Laparoscopic mesh-augmented hiatoplasty without fundoplication as a method to treat large hiatal hernias

Hiatal Hernias Revisited-A Systematic Review of Definitions, Classifications, and Applications

INTRODUCTION

A hiatal hernia (HH) can be defined as a condition in which elements from the abdominal cavity herniate through the oesophageal hiatus in the mediastinum and, in the majority of cases, parts of the proximal stomach. Today, the role of HHs within the complex entity of gastroesophageal reflux disease (GERD) is very important with regard to its pathophysiology, severity, and therapeutic and prognostic options. Despite this, the application and stringent use of the worldwide accepted classification (Skinner and Belsey: Types I-IV) are lacking. The aim of this study was to carry out a systematic review of the clinical applications of HH classifications and scientific documentation over time, considering their value in diagnosis and treatment.

METHODS

Following the PRISMA concept, all abstracts published on pubmed.gov until 12/2023 (hiatal hernia) were reviewed, and those with a focus and clear description of the application of the current HH classification in the full-text version were analysed to determine the level of classification and its use within the therapeutic context.

RESULTS

In total, 9342 abstracts were screened. In 9199 of the abstracts, the reports had a different focus than HH, or the HH classification was not used or was incompletely applied. After further investigation, 60 papers were used for a detailed analysis, which included more than 12,000 patient datapoints. Among the 8904 patients, 83% had a Type I HH; 4% had Type II; 11% had Type III; and 1% had Type IV. Further subgroup analyses were performed. Overall, the precise application of the HH classification has been insufficient, considering that only 1% of all papers and only 54% of those with a special focus on HH have documented its use.

CONCLUSIONS

The application and documentation of a precise HH classification in clinical practice and scientific reports are decreasing, which should be rectified for the purpose of scientific comparability.

Hiatal Hernia Repair With Tension-Free Mesh or Crural Sutures Alone in Antireflux Surgery: A 13-Year Follow-Up of a Randomized Clinical Trial

Importance

Antireflux surgery is an effective treatment of gastroesophageal reflux disease (GERD), but the durability of concomitant hiatal hernia repair remains challenging. Previous research reported that the use of a mesh-reinforced, tension-free technique was associated with more dysphagia for solid foods after 3 years without reducing hiatal hernia recurrence rates compared with crural sutures alone, but the long-term effects of this technique have not been assessed.

Objective

To assess the long-term anatomical and functional outcomes of using a mesh for hiatal hernia repair in patients with GERD.

Design, Setting, and Participants

A double-blind, randomized clinical trial was performed at a single center (Ersta Hospital, Stockholm, Sweden) from January 11, 2006, to December 1, 2010. A total of 159 patients were recruited and randomly assigned. Data for the current analysis were collected from September 1, 2021, to March 31, 2022. All analyses were conducted with the intention-to-treat population.

Interventions

Closure of the diaphragmatic hiatus with crural sutures alone vs a tension-free technique using a nonabsorbable polytetrafluoroethylene mesh (Bard CruraSoft).

Main Outcomes and Measures

The primary outcome was radiologically verified recurrent hiatal hernia after more than 10 years. Secondary outcomes were dysphagia scores (ranging from 1 to 4, with 1 indicating no episodes of dysphagia and 4 indicating more than 3 episodes of dysphagia per day) for solid and liquid foods, generic 36-Item Short Form Health Survey and disease-specific Gastrointestinal Symptom Rating Scale symptom assessment scores, proton pump inhibitor consumption, and reoperation rates. Intergroup comparisons of parametric data were performed using t tests; for nonparametric data, Mann-Whitney U, χ2, or Fisher exact tests were used. For intragroup comparisons vs the baseline at follow-up times, the Friedman test was used, and post hoc analysis was performed using Wilcoxon matched pairs.

Results

Of 145 available patients, follow-up data were obtained from 103 (response rate 71%; mean [SD] age at follow-up, 65 [11.3] years; 55 [53%] female), with 53 initially randomly assigned to mesh reinforcement, and 50 to crural suture alone. The mean (SD) follow-up time was 13 (1.1) years. The verified radiologic hiatal hernia recurrence rates were 11 of 29 (38%) in the mesh group vs 11 of 35 (31%) in the suture group (P = .61). However, 13 years postoperatively, mean (SD) dysphagia scores for solids remained significantly higher in the mesh group (mean [SD], 1.9 [0.7] vs 1.6 [0.9]; P = .01).

Conclusions and Relevance

Findings from this long-term follow-up of a randomized clinical trial suggest that tension-free crural repair with nonabsorbable mesh does not reduce the incidence of hiatal hernia recurrence 13 years postoperatively. This finding combined with maintained higher dysphagia scores does not support the routine use of tension-free polytetrafluoroethylene mesh closure in laparoscopic hiatal hernia repair for treatment of GERD.

Trial Registration

ClinicalTrials.gov Identifier: NCT05069493.

5-Year Collis-Nissen Gastroplasty Outcomes for Type III-IV Hiatal Hernia with Short Esophagus: A Prospective Observational Study

BACKGROUND

To assess the 5-year outcomes of patients undergoing Collis-Nissen gastroplasty for type III-IV hiatal hernia with short esophagus.

STUDY DESIGN

From a prospective observational cohort of patients who underwent antireflux surgery for type III-IV hiatal hernia between 2009 and 2020, those with short esophagus (abdominal length <2.5 cm) in whom a Collis-Nissen procedure was performed and reached at least 5 years of follow-up were identified. Hernia recurrence, patients' symptoms, and quality of life were assessed annually by barium meal x-ray, upper endoscopy, and validated symptoms and Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaires.

RESULTS

Of the 114 patients with Collis-Nissen gastroplasty, 80 patients who completed a 5-year follow-up were included (mean age 71 years). There were no postoperative leaks or deaths. Recurrent hiatal hernia (any size) was identified in 7 patients (8.8%). Heartburn, regurgitation, chest pain, and cough were significantly improved at each follow-up interval (p < 0.05). Preoperative dysphagia disappeared or improved in 26 of 30 patients, while new-onset dysphagia occurred in 6. Mean postoperative QOLRAD scores significantly improved at all dimensions (p < 0.05).

CONCLUSIONS

Collis gastroplasty combined with Nissen fundoplication provides low hernia recurrence, good control of symptoms, and improved quality of life in patients with large hiatal hernia and short esophagus.

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.

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.

Management of paraesophageal hernia review of clinical studies: timing to surgery, mesh use, fundoplication, gastropexy and other controversies

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.

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.

Paraesophageal hernia repair with bifacial mesh

Background.The paraesophageal hiatus hernias (PHH) are relatively uncommon, but an increased incidence has been reported and they now account for 5-10% of all hiatus hernias. The surgical treatment is recommended for all the patients with this pathology because of high risk of complications: obstruction, incarceration, strangulation or perforation. The use of prostheses is recommended in the process of repairing the giant PHH because the main problem of this operation is the high rate of recurrence. Case presentation.The patient is a 44-year-old male with a large and symptomatic paraesophageal hernia. Diagnosis was confirmed by instrumental examination. An elective laparoscopic repair was carried out by using polypropylene bifacial anti adhesive synthetic mesh (Surgimesh XB Aspide Medical). The postoperative period passed without severe complications. Conclusions.The laparoscopic approach as a therapeutic option can be successfully used in the repair of paraesophageal hernia. A selective use based on clinical experience was recommended, as the technique appeared to be safe, and in case of large hiatus hernia with hiatal defect, greater than 5 cm, the application of synthetic material to minimize the recurrence rate was recommended.

The importance of the mesh shape in preventing recurrence after Nissen fundoplication

Gastro esophageal reflux disease (GERD) is the most common gastrointestinal disorder and often is associated with hiatal hernia (HH). Nissen fundoplication is the most common surgical treatment method. Despite surgical treatment, recurrence rate is still high. In this study, we aimed to identify the importance of the mesh shape in preventing recurrence after Nissen fundoplication. A hundred twenty two patients who operated Nissen fundoplication owing to GERD and/or HH were evaluated. Nissen fundoplication was made all patients. Patients were divided into three groups according to hiatoplasty procedure; group 1 (V-shaped mesh), group 2 (V-shaped mesh + Fibrin glue), and group 3 (special designed mesh, Kar's mesh). Groups were compared regarding intraoperative, postoperative early- and long-term complications. Mean age was 42.75 years, and male to female ratio was 1:2.98. The mean follow-up period was 27 mounts. There was no mortality during follow-up. The most common presenting symptom was heartburn (93.4%). There wasn't difference between groups in terms of the intraoperative complications and postoperative early-term complications. The overall recurrences rate was 4.9% and dysphagia > 3 months rate was 1.6%. No recurrence was not observed in group 3, while recurrence was observed in 4 patients in group 1 (P = 0.030). Patients should be carefully selected for surgery because complication rate is high despite successful anti-reflux surgical treatment. In this study, we have used a special designed mesh. We believe that this special designed mesh can be used safely and effectively in anti-reflux surgery because recurrence and complications were not observed.

Repair of Paraesophageal Hiatal Hernias—Is a Fundoplication Needed? A Randomized Controlled Pilot Trial

BACKGROUND

The need for a fundoplication during repair of paraesophageal hiatal hernias (PEH) remains unclear. Prevention of gastroesophageal reflux represents a trade-off against the risk of fundoplication-related side effects. The aim of this trial was to compare laparoscopic mesh-augmented hiatoplasty with simple cardiophrenicopexy (LMAH-C) with laparoscopic mesh-augmented hiatoplasty with fundoplication (LMAH-F) in patients with PEH.

STUDY DESIGN

The study was designed as a patient- and assessor-blinded randomized controlled pilot trial, registration number: DRKS00004492 (www.germanctr.de/). Patients with symptomatic PEH were eligible and assigned by central randomization to LMAH-C or LMAH-F. Endpoints were postoperative gastroesophageal reflux, complications, and quality of life 12 months postoperatively.

RESULTS

Forty patients (9 male, 31 female) were randomized. Patients were well matched for baseline characteristics. At 3 months, the DeMeester score was higher after LMAH-C compared with LMAH-F (40.9 ± 39.9 vs. 9.6 ± 17; p = 0.048). At 12 months, the reflux syndrome score was higher after LMAH-C compared with LMAH-F (1.9 ± 1.2 vs. 1.1 ± 0.4; p = 0.020). In 53% of LMAH-C patients and 17% of LMAH-F patients, postoperative esophagitis was present (p = 0.026). Values of dysphagia (2.1 ± 1.6 vs 1.9 ± 1.4; p = 0.737), gas bloating (2.6 ± 1.4 vs 2.8 ± 1.4; p = 0.782), and quality of life (116.0 ± 16.2 vs 115.9 ± 15.8; p = 0.992) were similar. Relevant postoperative complications occurred in 4 (10%) patients and did not differ between the groups.

CONCLUSIONS

Laparoscopic repair of PEH should be combined with a fundoplication to avoid postoperative gastroesophageal reflux and resulting esophagitis. Fundoplication-related side effects do not appear to be clinically relevant. Multicenter randomized trials are required to confirm these findings.

Polypropylene, polyester or polytetrafluoroethylene-is there an ideal material for mesh augmentation at the esophageal hiatus? Results from an experimental study in a porcine model

PURPOSE

Knowledge about the influence of underlying biomaterial on behavior of surgical meshes at the esophageal hiatus is rare, but essential for safe and effective hiatal hernia surgery. This study aimed to characterize the influence of polymer material on mesh behavior at the hiatus.

METHODS

24 pigs in three groups of eight underwent implantation of either polypropylene (PP), polyester (PET) or polytetrafluoroethylene (PTFE) mesh placed circularly at the esophageal hiatus. After 8 weeks, necropsy and measurements were performed evaluating mesh deformation, adhesion formation, fixation of the esophagogastric junction and mesh position. Foreign body reaction was assessed by mononuclear cell count and immunostaining of Ki-67. Tissue integration was evaluated by immunostaining of type I and type III collagen fibers.

RESULTS

Mesh shrinkage was the highest for PTFE, lower for PP and the lowest for PET (34.9 vs. 19.8 vs. 12.1 %; p = 0.002). Mesh aperture for the esophagus showed an enlargement within all groups, which was highest for PTFE compared to PP and PET (100.8 vs. 47.0 vs. 35.9 %; p = 0.001). The adhesion score was highest for PP, lower for PTFE and the lowest for PET (11.0 vs. 9.5 vs. 5.0; p = 0.001) and correlated positively with the score of esophagogastric fixation (r s = 0.784, p < 0.001). No mesh migration, erosion or stenosis of the esophagus occurred. Evaluation of foreign body reaction and tissue integration showed no significant differences.

CONCLUSIONS

In this experimental setting, PP-meshes showed the most appropriate characteristics for augmentation at the hiatus. Due to solid fixation of the esophagogastric junction and low shrinkage tendency, PP-meshes may be effective in preventing hiatal hernia recurrence. The use of PTFE-mesh at the hiatus may be disadvantageous due to high shrinkage rates and correlating enlargement of the aperture for the esophagus.

The laparoscopic hiatoplasty with antireflux surgery is a safe and effective procedure to repair giant hiatal hernia

BACKGROUND

Although minimally invasive repair of giant hiatal hernias is a very surgical challenge which requires advanced laparoscopic learning curve, several reports showed that is a safe and effective procedure, with lower morbidity than open approach. In the present study we show the outcomes of 13 patients who underwent a laparoscopic repair of giant hiatal hernia.

METHODS

A total of 13 patients underwent laparoscopic posterior hiatoplasty and Nissen fundoplication. Follow-up evaluation was done clinically at intervals of 3, 6 and 12 months after surgery using the Gastro-oesophageal Reflux Health-Related Quality of Life scale, a barium swallow study, an upper gastrointestinal endoscopy, an oesophageal manometry, a combined ambulatory 24-h multichannel impedance pH and bilirubin monitoring. Anatomic recurrence was defined as any evidence of gastric herniation above the diaphragmatic edge.

RESULTS

There were no intraoperative complications and no conversions to open technique. Symptomatic GORD-HQL outcomes demonstrated a statistical significant decrease of mean value equal to 3.2 compare to 37.4 of preoperative assessment (p < 0.0001). Combined 24-h multichannel impedance pH and bilirubin monitoring after 12 months did not show any evidence of pathological acid or non acid reflux.

CONCLUSION

All patients were satisfied of procedure and no hernia recurrence was recorded in the study group, treated respecting several crucial surgical principles, e.g., complete sac excision, appropriate crural closure, also with direct hiatal defect where possible, and routine use of antireflux procedure.

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.