Less is more: cruroplasty alone is sufficient for revisional hiatal hernia surgery

Gastroesophageal reflux disease: indications for antireflux surgery, outcomes, and side effects

INTRODUCTION

Gastroesophageal reflux disease (GERD) is a frequent digestive disorder that presents with a broad spectrum of symptoms. Global consensus on which patients should be selected for anti-reflux surgery is lacking.

AREAS COVERED

This evidence-based review will analyze current indications for anti-reflux surgery, outcomes of the operation, and potential side effects.

EXPERT COMMENTARY

Treatment of GERD has three main purposes: control symptoms, improve quality of life, and prevent potential serious complications such as bleeding, esophageal stenosis, Barrett's esophagus, and esophageal adenocarcinoma. Although medical therapy is effective in the majority of patients, some might require anti-reflux surgery in order to achieve these goals. Adequate patient selection for anti-reflux surgery is critical to obtain optimal outcomes. Most patients undergoing a fundoplication have adequate long-term symptomatic relief. However, potential side effects of anti-reflux surgery should also be discussed with patients to help manage expectations from the operation.

Cruroplasty as a standalone treatment for recurrent hiatal hernia repair

PURPOSE

Following laparoscopic anti-reflux surgery (LARS), recurrence of hiatal hernia is common. Patients with symptomatic recurrence typically undergo revision of the fundoplication or conversion to magnetic sphincter augmentation (MSA) in addition to cruroplasty. However, patients with an intact fundoplication or MSA may only require repeat cruroplasty to repair their recurrent hiatal hernia. The purpose of this study is to compare outcomes following cruroplasty alone compared to full revision (i.e. redo fundoplication or MSA with cruroplasty) for the management of recurrent hiatal hernias.

METHODS

A retrospective review of patients undergoing surgical revision of a symptomatic recurrent hiatal hernia between February 2009 and October 2022 was performed. Preoperative characteristics, intraoperative details, and postoperative outcomes were compared between patients undergoing cruroplasty alone versus full revision.

RESULTS

A total of 141 patients were included in the analysis. 93 patients underwent full revision, and 48 patients underwent cruroplasty alone. The mean time between initial and revisional surgery was 8 ± 7.7 years. There was no significant difference in operative time or rates of intra-operative or post-operative complication between groups. Patients undergoing cruroplasty alone had a mean Gastroesophageal Reflux Disease Health Related Quality Life (GERD-HRQL) Questionnaire score of 9.6 ± 10.2 compared to a mean score of 8.9 ± 11.2 for full revision patients (p = 0.829). Recurrence rates following revision was 10.4% for cruroplasty alone patients and 11.8% in full revision patients (p > 0.999).

CONCLUSION

In patients with intact fundoplication or MSA, cruroplasty alone results in similar post-operative outcomes compared to full revision for recurrent hiatal hernia.

Laparoscopic revision paraesophageal hernia repair: a 16-year experience at a single institution

BACKGROUND

Laparoscopic paraesophageal hernia repair (PEHr) is a safe and effective procedure for relieving foregut symptoms associated with paraesophageal hernias (PEH). Nonetheless, it is estimated that about 30-50% of patients will have symptomatic recurrence requiring additional surgical intervention. Revision surgery is technically demanding and may be associated with a higher rate of morbidity and poor patient-reported outcomes. We present the largest study of perioperative and quality-of-life outcomes among patients who underwent laparoscopic revision PEHr.

METHODS

A retrospective review of all patients who underwent laparoscopic revision paraesophageal hernia repair between February 2003 and October 2019, at a single institution was conducted. All revisions of Type I hiatal hernias were excluded. The following validated surveys were used to evaluate quality-of-life outcomes: Reflux Symptom Index (RSI) and Gastroesophageal Reflux Disease Health-Related QOL (GERD-HRQL). Patient demographic, perioperative, and quality-of-life (QOL) data were analyzed using univariate analysis.

RESULTS

One hundred ninety patients were included in the final analysis (63.2% female, 90.5% single revision, 9.5% multiple revisions) with a mean age, BMI, and age-adjusted Charlson score of 56.6 ± 14.7 years, 29.7 ± 5.7 kg/m², and 2.04 ± 1.9, respectively. The study cohort consisted of type II (49.5%), III (46.3%), and IV hiatal hernia (4.2%), respectively. Most patients underwent either a complete (68.7%) or partial (27.7%) fundoplication. A Collis gastroplasty was performed in 14.7% of patients. The median follow-up was 17.6 months. The overall morbidity and mortality rate were 15.8% and 1.1%, respectively. The 30-day readmission rate was 9.5%. Additionally, at latest follow-up 47.9% remained on antireflux medication. At latest follow-up, there was significant improvement in mean RSI score (46.4%, p < 0.001) from baseline within the study population. Furthermore, there was no significant difference in QOL between patients who had a history of an initial repair only or history of revision surgery at latest review. The overall recurrence rate was 16.3% with 6.3% requiring a surgical revision.

CONCLUSION

Laparoscopic revision PEHr is associated with a low rate of morbidity and mortality. Revision surgery may provide improvement in QOL outcomes, despite the high rate of long-term antireflux medication use. The rate of recurrent paraesophageal hernia remains low with few patients requiring a second revision. However, longer follow-up is needed to better characterize the long-term recurrence rate and symptomatic improvements.

What works best in hiatus hernia repair, sutures alone, absorbable mesh or non-absorbable mesh? A systematic review and network meta-analysis of randomized clinical trials

Laparoscopic hiatal hernia repair (HHR) and fundoplication is a common low risk procedure providing excellent control of gastro-oesophageal reflux disease and restoring of normal anatomy at the hiatus. HHR may fail, however, resulting in hiatus hernia (HH) recurrence, and the use of tension-free mesh-augmented hernioplasty has been proposed to reduce recurrence. Previous research on this topic has been heterogeneous, including study methods, mesh type used and technique performed. A systematic review and network meta-analysis were carried out. An electronic systematic research was carried out using 'PUBMED', 'EMBASE', 'Medline (OVID)' and 'Web of Science', of articles identifying HHR with suture cruroplasty, non-absorbable mesh (NAM) and absorbable mesh (AM) reinforcement. Eight RCTs with 766 patients were evaluated. NAM had significantly (P < 0.05) lower early recurrence rates (OR: 0.225, 95% CI 0.0342, 0.871) compared with suture repair alone; however, no differences in late recurrences were evident. For AM, no difference in early (0.508, 95% CI 0.0605, 4.81) or late (1.07. 95% CI 0.116, 11.4) recurrence rates were evident compared with the suture only group. Major complication rates were similar in all groups. NAM reinforcement significantly reduced early HH recurrence when compared with sutured cruroplasty alone; however, late recurrence rates were similar with all techniques. Given the limited data in comparing AM with NAM, this study was unable to conclude which composition was significant. We emphasize caution when interpreting small sample size RCTs, and recommend more research with larger randomized studies.

The Controversial Role of Concurrent Crural Plasty in Bariatric Surgery: Where Is the Evidence?

Gastroesophageal reflux disease is diagnosed at an alarming rate after laparoscopic sleeve gastrectomy. Revisional surgery with conversion to Roux-en-Y gastric bypass does not guarantee reflux control and is associated with morbidity. There is a need to optimize the objective foregut patient pathway prior to bariatric surgery and to perform concurrent hiatal repair in individuals with a defective esophago-gastric junction and abnormal esophageal acid exposure. The role of adjunctive surgical procedures (hiatal reinforcement, fundoplication, magnetic sphincter augmentation) is still controversial due to lack of follow-up and standardized reporting, and current recommendations are based on expert opinion or case series.

Characteristics and outcomes of patients undergoing paraesophageal hernia repair with selective use of biologic mesh

BACKGROUND

The use of biologic mesh in paraesophageal hernia repair (PEHR) has been associated with decreased short-term recurrence but no statistically significant difference in long-term recurrence. Because of this, we transitioned from routine to selective use of mesh for PEHR. The aim of this study was to examine our indications for selective mesh use and to evaluate patient outcomes in this population.

METHODS

We queried a prospectively maintained database for patients who underwent laparoscopic PEHR with biologic mesh from October 2015 to October 2018, then performed a retrospective chart review. The decision to use mesh was made intraoperatively by the surgeon. Recurrence was defined as the presence of > 2 cm intrathoracic stomach on postoperative upper gastrointestinal (UGI) series.

RESULTS

Mesh was used in 61/169 (36%) of first-time PEHRs, and in 47/82 (57%) of redo PEHRs. Among first-time PEHRs, the indications for mesh included hiatal tension (85%), poor crural tissue quality (11%), or both (5%). Radiographic recurrence occurred in 15% of first-time patients (symptomatic N = 2, asymptomatic N = 3). There were no reoperations for recurrence. Among redo PEHRs, the indication for mesh was most commonly the redo nature of the repair itself (55%), but also hiatal tension (51%), poor crural tissue quality (13%), or both (4%). Radiographic recurrence occurred in 21% of patients (symptomatic N = 4, asymptomatic N = 1). There was 1 reoperation for recurrence in the redo-repair group.

CONCLUSIONS

We selectively use biologic mesh in a third of our first-time repair patients and in over half of our redo-repair patients when there is a perceived high risk of recurrence based on hiatal tension, poor tissue quality, or prior recurrence. Despite the high risk for radiologic recurrence, there was only 1 reoperation for recurrence in the entire cohort.