Surgical aspects of treatment of hiatal hernia

Stawinski P.M., Dziadkowiec K.N., Kuo L.A., Echavarria J., Saligram S.

Barrett’s esophagus (BE) is a change in the distal esophageal mucosal lining, whereby metaplastic columnar epithelium replaces squamous epithelium of the esophagus. This change represents a pre-malignant mucosal transformation which has a known association with the development of esophageal adenocarcinoma. Gastroesophageal reflux disease is a risk factor for BE, other risk factors include patients who are Caucasian, age > 50 years, central obesity, tobacco use, history of peptic stricture and erosive gastritis. Screening for BE remains selective based on risk factors, a screening program in the general population is not routinely recommended. Diagnosis of BE is established with a combination of endoscopic recognition, targeted biopsies, and histologic confirmation of columnar metaplasia. We aim to provide a comprehensive review of the epidemiology, pathogenesis, screening and advanced techniques of detecting and eradicating Barrett’s esophagus.

Chan D.L., Tran S., Kanakaratne S., Bruce H.M., Thilakanathan C., Bull N., Hennessy A., Iliopoulos J., Talbot M.L.

• A retrospective analysis of 174 consecutive patients (2005-2016) who underwent either primary closure or mesh-reinforced laparoscopic hiatal hernia repair by a single surgeon. • Patients received telephone and mail questionnaires to assess long-term satisfaction and Visick and Gastro-oesophageal reflux disease symptoms assessment scale (GSAS) scores. • Hiatal hernia recurrence between primary and non-absorbable mesh-reinforced repair (20.4% vs 17.6%, p=0.67) and reoperation rates (16.3% vs 10.4%, p=0.28) were similar. • GSAS scores (2.1 vs 1.8. p=0.74) and patient satisfaction (p=0.82) were similar. Resolution of symptoms (Visick 1) favoured the mesh-reinforced group (19.4% vs 46.5%, p=0.04). Interest in laparoscopic mesh-reinforced hiatal hernia (HH) repair is driven by concern of recurrences following primary suture repair alone. There is need for further evidence on non-absorbable mesh-related complications or the long-term outcomes and patient satisfaction of laparoscopic mesh-reinforced HH repair. A retrospective analysis of consecutive patients (2005-2016) of a single surgeon. Patients were further surveyed via telephone and mailed questionnaires to assess long-term satisfaction and outcomes using Visick and gastro-oesophageal reflux disease symptoms assessment scale (GSAS) scores. 174 patients underwent laparoscopic HH repair, either as part of laparoscopic anti-reflux surgery (ARS) or for treatment of para-oesophageal HH in this period and fulfilled the study criteria. Patients with crural defects > 2cm received primary closure and those with larger defects received mesh reinforcement. Primary repair was performed in 28.2% (n=49) and mesh-reinforcement in 71.8% (n=125). HH recurrence (20.4% vs 17.6%, p=0.67) and reoperation rates (16.3% vs 10.4%, p=0.28) were not significantly different between the two groups. GSAS scores (2.1 vs 1.8. p=0.74) and patient satisfaction (p=0.82) were similar. Resolution of symptoms (Visick 1) favoured the mesh-reinforced group (19.4% vs 46.5%, p=0.04). There were no mesh infections or erosions. In our cohort, laparoscopic non-absorbable mesh-reinforced HH repair of large defects had similar long-term results to primary repair of small defects. There were potential long-term improvements in patient symptomatic outcomes as determined by the Visick score.

Guan L., Nie Y., Yuan X., Chen J., Yang H.

Giant hiatal hernias are more common in older patients and can significantly reduce their quality of life. However, open surgery for patients of advanced age is thought to be associated with high morbidity and mortality. The aim of this retrospective study was to evaluate the safety of laparoscopic giant hiatal hernia repair for elderly patients as compared to younger patients.From January 2015 to January 2020, 152 consecutive patients underwent laparoscopic mesh repair of giant hiatal hernia. Two cases of missing follow up were excluded. Patients were divided into an elderly group (N=62, age ≥75) and a younger group (N=88, age

Petric J., Bright T., Liu D.S., Wee Yun M., Watson D.I.

This meta-analysis systematically reviewed published randomized control trials comparing sutured versus mesh-augmented hiatus hernia (HH) repair. Our primary endpoint was HH recurrence at short- and long-term follow-up. Secondary endpoints were: surgical complications, operative times, dysphagia and quality of life.Repair of large HHs is increasingly being performed. However, there is no consensus for the optimal technique for hiatal closure between sutured versus mesh-augmented (absorbable or nonabsorbable) repair.A systematic review of Medline, Scopus (which encompassed Embase), Cochrane Central Register of Controlled Trials, Web of Science, and PubMed was performed to identify relevant studies comparing mesh-augmented versus sutured HH repair. Data were extracted and compared by meta-analysis, using odds ratio and mean differences with 95% confidence intervals.Seven randomized control trials were found which compared mesh-augmented (nonabsorbable mesh: n = 296; absorbable mesh: n = 92) with sutured repair (n = 347). There were no significant differences for short-term hernia recurrence (defined as 6-12 months, 10.1% mesh vs 15.5% sutured, P = 0.22), long-term hernia recurrence (defined as 3-5 years, 30.7% mesh vs 31.3% sutured, P = 0.69), functional outcomes and patient satisfaction. The only statistically significant difference was that the mesh repair required a longer operation time (P = 0.05, OR 2.33, 95% confidence interval 0.03-24.69).Mesh repair for HH does not offer any advantage over sutured hiatal closure. As both techniques deliver good and comparable clinical outcomes, a suture only technique is still an appropriate approach.

Mittal S.K., Baboli K.M., Bremner R.M.

Esophageal adenocarcinoma (EAC) is difficult to treat and carries a poor prognosis. Barrett’s esophagus, which develops from long-standing gastroesophageal reflux disease, is the only known precursor to EAC. Endoscopic eradication therapy is a major advancement in the treatment of dysplastic Barrett’s esophagus and early EAC; however, failure to eradicate disease and a high rate of recurrence with risk of progression currently remain unacceptably high with the use of acid suppressive medication for reflux. Herein, we describe the physiology of gastroesophageal reflux and review the current literature on endoscopic eradication therapy for Barrett’s esophagus. We summarize that antireflux surgery for reflux control as an adjunct to endoscopic eradication therapy may decrease the need for multiple endoscopic sessions (to achieve eradication), decrease the risk for recurrence/progression, and potentially decrease the need for surveillance.

Laxague F., Sadava E.E., Herbella F., Schlottmann F.

Summary The use of mesh in laparoscopic hiatal hernia repair (LHHR) remains controversial. The aim of this systematic review was to determine the usefulness of mesh in patients with large hiatal hernia (HH), obesity, recurrent HH, and complicated HH. We performed a systematic review of the current literature regarding the outcomes of LHHR with mesh reinforcement. All articles between 2000 and 2020 describing LHHR with primary suturing, mesh reinforcement, or those comparing both techniques were included. Symptom improvement, quality of life (QoL) improvement, and recurrence rates were evaluated in patients with large HH, obesity, recurrent HH, and complicated HH. Reported outcomes of the use of mesh in patients with large HH had wide variability and heterogeneity. Morbidly obese patients with HH should undergo a weight-loss procedure. However, the benefits of HH repair with mesh are unclear in these patients. Mesh reinforcement during redo LHHR may be beneficial in terms of QoL improvement and hernia recurrence. There is scarce evidence supporting the use of mesh in patients undergoing LHHR for complicated HH. Current data are heterogeneous and have failed to find significant differences when comparing primary suturing with mesh reinforcement. Further research is needed to determine in which patients undergoing LHHR mesh placement would be beneficial.

Rausa E., Manfredi R., Kelly M.E., Bianco F., Aiolfi A., Bonitta G., Zappa M.A., Lucianetti A.

Background: Hiatal hernia repair (HHR) is a complex surgical procedure and its management is not standardized. Several meta-analyses have compared cruroplasty with hiatus reinforcement with mesh, and crura augmentation appears to have better outcomes. However, heterogeneity in type of mesh and placement techniques has differed significantly. Materials and Methods: A systematic review and network meta-analysis were carried out. An electronic systematic research was carried out throughout Pubmed, CENTRAL, and Web of Science, of articles analyzing HHR with cruroplasty, nonabsorbable mesh (NAM), and absorbable mesh (AM) reinforcement. Results: Seventeen articles based on 1857 patients were enrolled in this article. The point estimation showed that when compared against the control group (NAM), the HH recurrence risk in AM and cruroplasty group was higher (relative ratio [RR] 2.3; CrI 0.8-6.3, RR 3.6; CrI 2.0-8.3, respectively). Postoperative complication rates were alike in all groups. The prevalence of mesh erosion after HHR is low. Conclusions: This network meta-analysis showed that prosthetic reinforcement significantly reduced HH recurrence when compared with cruroplasty alone. However, there is not enough evidence to compare different mesh compositions.

Mikhaleva L.M., Voytkovskaya K.S., Fedorov E.D., Birukov A.E., Gracheva N.A., Shegoleva N.N., Chigrai L.V., Shidii-Zakrua A.V.

Campos V., Palacio D., Glina F., Tustumi F., Bernardo W., Sousa A.

The use of mesh associated with cruroplasty is still controversial, especially in cases of giant hernias, due to possible complications of the prosthesis reported in the literature, such as infection, chest migration, shrinkage, esophageal and aortic erosion, stenosis and obstruction. This systematic review and meta-analysis aimed to compare the use or not of mesh as a reinforcement in the laparoscopic repair of giant hernias and to determine which technique has the best results in recurrence and complication rates. A search was conducted using databases and included prospective and randomized studies. The studies should include patients with giant hernias who have undergone laparoscopic treatment comparatively analyzed between cruroplasty and suture associated with prosthetic reinforcement. Of the 768 articles analyzed, 8 were selected for systematic review, and 7 were included in the meta-analysis (3 randomized trials with higher evidence strength, 2 randomized trials with lower methodological quality, and 2 prospective cohorts). The meta-analysis showed no statistically significant differences in favor of any of the intervention methods (mesh versus suture cruroplasty) for the different outcomes evaluated: recurrence (RD -0.06, CI [-0.13,0.01], I 2 22%, p 0.27); postoperative complications (RD 0.04, CI [-0.01,0.9], I 2 5%, p 0.30); deaths (RD -0.01, CI [-0.04, 0.02], I 2 0%, p 74); intraoperative complications (RD -0.03, CI [-0.07, 0.1]); reoperation (RD -0.04, CI [-0.10, 0.02], p 0.14). There is no evidence supporting that routine mesh reinforcement in laparoscopic repair of giant hernias decreases recurrence and other complications. Systematic review registration number at PROSPERO: CRD42019147468. • The use of mesh repair is still controversial for the treatment of hiatal hernia. • There is no evidence supporting that routine mesh decreases recurrence. • There is no evidence supporting that routine mesh increases postoperative complications. • There is no statistically significant differences in favor of mesh or suture.