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Hanna NM, Kumar SS, Collings AT, Pandya YK, Kurtz J, Kooragayala K, Barber MW, Paranyak M, Kurian M, Chiu J, Abou-Setta A, Ansari MT, Slater BJ, Kohn GP, Daly S. Management of symptomatic, asymptomatic, and recurrent hiatal hernia: a systematic review and meta-analysis. Surg Endosc 2024; 38:2917-2938. [PMID: 38630179 DOI: 10.1007/s00464-024-10816-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND The surgical management of hiatal hernia remains controversial. We aimed to compare outcomes of mesh versus no mesh and fundoplication versus no fundoplication in symptomatic patients; surgery versus observation in asymptomatic patients; and redo hernia repair versus conversion to Roux-en-Y reconstruction in recurrent hiatal hernia. METHODS We searched PubMed, Embase, CINAHL, Cochrane Library and the ClinicalTrials.gov databases between 2000 and 2022 for randomized controlled trials (RCTs), observational studies, and case series (asymptomatic and recurrent hernias). Screening was performed by two trained independent reviewers. Pooled analyses were performed on comparative data. Risk of bias was assessed using the Cochrane Risk of Bias tool and Newcastle Ottawa Scale for randomized and non-randomized studies, respectively. RESULTS We included 45 studies from 5152 retrieved records. Only six RCTs had low risk of bias. Mesh was associated with a lower recurrence risk (RR = 0.50, 95%CI 0.28, 0.88; I2 = 57%) in observational studies but not RCTs (RR = 0.98, 95%CI 0.47, 2.02; I2 = 34%), and higher total early dysphagia based on five observational studies (RR = 1.44, 95%CI 1.10, 1.89; I2 = 40%) but was not statistically significant in RCTs (RR = 3.00, 95%CI 0.64, 14.16). There was no difference in complications, reintervention, heartburn, reflux, or quality of life. There were no appropriate studies comparing surgery to observation in asymptomatic patients. Fundoplication resulted in higher early dysphagia in both observational studies and RCTs ([RR = 2.08, 95%CI 1.16, 3.76] and [RR = 20.58, 95%CI 1.34, 316.69]) but lower reflux in RCTs (RR = 0.31, 95%CI 0.17, 0.56, I2 = 0%). Conversion to Roux-en-Y was associated with a lower reintervention risk after 30 days compared to redo surgery. CONCLUSIONS The evidence for optimal management of symptomatic and recurrent hiatal hernia remains controversial, underpinned by studies with a high risk of bias. Shared decision making between surgeon and patient is essential for optimal outcomes.
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Affiliation(s)
- Nader M Hanna
- Department of Surgery, Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
| | - Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Yagnik K Pandya
- Department of Surgery, MetroWest Medical Center, Framingham, MA, USA
| | - James Kurtz
- Department of Surgery, Providence Portland Medical Center, Portland, OR, USA
| | | | - Meghan W Barber
- Department of Surgery, University of Toledo College of Medicine, Toledo, OH, USA
| | - Mykola Paranyak
- Department of General Surgery, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Marina Kurian
- Department of Surgery, NYU Langone Health, New York, NY, USA
| | | | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | | | | | - Geoffrey P Kohn
- Department of Surgery, Monash University, Melbourne, Australia
- Melbourne Upper GI Surgical Group, Melbourne, Australia
| | - Shaun Daly
- Department of Surgery, University of California Irvine, Irvine, USA
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Clapp B, Hamdan M, Mandania R, Kim J, Gamez J, Hornock S, Vivar A, Dodoo C, Davis B. Is fundoplication necessary after paraesophageal hernia repair? A meta-analysis and systematic review. Surg Endosc 2022; 36:6300-6311. [PMID: 35024937 DOI: 10.1007/s00464-022-09024-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 01/03/2022] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Benjamin Clapp
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, 1700 N. Mesa., El Paso, TX, 79903, USA.
| | - Marah Hamdan
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, 1700 N. Mesa., El Paso, TX, 79903, USA
| | - Roshni Mandania
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, 1700 N. Mesa., El Paso, TX, 79903, USA
| | - Jisoo Kim
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, 1700 N. Mesa., El Paso, TX, 79903, USA
| | - Jesus Gamez
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, 1700 N. Mesa., El Paso, TX, 79903, USA
| | - Sasha Hornock
- William Beaumont Army Medical Center, El Paso, TX, USA
| | - Andres Vivar
- Universidad Autonoma de Guadalajara, Zapopan, Mexico
| | - Christopher Dodoo
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, 1700 N. Mesa., El Paso, TX, 79903, USA
| | - Brian Davis
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, 1700 N. Mesa., El Paso, TX, 79903, USA
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Dreifuss NH, Schlottmann F, Molena D. Management of paraesophageal hernia review of clinical studies: timing to surgery, mesh use, fundoplication, gastropexy and other controversies. Dis Esophagus 2020; 33:5848914. [PMID: 32476002 PMCID: PMC8344298 DOI: 10.1093/dote/doaa045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/14/2020] [Accepted: 05/02/2020] [Indexed: 12/11/2022]
Abstract
Despite paraesophageal hernias (PEH) being a common disorder, several aspects of their management remain elusive. Elective surgery in asymptomatic patients, management of acute presentation, and other technical aspects such as utilization of mesh, fundoplication or gastropexy are some of the debated issues. The aim of this study was to review the available evidence in an attempt to clarify current controversial topics. PEH repair in an asymptomatic patient may be reasonable in selected patients to avoid potential morbidity of an emergent operation. In acute presentation, gastric decompression and resuscitation could allow to improve the patient's condition and refer the repair to a more experienced surgical team. When surgical repair is decided, laparoscopy is the optimal approach in most of the cases. Mesh should be used in selected patients such as those with large PEH or redo operations. While a fundoplication is recommended in the majority of patients to prevent postoperative reflux, a gastropexy can be used in selected cases to facilitate postoperative care.
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Affiliation(s)
- Nicolás H Dreifuss
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina,Address correspondence to: Francisco Schlottmann, MD MPH, Department of Surgery, Hospital Alemán of Buenos Aires, Av. Pueyrredon 1640, C1118AAT Buenos Aires, Argentina.
| | - Daniela Molena
- Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Hall T, Warnes N, Kuchta K, Novak S, Hedberg H, Linn JG, Haggerty S, Denham W, Joehl RJ, Ujiki M. Patient-Centered Outcomes after Laparoscopic Paraesophageal Hernia Repair. J Am Coll Surg 2018; 227:106-114. [DOI: 10.1016/j.jamcollsurg.2017.12.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 12/12/2017] [Accepted: 12/13/2017] [Indexed: 01/20/2023]
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Abstract
BACKGROUND The management of paraesophageal hernia (PEH) is one of the most debated in surgery. Trends regarding indications, approach (open, laparoscopic, thoracoscopic), sac excision, mesh placement, and routine performance of fundoplication have changed over time. Today, most surgeons tend to perform a laparoscopic PEH repair that entails the excision of the sac, liberal use of a mesh to buttress the hiatus, and the addition of an anti-reflux procedure. Nevertheless, very little has been written on which type of fundoplication should be performed in these patients. Therefore, the goal of our study was to provide an evidence-based overview of which type of fundoplication should be performed during a PEH repair and the role of preoperative function tests in the decision-making METHODS: We searched the MEDLINE, Cochran, PubMed, Google Scholar, and Embase databases for papers published between 1996 and 2016 pertaining to the surgical treatment of PEH. We hand-searched the bibliographies of included studies and we excluded all reviews and case reports. We selected clinical studies and technical reports. We only considered papers stating rationales for the type of fundoplication performed. RESULTS Our search yielded 24 articles: 17 clinical studies and 7 technical reports. In five of the clinical studies, a fundoplication was added only to patients with reflux symptoms. In all clinical studies, the most performed procedure was a total fundoplication (Nissen or Nissen-Rossetti), whereas a partial fundoplication (Toupet more frequently than Dor) or no fundoplication was reserved to those with impaired esophageal motility. All seven technical reports recommended a tailored approach and suggested adding a partial fundoplication (mainly Toupet) when the manometric findings showed esophageal dismotility. CONCLUSION The argument of whether or not a fundoplication should be added to a PEH repair in patients without evidence of reflux still persists. However, this review highlights that, when a fundoplication is performed, a tailored approach based on preoperative function tests is almost always preferred.
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Olson MT, Singhal S, Panchanathan R, Roy SB, Kang P, Ipsen T, Mittal SK, Huang JL, Smith MA, Bremner RM. Primary paraesophageal hernia repair with Gore® Bio-A® tissue reinforcement: long-term outcomes and association of BMI and recurrence. Surg Endosc 2018; 32:4506-4516. [PMID: 29761272 DOI: 10.1007/s00464-018-6200-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 04/21/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic repair remains the gold-standard treatment for paraesophageal hernia (PEH). We analyzed long-term symptomatic outcomes and surgical reintervention rates after primary PEH repair with onlay synthetic bioabsorbable mesh (W. L. Gore & Associates, Inc., Flagstaff, AZ) and examined body mass index (BMI) as a possible risk factor for poor outcomes and for recurrence. METHODS We queried a prospectively maintained database to identify patients who underwent laparoscopic primary PEH repair with onlay patch of a bioprosthetic absorbable mesh (Bio-A® Gore®) between 05/28/2009 and 12/31/2013. Electronic health records were accessed to record demographic and operative data and were reviewed up to the present to identify any repeat procedures. Patients were grouped according to preoperative BMI (A: BMI < 25; B: BMI = 25-29.9; C: BMI = 30-34.9; D: BMI ≥ 35). Patients completed standardized satisfaction and symptom surveys. RESULTS In total, 399 patients were included. Most patients (n = 261; 65.4%) were women. Mean age was 59.6 ± 13.4 years; mean BMI was 29.9 ± 5.0 kg/m2. The patients were grouped as follows: A, 53 patients (13.3%); B, 166 (41.6%); C, 115 (28.8%); D: 65 (16.3%). Four procedures (1.0%) were converted from laparoscopy to open procedures. All patients underwent an antireflux procedure (225 Nissen, 170 Toupet, 4 Dor). A mean follow-up of 44.7 ± 22.8 months was available for 305 patients (76.4%). 24/305 patients (7.9%) underwent reoperation, and the number of reoperations did not differ among groups (P = 0.64). Long-term symptomatic outcomes were available for 217/305 patients (71.1%) at a mean follow-up of 54.0 ± 13.1 months; no significant difference was observed among groups. 194/217 patients (89.4%) reported good to excellent satisfaction, with no significant differences among the groups. CONCLUSIONS Laparoscopic primary PEH repair with onlay Bio-A® mesh is a safe and feasible procedure with excellent long-term patient-centered outcomes and acceptable symptomatic recurrence rate. BMI does not appear to be related to the need for surgical reintervention.
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Affiliation(s)
- Michael T Olson
- Grand Canyon University College of Science, Engineering, and Technology, Phoenix, AZ, USA.,Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA
| | - Saurabh Singhal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA
| | - Roshan Panchanathan
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA.,University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Sreeja Biswas Roy
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA
| | - Paul Kang
- University of Arizona College of Public Health, Phoenix, AZ, USA
| | - Taylor Ipsen
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA.,Midwestern University College of Osteopathic Medicine, Glendale, AZ, USA
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA
| | - Jasmine L Huang
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA
| | - Michael A Smith
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W. Thomas Road, Ste. 500, Phoenix, AZ, 85013, USA.
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Mimatsu K, Oida T, Kida K, Fukino N, Kawasaki A, Kano H, Kuboi Y, Amano S. Simultaneous laparoscopic Nissen fundoplication and percutaneous endoscopic gastrostomy to treat an elderly patient with a large paraesophageal hernia: a case report. Asian J Endosc Surg 2014; 7:165-8. [PMID: 24754880 DOI: 10.1111/ases.12081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 10/25/2013] [Accepted: 11/17/2013] [Indexed: 12/25/2022]
Abstract
Laparoscopic Nissen fundoplication (LNF) and gastrostomy are often performed in children with gastroesophageal reflux disease. With a population that is increasingly aging, the number of elderly patients with paraesophageal hernia who have a nutritional disorder due to dysphagia has increased. In these patients with feeding difficulties, LNF and percutaneous endoscopic gastrostomy (PEG) are effective procedures for providing nutritional support. Here, we describe the case of an 82-year-old woman with paraesophageal hernia and certain comorbidities. She was receiving enteral feeding through a nasogastric tube, which was discontinued because aspiration pneumonia occurred. Therefore, LNF and crural repair without mesh placement were performed. The PEG tube was placed using the Ponsky pull technique under direct visualization with a laparoscope and gastroscope. The patient's nutritional status improved after she received enteral nutrition through the PEG tube. Thus, LNF and PEG may be useful techniques for nutritional support in elderly patients with a large paraesophageal hernia.
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Affiliation(s)
- Kenji Mimatsu
- Department of Surgery, Social Insurance Yokohama Central Hospital, Yokohama, Japan
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