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Randle RJ, Liou DZ, Lui NS. Management of Paraesophageal Hernias. Thorac Surg Clin 2024; 34:163-170. [PMID: 38705664 DOI: 10.1016/j.thorsurg.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Paraesophageal hernias are classified according to the altered anatomic relationships between the gastroesophageal junction or stomach and the diaphragmatic hiatus. Herniation of these structures into the mediastinum may produce common complaints such as reflux, chest pain, and dysphagia. The elective repair of these hernias is well tolerated and significantly improves quality of life among patients with symptomatic disease. The hallmarks of a quality repair include the circumferential mobilization of the esophagus to generate 3 cm of tension-free intra-abdominal length and the performance of a fundoplication.
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Affiliation(s)
- Ryan J Randle
- Department of Surgery, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mail Code L223, Portland, OR, USA; Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford School of Medicine, 300 Pasteur Drive, Falk Building, Stanford, CA 94305, USA. https://twitter.com/radonrandle
| | - Douglas Z Liou
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford School of Medicine, 300 Pasteur Drive, Falk Building, Stanford, CA 94305, USA. https://twitter.com/DouglasLiou
| | - Natalie S Lui
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford School of Medicine, 300 Pasteur Drive, Falk Building, Stanford, CA 94305, USA.
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Sadeghi JK, Li LT, Singh VA, Zeltsman D, Glassman LR, Jurado JE, Hyman KM, Lee PC. Robotic hiatal hernia repair without mesh. J Thorac Dis 2024; 16:175-182. [PMID: 38410548 PMCID: PMC10894431 DOI: 10.21037/jtd-23-753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 09/01/2023] [Indexed: 02/28/2024]
Abstract
Background Newer minimally invasive techniques have supplanted laparotomy and thoracotomy for management of hiatal hernias. Limited data exists on outcomes after robotic hiatal hernia repair without mesh despite the increasing popularity of this approach. We report our high-volume experience with durable robotic hiatal hernia repair with gastric fundoplication without mesh. Methods A retrospective review was conducted on patients with type I-IV hiatal hernias who underwent an elective robotic-assisted repair from 2016 to 2019 using a novel technique of approximating the hiatus with running barbed absorbable (V-locTM) suture and securing it with interrupted silk sutures. Main outcomes included length of stay, readmission rate, and recurrence rate. Results A total of 144 patients were reviewed. The average age of the patient was 61 years. Most of the patients were female [95 females (66%) to 49 males], and the average body mass index (BMI) was 29.96 kg/m2. The average operating time was 173 minutes (standard deviation 62 minutes). The average length of stay in the hospital was 2 days, and 89% of patients went home within the first 3 days. Ten patients (6.9%) were readmitted within 30 days, there were no mortalities in 30 days, and there were 6 (4.2%) recurrences on follow up requiring reoperation. Conclusions Elective robotic hiatal hernia repair with fundoplication and primary closure of the hiatus with V-locTM and nonabsorbable suture without mesh is safe and effective. The robotic approach has similar operative times, lengths of stay, and complications compared to nationally published data on laparoscopic hiatal hernia repairs.
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Affiliation(s)
- John K. Sadeghi
- Department of Thoracic Surgery, Long Island Jewish Medical Center, Queens, NY, USA
- Department of Surgery, North Shore University Hospital, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
- Department of Thoracic Surgery, Northwell Health, New Hyde Park, NY, USA
| | - Leo T. Li
- Department of Thoracic Surgery, Long Island Jewish Medical Center, Queens, NY, USA
- Department of Surgery, North Shore University Hospital, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
- Department of Thoracic Surgery, Northwell Health, New Hyde Park, NY, USA
| | - Vijay A. Singh
- Department of Thoracic Surgery, Long Island Jewish Medical Center, Queens, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
- Department of Thoracic Surgery, Northwell Health, New Hyde Park, NY, USA
| | - David Zeltsman
- Department of Thoracic Surgery, Long Island Jewish Medical Center, Queens, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
- Department of Thoracic Surgery, Northwell Health, New Hyde Park, NY, USA
| | - Lawrence R. Glassman
- Department of Thoracic Surgery, Long Island Jewish Medical Center, Queens, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
- Department of Thoracic Surgery, Northwell Health, New Hyde Park, NY, USA
| | - Julissa E. Jurado
- Department of Thoracic Surgery, Long Island Jewish Medical Center, Queens, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
- Department of Thoracic Surgery, Northwell Health, New Hyde Park, NY, USA
| | - Kevin M. Hyman
- Department of Thoracic Surgery, Long Island Jewish Medical Center, Queens, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
- Department of Thoracic Surgery, Northwell Health, New Hyde Park, NY, USA
| | - Paul C. Lee
- Department of Thoracic Surgery, Long Island Jewish Medical Center, Queens, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
- Department of Thoracic Surgery, Northwell Health, New Hyde Park, NY, USA
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Liu X, Ma Q, Chen J, Yang H. A protocol for developing core outcome sets for laparoscopic hiatal hernia repair. Trials 2022; 23:907. [PMID: 36303243 PMCID: PMC9612608 DOI: 10.1186/s13063-022-06845-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 10/14/2022] [Indexed: 11/10/2022] Open
Abstract
Background Hiatal hernias negatively damage patients’ health and life quality. Laparoscopic hiatal hernia repair is currently the gold standard for the treatment of hiatal hernia (LHHR). Numerous clinical trials on laparoscopic hiatal hernia repair have been done, but the published findings are highly variable due to the lack of unique outcome sets. Basic outcome sets have ever been established over the previous decade for a few procedures, but not for hiatal hernia repair yet. This protocol outlines the procedure to develop a core outcome set for laparoscopic hiatal hernia repair COS-LHHR). COS-LHHR will provide a unique criteria for clinical investigations. Methods This study will be conducted in four phases: (1) scoping reviews of existing qualitative studies and outcome reporting in randomized controlled trials to develop a list of potential outcome domains; (2) qualitative interviews with patients to explore the impact of laparoscopic hiatal hernia repair and the outcomes that they care most; (3) a multi-round e-Delphi study to achieve preliminary consensus on the core outcome set; and (4) an evidence-based consensus on a core outcome set will be achieved through a structured group consensus meeting, recommending best assessment outcome sets. Discussion The development the COS-LHHR will guide clinical research of laparoscopic hiatal hernia repair with unique outcome assessment. This would improve comparative analyses among studies.
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Affiliation(s)
- Xiaoli Liu
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Qiuyue Ma
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jie Chen
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
| | - Huiqi Yang
- Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
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Cheverie JN, Neki K, Lee AM, Li JZ, Dominguez-Profeta R, Matsuzaki T, Broderick RC, Jacobsen GR, Sandler BJ, Horgan S. Minimally Invasive Paraesophageal Hernia Repair in the Elderly: Is Age Really Just a Number? J Laparoendosc Adv Surg Tech A 2021; 32:111-117. [PMID: 33709788 DOI: 10.1089/lap.2020.0792] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: Paraesophageal hernias readily affect the elderly with a median age of presentation between 65 and 75 years. Laparoscopic paraesophageal hernia repair (PEHR) is a technically challenging operation with potential for dire complications. Advanced age and medical comorbidities may heighten perioperative risk and limit surgical candidacy, potentially refusing patients an opportunity toward symptom resolution. Given the increased prevalence in the elderly and associated surgical risks, we aim to assess age as an independent risk factor for perioperative morbidity and mortality after PEHR. Methods: A retrospective analysis using a prospectively maintained database assessed patients undergoing PEHR from 2007 to 2018. Patients were stratified by age: Group A (age <65 years), Group B (65≤ age <80 years), and Group C (age ≥80 years). Patient demographics, preoperative symptoms, postoperative outcomes, and mortality rate were analyzed. Barium esophagram was performed on symptomatic postsurgical patients. Recurrence was confirmed radiologically. Results: In total, 143 patients underwent laparoscopic (94.4%) or robotic-assisted (5.6%) PEHR. Average age per group was Group A (n = 49) 55.4 years (standard deviation [SD] ±8.91), Group B (n = 76) 71.4 years (SD ±4.40), and Group C (n = 17) 84.1 (years) (SD ±3.37). Group C had significantly higher rates of nonelective surgery (P = .018), preoperative weight loss (P = .014), hypertension (P = .031), ischemic heart disease (P = .001), and cancer (P = .039); preoperative body mass index was significantly lower (P = .048). Charlson comorbidity index differences between groups were significant (2.00 versus 3.61 versus 5.28, P < .001). Median follow-up was 426 days (6-3199). Symptom improvement was seen in 78.3% of patients. Recurrence and reoperation rates were not significantly different between groups. No differences were seen in mortality, length of stay, or postoperative complications between groups. Conclusions: PEHR in elderly patients proved to be safe and effective. Avoidance of emergent intervention may be achieved through a judicious elective approach to this anatomic problem. Symptom resolution and quality-of-life improvement can be safely achieved with surgical repair in this patient population, demonstrating that age is truly just a number for PEHR.
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Affiliation(s)
- Joslin N Cheverie
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
| | - Kai Neki
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
| | - Arielle M Lee
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
| | - Jonathan Z Li
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
| | - Rebeca Dominguez-Profeta
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
| | - Tokio Matsuzaki
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
| | - Ryan C Broderick
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
| | - Garth R Jacobsen
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
| | - Bryan J Sandler
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
| | - Santiago Horgan
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California San Diego, San Diego, California, USA
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Köckerling F, Zarras K, Adolf D, Kraft B, Jacob D, Weyhe D, Schug-Pass C. What Is the Reality of Hiatal Hernia Management?-A Registry Analysis. Front Surg 2020; 7:584196. [PMID: 33195390 PMCID: PMC7642514 DOI: 10.3389/fsurg.2020.584196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/21/2020] [Indexed: 12/05/2022] Open
Abstract
Introduction: To date, the guidelines for surgical repair of hiatal hernias do not contain any clear recommendations on the hiatoplasty technique with regard to the use of a mesh or to the type of fundoplication (Nissen vs. Toupet). This present 10-years analysis of data from the Herniamed Registry aims to investigate these questions. Methods: Data on 17,328 elective hiatal hernia repairs were entered into the Herniamed Registry between 01.01.2010 and 31.12.2019. 96.4% of all repairs were completed by laparoscopic technique. One-year follow-up was available for 11,280 of 13,859 (81.4%) patients operated during the years 2010–2018. The explorative Fisher's exact test was used for statistical calculation of significant differences with an alpha = 5%. Since the annual number of cases in the Herniamed Registry in the years 2010–2012 was still relatively low, to identify significant differences the years 2013 and 2019 were compared. Results: The use of mesh hiatoplasty for axial and recurrent hiatal hernias remained stable over the years from 2013 to 2019 at 20 and 45%, respectively. In the same period the use of mesh hiatoplasty for paraesophageal hiatal hernia slightly, but significantly, increased from 33.0 to 38.9%. The proportion of Nissen and Toupet fundoplications for axial hiatal hernia repair dropped from 90.2% in 2013 to 74.0% in 2019 in favor of “other techniques” at 20.9%. For the paraesophageal hiatal hernias (types II–IV) the proportion of Nissen and Toupet fundoplications was 68.1% in 2013 and 66.0% in 2019. The paraesophageal hiatal hernia repairs included a proportion of gastropexy procedures of 21.7% in 2013 and 18.7% in 2019. The recurrent hiatal hernia repairs also included a proportion of gastropexies 12.8% in 2013 and 15.1% in 2019, Nissen and Toupet fundoplications of 72.7 and 62.7%, respectively, and “other techniques” of 14.5 and 22.2%, respectively. No changes were seen in the postoperative complication and recurrence rates. Conclusion: Clear trends are seen in hiatal hernia repair. The use of meshes has only slightly increased in paraesophageal hiatal hernia repairs. The use of alternative techniques has resulted in a reduction in the use of the “classic” Nissen and Toupet fundoplication surgical techniques.
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Affiliation(s)
- Ferdinand Köckerling
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Berlin, Germany
| | - Konstantinos Zarras
- Department of Visceral, Minimally Invasive and Oncological Surgery, Marien Hospital Düsseldorf, Düsseldorf, Germany
| | | | - Barbara Kraft
- Department of General and Visceral Surgery, Diakonie Hospital, Stuttgart, Germany
| | - Dietmar Jacob
- Chirurgisch-Orthopädischer PraxisVerbund (COPV)-Hernia Center, Berlin, Germany
| | - Dirk Weyhe
- Department of General and Visceral Surgery, University Hospital of Visceral Surgery, Pius Hospital Oldenburg, Oldenburg, Germany
| | - Christine Schug-Pass
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Berlin, Germany
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Surgical and clinical outcomes comparison of mesh usage in laparoscopic hiatal hernia repair. Surg Endosc 2020; 35:2724-2730. [PMID: 32556757 DOI: 10.1007/s00464-020-07703-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/09/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Use of absorbable mesh in hiatal hernia (HH) repair has been shown to decrease recurrence rates. Our aim was to compare the efficiency of three meshes in relation to the surgical outcomes of patients undergoing HH repair. METHODS A single-institution retrospective review was done for adult patients who underwent HH repair with mesh between 2004 and 2016. Demographics, intra-operative, and cost data were collected. Esophageal symptoms and medication use were assessed pre- and postoperatively. Surgical outcomes were evaluated at 6-, 12-months, and long-term follow-up. Three groups were created based on type of mesh: human tissue matrix (HTM), biosynthetic mesh (BIOS), or porcine tissue matrix (PTM). Comparisons were performed between groups using SPSS v.26.0 and PC SAS v9.4, α = 0.05. RESULTS 292 patients were included (HTM:N = 162, BIOS:N = 83, PTM:N = 47). Majority were male (60.4%), Caucasian (93.2%), median age, and BMI of 59 years [25-90 years] and 29.19 kg/m2 [18.9-58.0 kg/m2], respectively. 69% had a large HH. Median follow-up time was 27 months [1-166 months]. Overall recurrence rate was 39%, being significantly lower in BIOS at long-term (HTM: 31%, BIOS: 17%, PTM: 19%, p = 0.038). All groups had a significant postoperative improvement of esophageal symptoms, all p < 0.001. 65-70% of the cost difference between the groups was incurred by the cost of mesh alone (HTM: $1072, BIOS: $548, PTM: $1295), with the remainder attributable to the surgery itself. CONCLUSION While outcomes of the three mesh groups were similar in our data, there was a significant difference in mesh cost. Surgeon and hospital preference still play a role in choosing the type of mesh used; however, knowledge of the individual mesh cost will help surgeons make better informed decisions.
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