compared. Logistic regression was used to examine the impact of case status on 30-day mortality.

RESULTS

We identified 20,010 patients who underwent PEH. There were an increasing number of MIS PEH repairs in NSQIP between 2011 and 2016. Non-elective repairs were performed in 2,173 patients and 73.4% of these were completed laparoscopically. Elective MIS patients were younger, had a higher BMI, and were more likely to be functionally independent (p < 0.01) than their non-elective counterparts. Non-elective MIS patients had a higher wound class and ASA class compared to their elective counterparts. Compared to elective MIS cases, non-elective MIS PEH repair was associated with increased odds of mortality, even after controlling for patient characteristics (OR = 1.76, p = 0.02). There was no statistically significant difference in mortality for non-elective MIS vs. non-elective open PEH repair. There is an increase in non-elective PEH repairs recorded in NSQIP over time studied.

CONCLUSIONS

The population undergoing non-elective MIS PEH repairs is different from their elective MIS counterparts and experience a higher postoperative mortality rate. While the observed increased utilization of MIS techniques in non-elective PEH repairs likely provides benefits for the patient, there remain differences in outcomes for these patients compared to elective PEH repairs.