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Nickel F, Müller PC, Cizmic A, Häberle F, Muller MK, Billeter AT, Linke GR, Mann O, Hackert T, Gutschow CA, Müller-Stich BP. Evidence mapping on how to perform an optimal surgical repair of large hiatal hernias. Langenbecks Arch Surg 2023; 409:15. [PMID: 38123861 PMCID: PMC10733223 DOI: 10.1007/s00423-023-03190-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 11/19/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Symptomatic and large hiatal hernia (HH) is a common disorder requiring surgical management. However, there is a lack of systematic, evidence-based recommendations summarizing recent reviews on surgical treatment of symptomatic HH. Therefore, this systematic review aimed to create evidence mapping on the key technical issues of HH repair based on the highest available evidence. METHODS A systematic review identified studies on eight key issues of large symptomatic HH repair. The literature was screened for the highest level of evidence (LE from level 1 to 5) according to the Oxford Center for evidence-based medicine's scale. For each topic, only studies of the highest available level of evidence were considered. RESULTS Out of the 28.783 studies matching the keyword algorithm, 47 were considered. The following recommendations could be deduced: minimally invasive surgery is the recommended approach (LE 1a); a complete hernia sac dissection should be considered (LE 3b); extensive division of short gastric vessels cannot be recommended; however, limited dissection of the most upper vessels may be helpful for a floppy fundoplication (LE 1a); vagus nerve should be preserved (LE 3b); a dorso-ventral cruroplasty is recommended (LE 1b); routine fundoplication should be considered to prevent postoperative gastroesophageal reflux (LE 2b); posterior partial fundoplication should be favored over other forms of fundoplication (LE 1a); mesh augmentation is indicated in large HH with paraesophageal involvement (LE 1a). CONCLUSION The current evidence mapping is a reasonable instrument based on the best evidence available to guide surgeons in determining optimal symptomatic and large HH repair.
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Affiliation(s)
- Felix Nickel
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
- Department of General, Visceral and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany.
| | - Philip C Müller
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Amila Cizmic
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Frida Häberle
- Department of General, Visceral and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus K Muller
- Department of Surgery, Cantonal Hospital Thurgau, Frauenfeld, Switzerland
| | - Adrian T Billeter
- Department of Digestive Surgery, University Digestive Healthcare Center Basel, Basel, Switzerland
| | - Georg R Linke
- Department of Surgery, Hospital STS Thun AG, Thun, Switzerland
| | - Oliver Mann
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Christian A Gutschow
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Beat P Müller-Stich
- Department of Digestive Surgery, University Digestive Healthcare Center Basel, Basel, Switzerland
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Tsoposidis A, Thorell A, Axelsson H, Reuterwall Hansson M, Lundell L, Wallenius V, Kostic S, Håkanson B. The value of "diaphragmatic relaxing incision" for the durability of the crural repair in patients with paraesophageal hernia: a double blind randomized clinical trial. Front Surg 2023; 10:1265370. [PMID: 38026477 PMCID: PMC10667682 DOI: 10.3389/fsurg.2023.1265370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Background Surgical repair of paraesophageal hernias (PEHs) is burdened with high recurrence rates, and hitherto various techniques explored to enforce the traditional crural repair have not been successful. The hiatal reconstruction in PEH is exposed to significant tension, which may be minimized by adding a diaphragmatic relaxing incision to enhance the durability of the crural repair. Patients and methods All individuals undergoing elective laparoscopic repair of a large PEH, irrespective of age, were considered eligible. PEHs were classified into types II-IV. The preoperative work-up program included multidetector computed tomography and symptom assessment questionnaires, which will be repeated during the postoperative follow-up. Patients were randomly divided into a control group with crural repair alone and an intervention group with the addition of a left-sided diaphragmatic relaxing incision at the edge of the upper pole of the spleen. The diaphragmatic defect was then covered by a synthetic mesh. Results The primary endpoint of this trial was the rate of anatomical PEH recurrence at 1 year. Secondary endpoints included symptomatic gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular and pulmonary symptoms, and patient satisfaction in the immediate postoperative course (3 months) and at 1 year. Postoperative complications, morbidity, and disease burden were recorded for each patient. This was a double-blind study, meaning that the operation report was filed in a locked archive to keep the patient, staff, and clinical assessors blinded to the study group allocation. Blinding must not be broken during the follow-up unless required by any emergencies in the clinical management of the patient. Likewise, the patients must not be informed about the details of the operation. Trial Registration ClinicalTrials.gov, identification number NCT04179578.
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Affiliation(s)
- A. Tsoposidis
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - A. Thorell
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - H. Axelsson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital Östra, University of Gothenburg, Gothenburg, Sweden
| | - M. Reuterwall Hansson
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - L. Lundell
- Division of Surgery and Oncology CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - V. Wallenius
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital Östra, University of Gothenburg, Gothenburg, Sweden
| | - S. Kostic
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital Östra, University of Gothenburg, Gothenburg, Sweden
| | - B. Håkanson
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Ersta Hospital, Stockholm, Sweden
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