A Combined Nissen Plus Hill Hybrid Repair for Paraesophageal Hernia Improves Clinical Outcomes and Reduces Long-Term Recurrences Compared with Laparoscopic Nissen Alone

EAES Multidisciplinary Rapid Guideline: systematic review, meta-analysis, GRADE assessment and evidence-informed recommendations on the surgical management of paraesophageal hernias

BACKGROUND

New evidence has emerged since latest guidelines on the management of paraesophageal hernia, and guideline development methodology has evolved. Members of the European Association for Endoscopic Surgery have prioritized the management of paraesophageal hernia to be addressed by pertinent recommendations.

OBJECTIVE

To develop evidence-informed clinical practice recommendations on paraesophageal hernias, through evidence synthesis and a structured evidence-to-decision framework by an interdisciplinary panel of stakeholders.

METHODS

We performed three systematic reviews, and we summarized and appraised the certainty of the evidence using the GRADE methodology. A panel of general and upper gastrointestinal surgeons, gastroenterologists and a patient advocate discussed the evidence in the context of benefits and harms, the certainty of the evidence, acceptability, feasibility, equity, cost and use of resources, moderated by a Guidelines International Network-certified master guideline developer and chair. We developed the recommendations in a consensus meeting, followed by a modified Delphi survey.

RESULTS

The panel suggests surgery over conservative management for asymptomatic/minimally symptomatic paraesophageal hernias (conditional recommendation), and recommends conservative management over surgery for asymptomatic/minimally symptomatic paraesophageal hernias in frail patients (strong recommendation). Further, the panel suggests mesh over sutures for hiatal closure in paraesophageal hernia repair, fundoplication over gastropexy in elective paraesophageal hernia repair, and gastropexy over fundoplication in patients who have cardiopulmonary instability and require emergency paraesophageal hernia repair (conditional recommendation). A strong recommendation means that the proposed course of action is appropriate for the vast majority of patients. A conditional recommendation means that most patients would opt for the proposed course of action, and joint decision-making of the surgeon and the patient is required. Accompanying evidence summaries and evidence-to-decision frameworks should be read when using the recommendations. This guideline applies to adult patients with moderate to large paraesophageal hernias type II to IV with at least 50% of the stomach herniated to the thoracic cavity. The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/j7q7Gn .

CONCLUSION

An interdisciplinary panel provides recommendations on key topics on the management of paraesophageal hernias using highest methodological standards and following a transparent process.

GUIDELINE REGISTRATION NUMBER

PREPARE-2023CN018.

The Nissen-Hill Hybrid Repair: Experience with the First 500

INTRODUCTION

A new repair for gastroesophageal reflux and hiatal hernia, the Nissen-Hill hybrid repair (HYB), was developed to combine the relative strengths of its component repairs with the aim of improved durability. In several small series' it has been shown to be safe, effective and durable for paraesophageal hernia (PEH) , Barrett's esophagus (BE) and gastroesophageal reflux disease (GERD). This study represents our experience with the first 500 consecutive repairs for all indications .

METHODS

Retrospective study of prospectively collected data for the first 500 consecutive HYB repairs from March 2006 to December 2016 including all indications for surgery. Three quality of life metrics, manometry, radiographic imaging, and pH testing were administered before and at defined intervals after repair.

RESULTS

500 patients with median follow up of 6.1 years. Indications for surgery were GERD in 231 (46.2%), PEH in 202 (40.4%), and re-operative repair in 67 (13.4%). The mean age was 59, with BMI of 30 and 63% female. A minimally invasive approach was used in 492 (98%). Thirty-day operative mortality was 1 (0.2%), with a 4% major complication rate and a median length of stay of 2 days. Preoperative to postoperative pH testing was available for 390 patients at a median follow-up of 7.3 months, with median DeMeester score improving from 45.9 to 2.7. At long-term follow-up (229 responses) all median quality of life scores improved: QOLRAD 4 to 6.9, GERD-HRQL 22 to 3 and Swallowing 37.5 to 45 and proton pump inhibitor use dropped from 460 (92%) to 50 (10%) Fourteen (2.8%) underwent re-operation for failure.

CONCLUSION

The combined Nissen-Hill hybrid repair is safe and effective in achieving excellent symptomatic and objective outcomes and low recurrence rates beyond 5 years.

The role of laparoscopic Nissen, Hill, and Nissen-Hill hybrid repairs for uncomplicated gastroesophageal reflux disease

There are several elements that constitute the lower esophageal barrier against reflux. What characterizes the abnormality seen in gastroesophageal reflux disease (GERD) is the loss of an effective barrier combined with refluxed gastric contents. Several techniques including those described by Nissen, Toupet, and Hill have become options for reconstructing the physiologic barrier. In this paper, we describe our technique of performing laparoscopic Nissen, Hill, and a combined Nissen-Hill hybrid repair for the management of uncomplicated GERD. In a randomized study comparing 46 laparoscopic Nissen to 56 laparoscopic Hill repairs, subjective and objective short term and long term (13 months) outcomes including use of antisecretory agents were equivalent. The number of failures requiring reoperation were also the same but the difference in failure types prompted us to examine the two techniques and fuse them into one to maximize the integrity of the lower esophageal barrier. A comparative study of the Nissen, Hill, and hybrid repairs with 15-month follow-up showed similar subjective and objective outcomes and specifically no increase in dysphagia for the combined repair. There was also a trend towards less recurrence the hybrid group. More recently, we studied our Nissen repairs and compared them to hybrid repairs over a 22-month median follow-up period. Quality of life outcomes were superior for the hybrid group in all domains. For the subset of patients with a mean follow-up of 60 months the anatomic recurrence rate was 5% in the hybrid group compared to 45% in the Nissen group. These data strongly suggest that the anchoring of gastroesophageal junction with Hill sutures reduces the axial stresses on the Nissen wrap to maintain its integrity. The laparoscopic Nissen, and laparoscopic Hill procedures have been proven to have excellent results for the treatment of GERD. Larger studies are underway to demonstrate the long-term durability of the hybrid Nissen-Hill procedure in the management of GERD.

A Hill Gastropexy Combined with Nissen Fundoplication Appears Equivalent to a Collis-Nissen in the Management of Short Esophagus

INTRODUCTION

A Collis gastroplasty combined with a Nissen fundoplication is commonly used when a shortened esophagus is encountered. An alternative combines intra-abdominal fixation of the gastroesophageal junction via a Hill gastropexy with a Nissen fundoplication to maintain length and avoid juxtaposing acid-secreting tissue against the diseased esophagus.

METHODS

A retrospective case-controlled analysis of 106 consecutive patients with short esophagus undergoing Hill-Nissen (HN) or Collis-Nissen (CN) was compared to a cohort of 105 matched patients without short esophagus undergoing primary Nissen fundoplication (NF).

RESULTS

At a median follow-up of 27 months, all groups (HN:CN:NF) improved significantly over preoperative baseline with no differences in overall complications (18 vs 16 vs 19%, p = 0.78), DeMeester score (11.1 vs 19.1 vs 14.2, p = 0.49), postoperative PPI use (16 vs 22 vs 15%, p = 0.24), anatomic recurrences (11.7 vs 5.5 vs 7%, p = 0.43), or quality of life (6.8 vs 6.7 vs 6.4, p = 0.3).

CONCLUSIONS

The management of shortened esophagus with Hill-Nissen is safe and as effective as Collis gastroplasty with Nissen fundoplication. Both options appear to produce similar outcomes to patients requiring only a Nissen fundoplication suggesting a shortened esophagus does not beget an inferior outcome.

Tri-comparison of Laparoscopic Nissen, Hill, and Nissen-Hill Hybrid Repairs for Uncomplicated Gastroesophageal Reflux Disease

BACKGROUND

A randomized controlled trial (RCT) showed that laparoscopic Nissen fundoplication (LNF) and Hill (LHR) repairs are equivalent in treating uncomplicated GERD. We combined both repairs to create a laparoscopic Nissen-Hill Hybrid repair (HYB). The purpose of this study is to compare clinical and objective outcomes of a matched group of HYB to the two cohorts of the RCT.

METHODS

A retrospective analysis of prospectively collected data from the RCT and a prospectively collected data base was performed. Data were collected preoperatively, postoperatively short-term (ST) at 6 weeks and mid-term (MT) at 6-12 months. Evaluation was standardized according to the RCT and included three quality of life metrics (QOLRAD, GERD-HRQL, Dysphagia), endoscopy, manometry, pH testing, and barium swallow.

RESULTS

There were 51 HYB, 46 LNF, and 56 LHR patients. Age, BMI, follow-up, and gender were comparable. QOLRAD, HRQL, PPI use, DeMeester scores, and pH% time <4 significantly improved in all groups and were equivalent. Anatomic recurrence was seen in five LNF, four LHR, and two HYB patients. Reoperations were performed in three LHR, two LNF, and zero HYB patients.

CONCLUSION

Tri-comparison shows that HYB is a promising alternative to LHR and LNF. Side effects were not increased and there were fewer reoperations for failure.