Management of symptomatic, asymptomatic, and recurrent hiatal hernia: a systematic review and meta-analysis

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.

BRAZILIAN HERNIA AND ABDOMINAL WALL SOCIETY STATEMENT ON LARGE HIATAL HERNIAS MANAGEMENT

Large hiatal hernias, besides being more prevalent in the elderly, have a different clinical presentation: less reflux, more mechanical symptoms, and a greater possibility of acute, life-threatening complications such as gastric volvulus, ischemia, and visceral mediastinal perforation. Thus, surgical indications are distinct from gastroesophageal reflux disease-related sliding hiatal hernias. Heartburn tends to be less intense, while symptoms of chest pain, cough, discomfort, and tiredness are reported more frequently. Complaints of vomiting and dysphagia may suggest the presence of associated gastric volvulus. Signs of iron deficiency and anemia are found. Surgical indication is still controversial and was previously based on high mortality reported in emergency surgeries for gastric volvulus. Postoperative mortality is especially related to three factors: body mass index above 35, age over 70 years, and the presence of comorbidities. Minimally invasive elective surgery should be offered to symptomatic individuals with good or reasonable performance status, regardless of age group. In asymptomatic and oligosymptomatic patients, besides obviously identifying the patient's desire, a case-by-case analysis of surgical risk factors such as age, obesity, and comorbidities should be taken into consideration. Attention should also be paid to situations with greater technical difficulty and risks of acute migration due to increased abdominal pressure (abdominoplasty, manual labor, spastic diseases). Technical alternatives such as partial fundoplication and anterior gastropexy can be considered. We emphasize the importance of performing surgical procedures in cases of large hiatal hernias in high-volume centers, with experienced surgeons.

Feasibility of Anti-reflux Gastric Bypass for Massive Paraesophageal Hernia in Obese Patients With Gastroesophageal Reflux Disease

Background The objective of this study is to demonstrate the safety and feasibility of anti-reflux gastric bypass (ARGB) as a treatment for symptomatic massive paraesophageal hernias (PEH) in the obese population. Both gastroesophageal reflux disease (GERD) and PEH are particularly prevalent in the obese patient population, and obesity adversely affects the long-term outcomes of all anti-reflux procedures. Methods This is a single-center, retrospective review of 17 obese adults who underwent ARGB for the treatment of massive PEH between September 2019 and December 2021. Massive PEH was defined as >5 cm in a singular direction, and obesity as BMI ≥30 kg/m2. Patients without preoperative diagnostic testing were excluded. We reviewed and analyzed patient demographic data, postoperative symptom resolution, weight loss, and complications using descriptive statistics, change from baseline, and comparison of proportions. Results Sixteen of the 17 subjects were female. The median age was 48, and the median BMI was 39.10 kg/m2 (30.0-49.3 kg/m2). The average PEH size on imaging was 6.48 (H) x 6.25 (W) cm. The resolution of heartburn was 93.8% (p<0.001), and the resolution of nausea and vomiting was 80.0%. The mean postoperative length of follow-up was 9.12 months. Median excess body weight loss percentages at one, three, six, and 12 months were 16.43% (p<0.001), 35.92% (p<0.001), 40.64% (p=0.001), and 58.58% (p<0.01), respectively. Five patients experienced adverse events requiring additional intervention or hospitalization. There were no symptomatic hernia recurrences or mortality. Conclusion This study demonstrates that ARGB is feasible and potentially effective in treating symptomatic massive paraesophageal hernias in the obese patient population. Further investigation is needed to determine efficacy and long-term outcomes compared to standard surgical repair.

Roux-en-Y Gastrojejunostomy: is it an effective treatment for complex Hiatal hernias in the morbidly obese?

BACKGROUND

Primary repair failure rates for hiatal hernias (HH) can reach up to 40%, this is especially high in the morbidly obese patient. There is no clear data on how to manage this patient subset. This paper evaluates the efficacy of Roux-N-Y Gastrojejunostomy (RNY GJ) for treatment of symptomatic HH.

METHODS

A retrospective analysis of all patients who received a Roux-en-Y Gastrojejunostomy (RNY GJ) for HH at our institution between January 2016 and January 2021 was performed. Patient demographics, symptoms, and post-operative outcomes were recorded and univariate analysis was performed between preoperative and postoperative symptoms.

RESULTS

Thirty-seven patients with a mean age of 56.9 years (SD 11.8) underwent RNY GJ. Patients were mostly female (81.1%) with a mean BMI of 36.8 (SD 8.4). An 78.4% reduction in symptoms of either heartburn, dysphagia, or regurgitation was noted at follow up (p < 0.001).

CONCLUSIONS

RNY GJ represents a safe procedure for morbidly obese patients with hiatal hernias with no mortalities amongst our patient cohort along with a significant reduction in pre-operative symptoms and no symptomatic recurrences. RNY GJ should be considered as the operation of choice for repair for this patient population.

Augmentation of Hiatal Repair with the Ligamentum Teres Hepatis for Intrathoracic Gastric Migration After Bariatric Surgery

PURPOSE

The augmentation of hiatoplasty (HP) with the ligamentum teres hepatis (LTA) is a new concept for intrathoracic migration of a gastric sleeve or pouch (ITGM). We retrospectively analyzed all cases of hiatal hernia repair in a single center between 2015 and 2019.

METHODS

A total of 171 patients underwent 307 hiatal hernia repairs after sleeve gastrectomy (SG) (n = 79), Roux-en-Y gastric bypass (RYGB) (n = 129), and one anastomosis gastric bypass (OAGB) (n = 99). Each hiatal hernia repair was defined as a "case" and assigned to the LTA group or the non-LTA group. The primary outcome was the recurrence of ITGM as detected by endoscopy or CT.

RESULTS

The basic characteristics in the LTA group (78 cases) and the non-LTA group (229 cases) were comparable with the exception of the rate of revisional HP (72% vs. 21%), the rate of prior conversion to RYGB (33% vs. 17%), the initial BMI (45.9 ± 8.2 kg/m² vs. 49.0 ± 8.8 kg/m²), and the follow-up (7 months (1-16) vs. 8 months (1-54)). The ITGM recurrence rate was 15% in the LTA group and 72% in non-LTA group (p < 0.001). Multivariate analysis showed that the length of ITGM and the type of surgical repair were independent risk factors. The addition of LTA to HP lowered the probability of ITGM recurrence by a factor of 0.35 (p = 0.015), but the conversion from SG or OAGB to RYGB did not reduce the risk.

CONCLUSIONS

LTA reduces the risk of early ITGM recurrence. The long-term durability, however, needs to be further investigated.

Treatment of achalasia in the bariatric surgery population: a systematic review and single-institution experience

BACKGROUND

Although the link between achalasia and morbid obesity is unclear, the reported prevalence is 0.5-1% in this population. For bariatric surgery patients, optimal type and timing of achalasia intervention is uncertain.

METHODS

Patient charts from a single academic institution were retrospectively reviewed. Between 2012 and 2019, 245 patients were diagnosed with achalasia, 13 of whom underwent bariatric surgery and were included. Patients were divided into two groups depending on the timing of their achalasia diagnosis and bariatric surgery. Groups were compared in terms of type and timing of intervention as well as treatment response.

RESULTS

Group 1 included 4 patients diagnosed with achalasia before bariatric surgery. Three had laparoscopic Heller myotomy (LHM) and 1 had a per oral endoscopic myotomy (POEM). These patients had laparoscopic gastric bypass (LGB) within 5 years of achalasia diagnosis. Postoperatively, 1 had severe reflux with regurgitation necessitating radiofrequency energy application to the lower esophageal sphincter. All had relief from dysphagia. Group 2 included 9 patients diagnosed with achalasia after bariatric surgery. Achalasia subtypes were evenly distributed. Initial operations were: 5 LGB, 2 laparoscopic sleeve gastrectomy (LSG), 1 duodenal switch (DS), 1 lap band. One LSG patient was converted to LGB concurrently with LHM. On average, achalasia was diagnosed 8.3 years after bariatric surgery. Achalasia interventions included: 1 pneumatic dilation, 1 Botox injection, 1 POEM, 6 LHM. While LHM was the most common procedure, 4 of 6 patients experienced recurrent dysphagia, one of whom required esophagectomy.

CONCLUSIONS

Achalasia is a challenging problem in the bariatric surgery population. Recurrent symptoms are common. Patients treated for achalasia after bariatric surgery tended to have worse symptom resolution than those diagnosed prior to bariatric surgery. Additional prospective studies are needed to elucidate whether interventions for achalasia should be performed concurrently or in a particular sequence for optimal results.