Repair Of Giant Hiatus Hernia Research Articles

Trends in outcomes of 862 giant hiatus hernia repairs over 30 years

PurposeLaparoscopic giant hiatus hernia repair is technically difficult with ongoing debate regarding the most effective surgical technique. Repair of small hernia has been well described but data for giant hernia is variable. This study evaluated trends in outcomes of laparoscopic non-mesh repair of giant paraesophageal hernia (PEH) over 30 years.MethodsRetrospective analysis of a single-surgeon prospective database. Laparoscopic non-mesh repairs for giant PEH between 1991 and 2021 included. Three-hundred-sixty-degree fundoplication was performed routinely, evolving into “composite repair” (esophagopexy and cardiopexy to the right crus). Cases were chronologically divided into tertiles based on operation date (Group 1, 1991–2002; Group 2, 2003–2012; Group 3, 2012–2021) with trends in casemix, operative factors and outcomes evaluated. Hernia recurrence was plotted using weighted moving average and cumulative sum (CUSUM) analysis.Results862 giant PEH repairs met selection criteria. There was an increasing proportion of “composite repair” after the first decade (Group 1, 2.7%; Group 2, 81.9%; Group 3, 100%; p < 0.001). There were less anatomical hernia recurrence (Group 1, 36.6%; Group 2, 22.9%; Group 3, 22.7%; p < 0.001) and symptomatic recurrence (Group 1, 34.2%; Group 2, 21.9%; Group 3, 7%; p < 0.001) over time. The incidence of anatomical recurrence declined over time, decreasing from 30.8% and plateauing below 17.6% near the study’s end. Median followup (months) in the first decade was higher but followup between the latter two decades comparable (Group 1, 49 [IQR 20, 81]; Group 2, 30 [IQR 15, 65]; Group 3, 24 [14, 56]; p < 0.001). There were 10 (1.2%) Clavien–Dindo grade ≥ III complications including two perioperative deaths (0.2%).ConclusionHernia recurrence rates decreased with increasing case volume. This coincided with the increasing adoption of “composite repair”, supporting the possible improvement in recurrence rates with this approach.

ThTP2.11 Three-year follow up outcomes in mesh-augmented vs sutured cruroplasty in giant hiatal hernia repair

Abstract Aims There is no consensus for indications on mesh-augmentation of crural repair in hiatus hernia. We evaluated outcomes following mesh-augmented versus suture repair of giant hiatus hernia. Methods Giant hiatus hernia was defined as a hernia containing at least 30% of the stomach in the thorax. We undertook a retrospective analysis of records for patients undergoing surgical repair of hiatus hernia in a tertiary centre between 2016 and 2019, with a minimum follow up of three years. Patients were identified using clinical coding. Pre-operative investigations (OGD, barium swallow, CT) and operative findings were used to identify those patients with giant hiatus hernias. Outcomes assessed included morbidity, recurrence and revisional surgery. Results 58 patients of median age 72 (27-90) underwent repair of a giant hiatus hernia. 56 (97%) were performed laparoscopically (1 conversion, 1 open). All were primary procedures, 50 elective and 8 emergency. 20 had mesh-augmented suture repair (19 BIO-A, 1 Permacol) and 38 had primary suture repair alone. 26 (44.8%) had additional fundoplication. By three years post-surgery 14/58 (24%) recurrent hiatus hernias were identified on further investigation, similar in both groups (5/20 vs 9/38). Symptomatic revisional surgery was undertaken in 2/20 (10%) mesh-augmented and 2/38 (5%) suture only repairs. 30-day mortality was 0%. Morbidity (Clavien-Dindo 3+) was recorded in 5 patients (8.6%). Conclusion Giant hiatal hernia repair complication and recurrence rates were comparable to published studies. Those patients with recurrence following mesh-augmented repair were more likely to require revision surgery. However mesh may be used in cruroplasty for perceived weaker or wider crura.

TU8.8 Fundoplication or gastropexy in emergency giant hiatus hernia repair?

Abstract Aims Operative management of emergency presentation with a hiatal hernia aims to reduce the herniated stomach, dissect the hernial sac and reapproximate the crura. This will often be followed by fundoplication or gastropexy to minimise the risk of recurrence. This study compares the recurrence rates between patients who underwent fundoplication and gastropexy. Methods From October 2012 to November 2020, 80 patients were admitted to a tertiary oesophagogastric centre requiring emergency surgery to repair a giant hiatal hernia. We conducted a retrospective review and analysis of their admission and follow-up. The primary outcome measure was acute and post-discharge symptomatic recurrence of hiatal hernia. Results Of the 80 patients requiring emergency hiatal hernia surgery, 38% had fundoplication procedures, 53% had gastropexy, and 3% had both (n 30, 42, 2 respectively). One patient had neither, and 6% (n 5) patients had a complete or partial stomach resection due to necrosis. Eight patients (10%) had a symptomatic recurrence of hiatal hernia requiring a repeat operation; three within the index admission, five postdischarge. 50% had undergone fundoplication, 38% underwent gastropexy and 13% underwent a resection (n 4, 3, 1)(p-value 0.5). 19% (n 15) patients were readmitted. Post-operative mortality was 6% (n 5). Conclusions There is no conclusive evidence in the literature favouring fundoplication versus gastropexy. The surgeon's experience and patient factors influence choice of technique. This review, which includes the largest cohort of patients available in the literature, demonstrates that surgical technique does not influence the symptomatic recurrence rate in our patient group.

P-BN43 Giant Hiatus Hernia Repair Significantly Improves Quality of Life

Abstract Background Giant hiatus hernias (GHH), defined as more than 30% of the stomach herniating into the chest cavity accounts for 5%-10% of all hiatus hernias. GHH repair is undertaken electively in symptomatic patients, to prevent complications such as volvulus of the stomach with resultant mortality. Advances in laparoscopy and perioperative care have reduced the risk of operation, and improvement in quality of life (QoL) has become an important outcome measure. “Quality of Life in Reflux and Dyspepsia” (QOLRAD) questionnaire is a disease specific validated tool used to assess QoL. We present our prospective data assessing change in QoL following GHH repair. Methods Symptomatic patients undergoing elective repair of GHH, by a single surgical team, between January 2010 and June 2021 were identified from a prospectively kept database. Demographic data and operative details were recorded from patient notes. From 2015 onwards the QOLRAD questionnaire was introduced. Patients who underwent GHH repair completed the questionnaire pre-operatively and then at 6 weeks, 6 months, 1 year and 2 years post-operatively. Patients, who were not operated on, completed the questionnaire at 6 month intervals over 2 years. Mann-Whitney U test was used to compare QOLRAD scores between hernia size, type and symptomatology. Results Sixty-eight patients underwent GHH repair from 2010 to 2014. Statistically significant(p &amp;lt; 0.001) improvement in QoL was only seen in patients with ‘heartburn’ symptoms. Thirty patients were included in the post 2015 group. Statistically significant improvement in all QOLRAD domains was observed as demonstrated the table below. Conclusions GHH repair is a safe operation in symptomatic patients that results in an improvement in QoL across all QOLRAD domains and may prevent deterioration in QoL.

680 ACUTE GASTRIC DILATATION: A LIFE-THREATENING EARLY COMPLICATION FOLLOWING LAPAROSCOPIC HIATUS HERNIA REPAIR

Abstract Laparoscopic anti-reflux surgery prevents reflux of gastric fluid into the oesophagus but it may also inhibit belching. Gastric outflow impairment may lead to a closed-loop obstruction and life-threatening acute gastric dilatation. Methods We report a case of a 69-year-old female who underwent a laparoscopic giant hiatus hernia repair and anterior 180° fundoplication. Post operatively, she suffered from gastroparesis that resulted in a closed-loop obstruction. This was managed successfully with nasogastric tube insertion and commencement of prokinetic agents. A review of the literature of acute gastric dilatation and hiatus hernia repair was made. Results In the last 30 years, there have been 7 cases of acute gastric dilatation following hiatus hernia repair. Timing was 7 months to 14 years following a 360 degree fundoplication. In most cases, the ensuing gastric dilatation led to venous congestion, tissue necrosis and perforation, necessitating emergency gastrectomy for control of sepsis. All patients required a prolonged hospital stay and one mortality was reported. Our case is unique, characterized by its early presentation, and occurring after a partial 180° fundoplication. Our patient was successfully managed non-operatively with nasogastric decompression and supportive measures. Conclusion Surgeons should be aware that acute gastric dilatation is a life-threatening complication which may occur following laparoscopic partial fundoplication. Early diagnosis and prompt nasogastric decompression are required to avoid gastric necrosis and significant morbidity.

Do Poor Functional Outcomes and Higher Morbidity Following Emergency Repair of Giant Hiatus Hernia Warrant Elective Surgery in Asymptomatic Patients?

Background: Patients with a giant hiatus hernia may present with acute symptoms caused by obstruction, strangulation, perforation and uncontrolled bleeding. Emergency surgical repair has been associated with significant mortality and even greater morbidity. The aim of this study is to investigate the short-term outcomes following emergency repair of giant hiatus hernias.Methods: Data were retrospectively collected for all patients who underwent emergency surgical repair of giant hiatus hernia in a university teaching hospital between 2009 and 2019. Outcomes were short-term morbidity and mortality. We also assessed the association of clinical predictor covariates, including age, ASA class and time to surgery, with risk for major morbidity.Results: Thirty-seven patients with a median age of 68 years were identified. Following surgery, 9 patients (24.3%) developed organ dysfunction that required admission to the intensive care unit. Two patients (5.4%) underwent revision surgery and 3 (8.1%) developed pneumothorax that necessitated chest drain insertion. The commonest complication was pneumonia, which occurred in 13 patients (35.1%). Two deaths (5.4%) occurred within 30 days from surgery.Conclusions: Emergency repair of giant hiatus hernia is associated with high rates of major morbidity, which includes poor functional status, further interventions, repeat surgery, and admission to the intensive care unit. Larger studies are warranted for long-term follow-up to assess post-operative quality of life is needed for asymptomatic patients and for those undergoing emergency surgery.

Quality of life after giant hiatus hernia repair: A systematic review

Background:Elective surgery is the treatment of choice for symptomatic giant hiatus hernia (GHH), and quality of life (QoL) has become an important outcome measure following surgery. The aim of this study is to review the literature assessing QoL following repair of GHH.Methodology:A systematic literature search was performed by two reviewers independently to identify original studies evaluating QoL outcomes after GHH surgery. MeSH terms such as paraoesophageal; hiatus hernia; giant hiatus hernia and quality of life were used in the initial search. Original studies in English language using validated questionnaires on humans were included. Review articles, conference abstracts and case reports and studies with duplicate data were excluded.Results:Two hundred and eight articles were identified on initial search, of which 38 studies (4404 patients) were included. Studies showed a significant heterogeneity in QoL assessment tools, surgical techniques and follow-up methods. All studies assessing both pre-operative and post-operative QoL (n = 31) reported improved QoL on follow-up after surgical repair of GHH. Improvement in QoL following GHH repair was not affected by patient age, surgical technique or the use of mesh. Recurrence of GHH after surgery may, however, adversely impact QoL.Conclusion:Surgical repair of GHH improved QoL scores in all the 38 studies. The impact of recurrence on QoL needs further assessment. The authors also recommend uniform reporting of surgical outcomes in future studies.

470 OUTCOMES OF COMPOSITE REPAIR OF GIANT HIATAL HERNIA IN A LARGE SINGLE CENTRE COHORT.

Abstract Giant hiatus hernia (GHH) is usually symptomatic and can have significant impact on a patient’s quality of life. There is ongoing debate about optimal technique of giant hiatus hernia repair. This paper aims to look at the outcomes of laparoscopic composite repair of giant hiatus hernia from a large single centre cohort. Methods A retrospective analysis of prospectively maintained database was performed. Patients undergoing composite repair for GHH defined as &amp;gt;30% stomach above diaphragm were included. Primary outcome was hernia recurrence. Secondary outcomes were perioperative morbidity and mortality, correlation of symptoms and hernia recurrence post operatively, need for revision surgery, resolution of symptoms post operatively and patient self-reported quality of life (GIQOL, Visik score). Results Inclusion criteria were met by 221 patients. Post-operative endoscopic and/or barium swallow follow up was performed in 198 patients with 23.74% recurrence rate. There was no correlation with recurrence of hernia and persistent post-operative symptoms. The most common presenting symptom was shortness of breath, followed by dysphagia, chest pain and heartburn. Dysphagia was most common post-operative symptom. There was significant improvement in QOL post-operatively. Conclusion Laparoscopic composite repair was proven safe and effective in this cohort. Hernia recurrence was not associated with ongoing symptoms and did not have an effect on QOL. A small proportion of patients with recurrence required revision surgery. Overall satisfaction with surgery was high.

Medium-term durability of giant hiatus hernia repair without mesh.

Introduction This is the second report on objective review of 100 patients who underwent composite fundoplication-cardiopexy for repair of giant hiatus hernia (GHH) at a median of 24 months following surgery. Outcomes were objective follow-up by endoscopy and quality of life (QoL) by Gastrointestinal Quality of Life Index (GIQLI), modified Visick scores and dysphagia scores. The initial report for this cohort suggested a low objective recurrence rate (9%) and substantial improvements in QoL indices. Methods The rate of hernia recurrence was assessed with Kaplan-Meier analysis and covariates were analysed with the Cox proportional hazards model. Paired t-tests and related samples Wilcoxon signed-rank tests were used to compare QoL scores. Unpaired data were compared with the independent samples t-test and Mann-Whitney U test. Results Objective review was obtained in 97% of the patients. There were five recurrences of hernias that had a vertical height of >2cm from the diaphragmatic hiatus, with three patients requiring reoperation for severe dysphagia. Small recurrences (<2cm) occurred in 20 patients. The median time to recurrence was 40 months (95% confidence interval: 34-46 months). At two years, recurrence of any size had occurred in 24% of cases. At follow-up review (median: 27 months), the mean GIQLI score was 109 (p=0.279), the median modified Visick score was 2 (p=0.954) and the median dysphagia score was 41 (p=0.623). There was no evidence that the GIQLI score (p=0.089), the modified Visick score (p=0.339) or the dysphagia score (p=0.445) changed significantly after recurrence. Conclusions There was a sustained improvement in overall QoL and reflux scores after GHH repair. QoL scores showed persistent improvement in reflux and overall health, even in the subgroup with recurrence. The majority (80%) of recurrences were small and recurrent herniation did not appear to significantly change QoL. The rates of recurrence and QoL are comparable with those for other methods of repair.

PTH-160 Laparoscopic repair of giant hiatus hernia significantly improves quality of life – a single centre experience

Introduction Centralisation of Upper Gastrointestinal cancer services has been associated with increase in number of referrals of giant hiatus hernia (GHH) over last 5 years. Laparoscopic repair (LR) of GHH is associated with recurrence rate of up to 30% and high mortality and morbidity. Therefore, we offer surgery only to symptomatic patients presenting with reflux, dysphagia, chest symptoms and intermittent gastric volvulus. The aim of this study is to evaluate quality of life (QoL) of these patients after LR of GHH. Method This is a postal questionnaire study of all the patients undergoing GHH repair between 2010 to 2014 in a tertiary referral centre. Patients were sent 2 questionnaires, 1. The Quality of Life in Reflux and Dyspepsia (QOLRAD) and 2. Our own short questionnaire. The QOLRAD questionnaire was made up of 25 questions; each scored out of 7 with 7 representing a high quality of life and 1 representing a low quality of life. A combination of these questions made up 5 dimensions namely emotional distress, sleep disturbance, food/drink problems, physical/social functioning and vitality. The second questionnaire assessed improvement in patient’s individual symptoms namely heartburn/reflux, weight loss, abdominal or chest pain/discomfort, vomiting, shortness of breath, nausea, bloating, difficulty swallowing and also overall improvement in health and QoL on a scale of 0 to 10, 0 being no improvement and 10 being excellent results. Results From a total of 68 patients, 2 died post-operatively (1 was an emergency and the other was an elective case). The other 2 died of unrelated causes. Of the remaining 64 patients, 27 (42.2%) responded. Mean score for each dimension in QOLRAD (out of 7) were as follows-emotional distress (6.15), sleep disturbance (6.22), food/drink problems (6.07), physical/social functioning (6.43) and vitality (6.02). In the second questionnaire, patients scored overall improvement of their symptoms out of 10. Of the 27 patients, 1 (3.7%) scored 1–3, 5 (18.5%) scored 4–6, 3 (11.1%) scored 7–8 and 18 (66.7%) scored 9–10. Similar findings were reported for improvement in QoL. Conclusion Our case series showed acceptable operative mortality of 2.9%; with a significant improvement in QoL in approximately two thirds of patients. Patient selection and standardisation of operation may be responsible for these results. Disclosure of interest None Declared.

Durability of giant hiatus hernia repair in 455 patients over 20 years.

The surgical management of symptomatic giant hiatus hernia (GHH) aims to improve quality of life (QoL) and reduce the risk of life threatening complications. Previous reports are predominantly those with small sample sizes and short follow-up periods. The present study sought to assess a large cohort of patients for recurrence and QoL over a longer time period. This was a follow-up study of a prospectively collected database of 455 consecutive patients. Primary repair of GHH was evaluated by endoscopy/barium meal for recurrence and a standardised symptom questionnaire for QoL. Recurrence was assessed for size, elapsed time, oesophagitis and symptoms. Objective and subjective review was achieved in 91.9% and 68.6% of patients. The median age was 69 years (range: 15-93 years) and 64% were female. Laparoscopic repair was completed in 95% (mesh in 6% and Collis gastroplasty in 7%). The 30-day mortality rate was 0.9%. The proportion of patients alive at five and ten years were 90% and 75% respectively. Postoperative QoL scores improved from a mean of 95 to 111 (p<0.01) and were stable over time (112 at 10 years). The overall recurrence rate was 35.6% (149/418) at 42 months; this was 11.5% (48/418) for hernias >2cm and 24.2% (101/418) for <2cm. The rate of new recurrence at 0-1 years was 13.7% (>2cm = 3.4%, <2cm = 10.3%), at 1-5 years it was 30.8% (>2cm = 9.5%, <2cm = 21.3%), at 5-10 years it was 40.1% (>2cm = 13.8%, <2cm = 26.3%) and at over 10 years it was 50.0% (>2cm = 25.0%, <2cm = 25.0%). Recurrence was associated with oesophagitis but not decreased QoL. Revision surgery was required in 4.8% of cases (14.8% with recurrence). There were no interval major GHH complications. Surgery has provided sustained QoL improvements irrespective of recurrence. Recurrence occurred progressively over ten years and may predispose to oesophagitis.

Distal antral gastropexy – A novel technique to prevent recurrence of giant hiatus hernia in selected cases – A cohort study

IntroductionThe recurrence rate of giant hiatus hernias (GHH) following repair is high (30%) and increases with the hernia size and previous revision surgery. The mechanism of recurrence is poorly understood. MethodsThis is a retrospective cohort study of all consecutive patients who underwent repair of giant hiatus hernia in a tertiary upper GI referral centre from November 2000 to November 2014. Patients who underwent redo surgery were identified and data on intra-operative findings and procedure performed at primary and redo surgery from their operation notes were collected. ResultsA total of 81 patients underwent primary repair of GHH over the 14 year study period. 10 (12.3%) had symptomatic/radiological recurrence of which 4 were found to have the distal stomach herniating into the chest despite having an intact intra-abdominal wrap/gastropexy. To prevent migration of the distal stomach into the chest, distal gastropexy - fixing the antrum to the anterior abdominal wall, was added to ‘conventional’ gastropexy in 5 subsequent cases, in whom the antrum was in the chest preoperatively. These cases have no evidence of recurrence at the end of 6 months follow up. ConclusionSecuring the antrum of stomach to the anterior abdominal wall may prevent migration of the distal stomach and other infracolic organs into the chest and thus reduce recurrence of some GHH where antrum had been in chest previously.

Erratum to: Laparoscopic repair of giant hiatus hernia: prosthesis is not required for successful outcome

Erratum to: Laparoscopic repair of giant hiatus hernia: prosthesis is not required for successful outcome

Laparoscopic repair of giant hiatus hernia: prosthesis is not required for successful outcome

Giant hiatus hernia (GHH) are difficult to manage effectively. This study reports a laparoscopic, prosthesis-free technique to repair of GHH. Retrospective analysis of a prospectively populated database of a single surgeon's experience of GHH (>30 % intrathoracic stomach) repair using a novel, uniform technique was performed. Routine postoperative endoscopy, quality of life (QOL), and Visick scoring was conducted. Surgery was conducted in 100 patients (70F, 30 M). Mean (standard deviation [SD]) age was 69.1 (±11.4), median (interquartile range) ASA was 2 (range, 2-3), and mean (SD) body mass index (BMI) was 29.1 (±4.5). Mean follow-up was 574.1 (±240.5) days. One (1 %) patient was converted to an open procedure due to technical issues. Median stay was 2.5 days (range, 2-4). One postoperative death occurred secondary to respiratory sepsis. Eight (8 %) patients had perioperative complications: 4 major (PE, non-ST elevation MI, postoperative bleed managed conservatively, infected mediastinal fluid collection); and 4 minor (pneumothorax, asymptomatic troponin leak, subacute small bowel obstruction, and urinary retention). Ninety-nine (99 %) patients had objective screening for recurrence at 3-6 months. Two (2 %) patients have had symptomatic recurrence of their hiatus hernia; both involved a recurrent fundal herniation. Another seven (7 %) had small (<2 cm), asymptomatic recurrences diagnosed only on routine follow-up. Seven (7 %) patients have required reintervention for dysphagia with endoscopic dilatation conducted to good effect in all cases. Two (2 %) patients have required revisional surgery: one for a symptomatic recurrence at 3 months and a second for recurrent mediastinal collection. The Visick score fell from a mean (SD) of 3 (±1.1) to 1.7 (±0.8) postoperatively (p < 0.0001). The mean (SD) QOL preoperatively was 87.8 (±24) versus 109.1 (±22.3) postoperatively (p < 0.0001). GHH can be managed safely and effectively laparoscopically, without the use of a prosthesis.

Primary Repair of Giant Hiatus Hernia Is Satisfactory Without Mesh: Early Results of a Method Revisited

Small numbers of hiatus hernias are very large, cause other nonreflux symptoms as well, and have an attached morbidity and mortality through strangulation. Patients are elderly and unfit, and surgery has been troubled by recurrence. Mesh repair has been advocated in an attempt to reduce a perceived high revision rate. We describe the early results of a "composite" form of laparoscopic repair where no mesh has been used, with excellent early results in levels of symptom control, morbidity, mortality, and recurrence, and discuss the value of mesh repair as a primary operation against the recently recognized severe complications secondary to mesh repair failure. The technique requires five-port laparoscopy, primary nonabsorbable diaphragmatic repair, and fixation of the cardioesophageal junction, within a fundoplication, to the posterior crural repair and median arcuate ligament. Thirty-eight patients with a mean age of 70 years operated on during 1 year had a recurrence of 6% but of minimal size by objective measure between 4 and 19 months of operation. Mesh repair in the literature is poorly supported, highly complicated, and by these figures not required.

PTU-169 Giant hiatus hernia repair: a single-centre experience of the Crurasoft® (BARD) composite mesh

IntroductionUse of prosthetic mesh is advocated in giant hiatus hernia repair to reduce the chance of recurrence. However, complications related to the use of mesh at the oesophageal hiatus have...

Analysis of adherence to published guidelines for vestibular schwannoma screening: Correlating published guidelines to diagnostic yield

Analysis of adherence to published guidelines for vestibular schwannoma screening: Correlating published guidelines to diagnostic yield