Suture cruroplasty versus prosthetic hiatal herniorrhaphy for large hiatal hernia: a meta-analysis and systematic review of randomized controlled trials

OBJECTIVE: The aim was to conduct a meta-analysis of randomized controlled trials (RCTs) comparing 2 methods of hiatal closure for large hiatal hernia and to evaluate their strengths and flaws. METHODS: Prospective RCTs comparing suture cruroplasty versus prosthetic hiatal herniorrhaphy for large hiatal hernia were selected by searching PubMed, Medline, Embase, Science Citation Index, Current Contents, and the Cochrane Central Register of Controlled Trials published between January 1991 and October 2014. The outcome variables analyzed included operating time, complications, recurrence of hiatal hernia or wrap migration, and reoperation. These outcomes were unanimously decided to be important because they influence the practical approach toward patient management. Random effects model was used to calculate the effect size of both dichotomous and continuous data. Heterogeneity among the outcome variables of these trials was determined by the Cochran's Q statistic and I index. The meta-analysis was prepared in accordance with Preferred Reporting of Systematic Reviews and Meta-Analyses guidelines. RESULTS: Four RCTs were analyzed totaling 406 patients (Suture = 186, Prosthesis = 220). For only 1 of the 4 outcomes, ie, reoperation rate (OR 3.73, 95% CI 1.18, 11.82, P = 0.03), the pooled effect size favored prosthetic hiatal herniorrhaphy over suture cruroplasty. For other outcomes, comparable effect sizes were noted for both groups which included recurrence of hiatal hernia or wrap migration (OR 2.01, 95% CI 0.92, 4.39, P = 0.07), operating time (SMD -0.46, 95% CI -1.16, -0.24, P = 0.19) and complication rates (OR 1.06, 95% CI 0.45, 2.50, P = 0.90). CONCLUSIONS: On the basis of our meta-analysis and its limitations, we believe that the prosthetic hiatal herniorrhaphy and suture cruroplasty produces comparable results for repair of large hiatal hernias. In the future, a number of issues need to be addressed to determine the clinical outcomes, safety, and effectiveness of these 2 methods for elective surgical treatment of large hiatal hernias. Presently, the use of prosthetic hiatal herniorrhaphy for large hiatal hernia cannot be endorsed routinely and the decision for the placement of mesh needs to be individualized based on the operative findings and the surgeon's recommendation

Surgical reconstruction of functional and anatomical defects in the diaphragmatic hiatus

Gastroesophageal reflux disease (GERD) is characterized mainly by heartburn and acid regurgitation but in the more severe forms even organic manifestations can occur. Proton pump inhibitors (PPIs) is the main medical treatment of GERD but antireflux surgery should be looked upon as an effective long-term therapeutic option. The hiatus hernia (HH) is an important factor in the pathogenesis of GERD since it may disrupt both the anatomy and physiology of the antireflux barrier. The overall aim of this thesis was to critically assess important components in the surgical repair confined to the diaphragmatic hiatus, in patients with HH and with or without GERD. Study I was a double-blind randomized clinical trial in which 159 patients with GERD and HH > 2cm allocated to closure of the hiatal defect with simple crural sutures or with nonabsorbable mesh. The aim of the study was to assess the anatomical and functional outcomes of the use of a mesh for the repair of HH in patients with GERD. Similar anatomical recurrence rates of the HH were noted in the two study groups at 1 year (mesh; 9%, sutures; 3%) and at 3 years (mesh; 13%, sutures; 10%) after the surgery. Both procedures controlled reflux equally well and quality of life scores were comparable. However, more patients had dysphagia for solid food after mesh closure. Study II contained long-term follow up observations of the study I, and assessed the risk for recurrence of HH as well as differences in functional results between the two procedures when assessed more than 10 years later. The mean (SD) follow up of the study was 13 (1.1) years. The radiological recurrence of the HH was 46% in the mesh and 28% in the suture group (p=0.175) but most of the recurrences were small. No differences emerged over time in quality of life between the two procedures but we observed a maintained higher dysphagia scores for solid food items in the mesh group (p=0.011). Study III was a long-term follow up of a randomized double-blind clinical trial of patients with GERD allocated to a total (3600) or partial posterior (2700) fundoplication. The aim of the study was to assess the long-term functional outcomes of these two procedures (>15 years after the operation). The mean (SD) follow up of this study was 16 (1.3) years. The study found that both procedures controlled GERD and quality of life equally well at the time of the follow up with only minor differences in mechanical side effects. Study IV was a double-blind randomized clinical trial conducted in two centers. The aim of the study was to identify any differences between two different types of fundoplication (1800 or 3600) in patients with paraesophageal hernia in terms of early postoperative functional outcomes. In total, 70 patients were included in the study and the follow up was 6 months. Dysphagia was assessed by the Ogilvie and the Dakkak dysphagia scores. The study found that during the follow-up, Ogilvie dysphagia scores were stable in the total fundoplication group but significantly improved in the Toupet group at 3 and 6 months after the operation ( p=0.003 and 0.001, respectively). Moreover, at 6 months, Dakkak dysphagia scores were significantly higher in the total fundoplication group (p=0.003). Finally, there was no difference in reflux control or HH recurrence between the two procedures at the time of the follow-up. In conclusion, tension-free crural repair with non-absorbable mesh in patients with GERD undergoing a Nissen fundoplication does not reduce the risk for radiological recurrence of the HH in the short- or the long-term. In addition, the finding of maintained higher dysphagia scores at 13 years postoperatively in the mesh group, implies that PTFE mesh closure cannot be recommended for routine use in HH repair associated with antireflux surgery. Both the total and the partial posterior fundoplication control GERD and quality of life well when assessed as long as 15 years after surgery. The addition of a total fundoplication in patients with paraesophageal hernia undergoing surgery, may be burdened by higher risk for postoperative dysphagia

Large hiatal hernia: minimizing early and long-term complications after minimally invasive repair

Paraesophageal Hernia (PEH) is the protrusion of the stomach and/or other abdominal viscera into the mediastinum due to an enlargement of the diaphragmatic hiatus. The treatment of PEH is challenging: On the one hand, watchful waiting carries the risk of developing acute life-threatening complications requiring an emergency operation. On the other hand, elective repair of PEH has non-negligible morbidity and mortality rates, also due to the characteristics of PEH affected patients, who are generally elder and frail. A review of the literature is presented to highlight strategies that can be adopted to minimize early and long-term complications after PEH surgical repair. The laparoscopic approach has been shown to provide reduced hospital stay, postoperative morbidity and mortality, and overall costs compared to traditional open surgery, and it is currently considered the standard approach both to elective and emergency operations. The evidence suggests that strict adherence to surgical principles, such as hernia sac excision, extended mediastinal dissection of the esophagus, and tension-free crural repair with or without mesh are mandatory to achieve optimal surgical outcomes and reduce PEH recurrence rate. Different shapes, materials, and techniques of prosthetic repair and the use of relaxing incisions have been proposed, but long-term data are lacking, and no conclusions can be drawn regarding the ideal method of crural closure. When a short esophagus is recognized despite extensive mediastinal dissection, esophageal lengthening procedures are indicated. Systematic addition of a fundoplication is strongly encouraged, for either treating gastroesophageal reflux or reducing recurrence rate

Reconstruction in the gastroesophageal junction- from routine to advanced.

The general aim of the thesis was to contribute to a more evidenced based framework in the surgical treatment of diseases in the gastroesophageal junction (GEJ), by comparing outcome, measured by complication and survival rates, and evaluate different reconstructions regarding long-term symptoms and quality of life (QoL). The GEJ is a poorly defined anatomic area that represents the lower part of the esophagus and its’ junction to the proximal stomach.Diseases in this area cause symptoms that affect negatively the QoL for the patients and often interfere with the ability to eat and drink. The surgical treatments not only aim at eliminating the patient’s symptoms but also to cure her/his sometimes life-threatening condition. In Paper I we compared two different antireflux procedures in the treatment of gastroesophageal reflux disease (GERD). Many patients do not respond to acid suppressor medication making the need of an antireflux procedure with good long-term functional results important. Epiphrenic diverticula are rare but can cause life-threatening conditions. In Paper II we studied the treatment of symptomatic epiphrenic diverticula, and evaluated the outcome after an antireflux procedure had been added to the myotomy, and studied the long-term effect after surgery both regarding symptoms relief and QoL. The incidence of adenocarcinoma (AC) in the GEJ increases rapidly in the Western world. In Paper III we compared the extensive and less used extended gastrectomy with long Roux-en-Y loop with the more commonly used esophagectomy with gastric tube in the treatment of AC in the GEJ. In Paper IV, we validated the paracetamol absorption test for measuring emptying from the gastric tube and compared it to gold standard, scintigraphy. In Paper V, we evaluated if there is a place for redoing reconstruction of the esophagus when the primary reconstruction fails. In conclusion, reconstruction for diseases in the GEJ can, both for benign and malignant diseases, be performed with a low postoperative morbidity and mortality, and with good long-term results. In the treatment of GERD, both a total and an anterior 120° fundoplication result in good long-term QoL. Treatment of epiphrenic diverticula should include a myotomy extended through the LES and an antireflux procedure, although the long-term QoL will remain impaired despite good postoperative regression of the primary symptoms. For AC in the GEJ, the extended gastrectomy can be used safely as a complement to esophagectomy and with good long term functional results and QoL. The paracetamol absorption test may be used as an alternative to scintigraphy for identifying delayed emptying from the gastric tube. In case of failure of the primary reconstruction, the patient should be offered another attempt, since it is possible to achieve an equally good outcome after a redo-reconstruction as after a primary reconstruction

Posição da Sociedade Brasileira de Hérnia e Parede Abdominal sobre o tratamento de grandes hérnias de hiato.

Large hiatal hernias (LHH) besides being more prevalent in the elderly, have different clinical presentation: fewer 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 (GERD-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 (BMI above 35), age over 70 years and presence of comorbidity. 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, case-by-case analysis of surgical risk factors such as age, obesity and comorbidities, should be taken under consideration. One should also pay attention to situations with greater technical difficulty and risks of acute migration due to increased abdominal pressure (abdominoplasty, manual workers, 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 LHH in high-volume centers, with experienced surgeons.As grandes hérnias de hiato (HHG), além de serem mais prevalentes em idosos, têm apresentação clínica diferente: menos refluxo, mais sintomas mecânicos e maior possibilidade de complicações agudas e potencialmente fatais, como vólvulo gástrico, isquemia e perfuração mediastinal visceral. Assim, as indicações cirúrgicas são distintas das hérnias de hiato por deslizamento, relacionadas à doença do refluxo gastroesofágico (DRGE). A azia tende a ser menos intensa, enquanto os sintomas de dor no peito, tosse, desconforto e cansaço são relatados com maior frequência. Queixas de vômitos e disfagia podem sugerir a presença de volvo gástrico associado. São encontrados sinais de deficiência de ferro e anemia. A indicação cirúrgica ainda é controversa e foi anteriormente baseada na alta mortalidade relatada em cirurgias de emergência para volvo gástrico. A mortalidade pós-operatória está especialmente relacionada a três fatores: índice de massa corporal (IMC acima de 35), idade superior a 70 anos e presença de comorbidades. A cirurgia eletiva minimamente invasiva deve ser oferecida a indivíduos sintomáticos, com desempenho bom ou razoável, independentemente da faixa etária. Em pacientes assintomáticos e oligossintomáticos, além de obviamente identificar o desejo do paciente, deve-se levar em consideração a análise caso a caso dos fatores de risco cirúrgico, como idade, obesidade e comorbidades. Deve-se atentar também para situações de maior dificuldade técnica e riscos de migração aguda por aumento da pressão abdominal (abdominoplastia, trabalhos manuais, doenças espásticas). Alternativas técnicas como fundoplicatura parcial e gastropexia anterior podem ser consideradas. Ressaltamos a importância da realização de procedimentos cirúrgicos nos casos de GHH em centros de grande volume, com cirurgiões experientes

Minimally invasive endoscopic therapies for gastro-oesophageal reflux disease

The prevalence of the gastro-oesophageal reflux disease (GORD) in the western world is increasing. Uncontrolled GORD can lead to harmful long-term sequela such as oesophagitis, stricture formation, Barrett's oesophagus and oesophageal adenocarcinoma. Moreover, GORD has been shown to negatively impact quality of life. The current treatment paradigm for GORD consists of lifestyle modification, pharmacological control of gastric acid secretion or antireflux surgery. In recent years, several minimally invasive antireflux endoscopic therapies (ARET) have been developed which may play a role in bridging the unmet therapeutic gap between the medical and surgical treatment options. To ensure optimal patient outcomes following ARET, considered patient selection is crucial, which requires a mechanistic understanding of individual ARET options. Here, we will discuss the differences between ARETs along with an overview of the current evidence base. We also outline future research priorities that will help refine the future role of ARET

Лапароскопическая пластика грыж пищеводного отверстия диафрагмы и фундопликация по ниссену: анализ отдаленных результатов, новая классификация и научные тенденции

The choice of method of hiatal hernia repair is still controversial. Recurrences after repair of large and giant hiatal hernia reach 42%. Mesh repair may decrease failure rate but bears risk of oesophageal complications. Thus, development of optimal methods of hiatal closure for prevention of repair-related recurrences and dysphagia is a very actual question. Aim of the study was to analyse long-term results (i. e. anatomical recurrences and repair-related dysphagia) of different types of laparoscopic hiatal repair depending on hiatal surface area (HSA).Авторы советуют рутинно вымерять HSA и использовать новую классификацию. Оптимальным методом пластики малых грыж является крурорафия. При больших грыжах оригинальная методика sub-lay пластики облегченной сеткой, которая частично рассасывается, представляется наилучшей. Для гигантских грыж оригинальная методика дает результаты, соответствующие литературе, хотя эти результаты нуждаются в улучшении