Management of paraesophageal hernia review of clinical studies: timing to surgery, mesh use, fundoplication, gastropexy and other controversies

SUMMARY

Despite paraesophageal hernias (PEH) being a common disorder, several aspects of their management remain elusive. Elective surgery in asymptomatic patients, management of acute presentation, and other technical aspects such as utilization of mesh, fundoplication or gastropexy are some of the debated issues. The aim of this study was to review the available evidence in an attempt to clarify current controversial topics. PEH repair in an asymptomatic patient may be reasonable in selected patients to avoid potential morbidity of an emergent operation. In acute presentation, gastric decompression and resuscitation could allow to improve the patient’s condition and refer the repair to a more experienced surgical team. When surgical repair is decided, laparoscopy is the optimal approach in most of the cases. Mesh should be used in selected patients such as those with large PEH or redo operations. While a fundoplication is recommended in the majority of patients to prevent postoperative reflux, a gastropexy can be used in selected cases to facilitate postoperative care.

INTRODUCTION

Hiatal hernia (HH) is a common disorder that affects 10–50% of the general population. ¹ It is characterized by a protrusion of any abdominal structure other than the esophagus into the thoracic cavity through a widening of the hiatus of the diaphragm. Four types of HH has been described: type I is a sliding hernia, in which the gastroesophageal junction migrates into the thorax and accounts for 95% of all cases. Types II–IV hernias are varieties of paraesophageal hernias (PEH). Type II consists in the herniation of the gastric fundus with a normally positioned gastroesophageal junction. Type III combines the characteristics of types I and II, while type IV hernia is associated with a large defect in the phrenoesophageal membrane, allowing stomach and other organs to enter the hernia sac. More than 90% of PEH are type III, and the least common is type II. ² PEH are an infrequent type of real hernias because they have a true hernia sac including a peritoneal layer. ³ The vast majority of sliding hernias do not require surgical therapy, unless gastroesophageal reflux disease is present. While most symptomatic PEH should be considered for surgical treatment, routine elective repair of a completely asymptomatic PEH is a matter of debate. ⁴ Some recommend surgical therapy to prevent PEH potentially life-threatening complications, such as volvulus, strangulation, incarceration or perforation. ^5–6 In contrast, others recommend observation due to the low risk of developing acute symptoms requiring emergency surgery. ⁷

Acute PEH is a surgical emergency presenting with chest or abdominal pain, vomiting, dysphagia, respiratory failure or sepsis due to gastric volvulus, incarceration, strangulation or perforation. When patient presents with clear signs of gastric compromise or perforation surgery is mandatory. For other patients with an acute but less severe presentation, controversy exists regarding the timing and need for surgery. Emergent, semi-elective or elective surgery after gastric decompression are possible options. Moreover, in case surgical repair is decided, the ideal approach (open vs. laparoscopic, abdominal vs. thoracic vs. combined), utilization of mesh for hiatal closure reinforcement and, whether to include or not an anti-reflux procedure or a gastropexy are also a matter of debate.

The aim of this study was to review the available evidence regarding the management of asymptomatic PEH, acute presentation, timing to surgery and technical aspects, such as surgical approach, utilization of mesh, fundoplication and gastropexy.

METHODS

An electronic review of the Medline database was performed to identify publications regarding paraesophageal hernia management. Key terms used were: ‘paraesophageal hernia’, ‘hiatal hernia’, ‘diaphragmatic hernia’, ‘hiatal hernia surgery’, ‘complicated’, and ‘acute'. Keywords were used in all possible combinations to obtain the maximal number of articles. The search strategy was restricted to studies on human subjects, reported in English and published between 2000 and 2019. For the nature of the study, no Institutional Review Board approval or written consent was required.

Inclusion criteria were the following: (i) type of study: randomized controlled trials, non-randomized, prospective and retrospective studies in patients who underwent PEH repair. Systematic reviews and reviews were also analyzed; (ii) human studies; (iii) age: >16 years old. Exclusion criteria were the following: (i) case reports; (ii) posters; (iii) technical notes; (iv) conference papers.

A first screening was run based on the publication’s title and abstract. The articles review was performed by two independent reviewers, with discrepancies reconciled by the senior author. The initial search yielded 1483 articles. After eliminating duplicates and applying exclusion criteria, 200 articles were screened based on full text assessment and 65 were finally included in the review: 42 retrospective, 9 randomized controlled trials, 6 prospective non-randomized, 4 reviews, 3 meta-analysis and 1 systematic review.

For mesh and fundoplication analysis, the primary outcome of interest was recurrence rate. Secondary outcomes of interest were dysphagia and GERD/esophagitis rates for mesh and fundoplication use, respectively.

Paraesophageal hernia: elective repair or observation?

Decision to operate or observe an asymptomatic or minimally symptomatic PEH is controversial. Historically, surgery was indicated to avoid potentially life-threatening complications related to PEH and the morbidity or mortality associated with emergent repairs, with reports as high as 25–50%. ^{5–6  ,   8} In contrast, the development of less-morbid minimally invasive techniques and the relatively low risk of complication of PEH have challenged this belief. ⁷

Polomsky et al. ⁹ analyzed a New York database and found 4858 hospital admissions with primary diagnosis of intrathoracic stomach over a 5-year period. Compared with elective admissions, emergent admissions had higher mortality (2.7% vs. 1.2%, P < 0.001), longer length of hospital stay (LOS) (7.3 vs. 4.9 days, P < 0.0001), and higher costs ($28,484 vs. $24,069, P < 0.001). In addition, patients who underwent emergent surgery had higher mortality (5.1% vs. 1.1%, P < 0.0001), longer LOS (13.1 vs. 4.9 days, P < 0.0001), and higher costs ($55,460 vs. $24,760, P < 0.0001). Authors concluded that their data support elective repair of PEH regardless the presence of symptoms. A study conducted by Poulose and colleagues ¹⁰ analyzed 1005 PEH repairs in octogenarians using the US Nationwide Inpatient sample data for 2005. The authors found that non-elective repair had higher mortality (16% vs. 2.5%, P < 0.05) and LOS (14.3 vs. 7 days, P < 0.05) when compared to elective repair, concluding that early elective repair may be a reasonable option to reduce mortality in these population. Moreover, Sihvo et al. ¹¹ conducted a population-based study of patients with PEH in Finland and reported that mortality rate after surgical repair was 2.7%. Twelve and three patients died after emergent and elective repair, respectively. Mortality rate of hospitalized patients for symptomatic PEH who underwent conservative treatment was 16.4%, estimating that 13% of deaths might have been prevented by elective surgical repair. Similarly, Jassim et al. ¹² analyzed 41,723 patients undergoing PEH repair from the US Nationwide Inpatient Sample. Authors found that emergent repair was associated with increased morbidity (33.4% vs. 16.5%, P > 0.001) and mortality (3.2% vs. 0.37%, P > 0.001) than elective repair. In addition, emergent repair was less likely to be laparoscopic. Considering these data, authors recommended elective PEH repair with experienced laparoscopic surgeons.

Stylopoulos et al. ⁷ developed a Markov Monte Carlo decision analytic model to track a hypothetical cohort of patients with asymptomatic PEH and analyze the outcomes associated with two strategies: elective laparoscopic repair or watchful waiting. Input variables derived from pooled analysis of published studies and the NIS-HCUP database. Authors stated that the annual probability of an asymptomatic PEH developing acute symptoms requiring emergency surgery was 1.1% per year and that published studies overestimated the mortality of emergency surgery (17% vs. 5.4%). In addition, while mortality for elective laparoscopic PEH repair was 1.4%, the overall lifetime risk of death due to a PEH in a patient managed by watchful waiting was also approximately 1%. The Markov model predicted that watchful waiting was the optimal treatment strategy in 83% of asymptomatic PEH and elective repair in the remaining 17%. For that reason, the authors concluded that watchful waiting was a reasonable initial approach for asymptomatic PEH. Larusson and colleagues ¹³ evaluated predictive factors for postoperative morbidity and mortality after laparoscopic PEH repair. Authors concluded that indication of surgery must be carefully balanced against the individual patient’s comorbidities (ASA III-IV), age (>70 years), symptoms, and the potentially life-threatening complications.

Current SAGES guidelines ⁴ for the management of HHs stated that all symptomatic PEH should be repaired. Conversely, routine elective repair of completely asymptomatic PEH may not always be indicated and consideration of surgery should include patient age, surgical risk and comorbidities. This recommendation was based on recent reports ^{11  ,   14} showing lower mortality rates in emergency surgery and less than 2% per year risk of developing acute symptoms requiring emergency operation. ^{7  ,   15–17}

In conclusion, conflicting data exist regarding the optimal approach of PEH. Decision to operate or observe a PEH should consider the presence of symptoms, patient’s age, comorbidities and perioperative risks. While the risk of complication on an asymptomatic PEH seems low, morbidity of emergent surgery is higher than elective repair. However, the increment in use of minimally invasive surgery in the emergent scenario may improve postoperative outcomes.

Acute paraesophageal hernia repair: timing to surgery and influence of surgical volume

Management of patients with complicated PEH is challenging. Emergent surgery for acute PEH has historically been associated with higher morbidity and mortality when compared to elective repair. ^{9  ,   12  ,   18} Clinical or radiological suspicion of acute gastric ischemia or perforation require emergent surgery. However, most of the patients presenting acutely are clinically stable and their symptoms might be managed by conservative measures. Therefore, it is often possible to improve patient’s clinical condition and perform an operation by a more experienced surgical team which may improve postoperative outcomes.

Timing to surgery: emergent, semielective or elective repair

The ideal moment to perform surgery in case of acute presentation of PEH is a matter of debate. Kohler et al. ¹⁹ conducted a retrospective analysis of 24 patients hospitalized due to emerging acute symptoms of an intrathoracic stomach. Patients were categorized in 3 groups according to severity of complaints and success of conservative treatment: emergent (<24 hours of admission), semi-elective (<7 days after admission) and elective operation (within 4 weeks of admission). They found that only 12.5% of patients required emergency surgery, while the remaining 25% and 62.5% underwent semi-elective and elective repair, respectively. This allowed the surgical team to resuscitate and optimize the patient before the operation. Another study by Wirsching and colleagues ²⁰ analyzed 38 patients presenting with acute PEH. Emergency surgery was only required in three patients (8%), while the remaining 35 (92%) were managed in a staged approach with gastric decompression prior to semi-elective surgery. Although this approach was associated with an increased LOS, it did not increase morbidity or mortality when compared to elective PEH repairs. Bawahab and colleagues ²¹ retrospectively analyzed 20 patients admitted with acute PEH. Only 3 patients required emergent surgery due to clinical instability, perforation or gastric compromise. Two clinically stable patients underwent urgent surgery (24–48 hours from admission) because of lack of contrast flow through the stomach. The majority of patients (75%) responded well to resuscitation and gastric decompression and were operated semi-urgently (within 1–2 weeks) with a laparoscopic approach. In line with these findings, Polomsky et al. ⁹ found in a population-based analysis that the majority of emergent admissions for PEH (1703 of 2562) were treated non-operatively. Similarly, Markar et al. ²² analyzed 12,441 acute admissions with PEH on a large national database of English NHS hospitals and showed that only 12.8% of patients underwent urgent surgery during initial admission.

In contrast, Bhayani and colleagues ²³ investigated outcomes after 224 acute PEH repairs using the National Surgical Quality Improvement Project (NSQIP) database. Patients were divided in two groups by time to surgery: ≤1 day of admission (early repair) or >1 day of admission (interval repair). Despite similar mortality was found between groups, early repair was associated with less sepsis (2.7% vs. 13%, P = 0.002) and shorter LOS (5 vs. 11 days, P < 0.001). Moreover, overall morbidity was higher (17% vs 30%) for interval repair. Interestingly, authors showed that mortality of emergent repairs (3.9%) was not as high as historically reported.

While a minority of patients with acute presentation of PEH require emergent surgery (ischemia, perforation), most of the patients can be initially managed with gastric decompression. This measure allows to improve patient’s clinical condition and perform a minimally invasive operation with outcomes similar to those in the elective setting.

Surgical volume and perioperative outcomes

The relationship between high volume surgeons and patient’s outcomes, and how the results of an operation are influenced by specialist management have been described for different procedures. ^24–28 One of the potential advantages of delaying PEH repair is the possibility of referring the patient to a high-volume center which may improve patient’s outcomes.

For example, Schlottmann et al. ²⁹ studied the impact of surgical volume on perioperative results after 63,812 PEH repairs in the USA using the National Inpatient Sample for the period 2000–2013. Surgical volume was categorized as small (<6 operations/year), intermediate (6–20 operations/year) or high (>20 operations/year). Authors found that the rate of laparoscopic procedures was significantly different among groups (small volume 38.4%; intermediate volume 41.8%; high volume 67.4%, P < 0.0001). Lower surgical morbidity (small volume 26.4%; intermediate volume 24.1%; high volume 12.7%, P < 0.0001), lower mortality (small volume 2.9%; intermediate volume 2.4%; high volume 0.8%, P < 0.0001) and shorter median LOS (small volume 5 days; intermediate volume 4 days; high volume 2 days, P < 0.0001) were found when hospital volume increased. Interestingly, authors reported that during the last decade the rate of procedures in high-volume centers increased from 65.8% to 94.4%. Similar findings were reported by Whealon and colleagues. ³⁰ After analyzing 31,228 laparoscopic diaphragmatic hernia repairs from the US National Inpatient Sample, they found that low-volume hospitals (<10 cases/year) had almost two-fold higher mortality compared to high-volume hospitals (0.23% vs. 0.12%, P = 0.02). Another study by Markar et al. ²² analyzed 12,441 admissions for acute PEH and found that high-volume centers were associated with significant reductions in utilization of emergent surgery (8.8% vs. 14.9%, P < 0.0001), 30-day mortality (5.3% vs. 7.8%, P < 0.0001), and 90-day mortality (9.3% vs. 12.7%, P < 0.0001) when compared with lower volume centers.

While the exact number of cases to be considered as a high-volume surgeon/center is still under debate, it seems that outcomes of surgical management of PEH have a positive correlation with the experience of the surgical team.

Surgical management of paraesophageal hernia: technical aspects

Multiple technical aspects for PEH repair remain elusive. Currently, main controversial aspects are: surgical approach, use of mesh for crural reinforcement, systematic incorporation of an anti-reflux procedure, and whether to perform or not an anterior gastropexy.

Open versus minimally-invasive surgery (MIS) and abdominal versus thoracic approach

Historically, open repairs through a laparotomy or thoracotomy were used. Unfortunately, these procedures were associated with significant morbidity. In the last decades, laparoscopic and thoracoscopic procedures emerged as promising alternatives with recognized benefits. ^{4  ,   31–33}

For instance, Zehetner and colleagues ³¹ performed a retrospective analysis of 146 PEH repair by open and laparoscopic approach. Reported postoperative complications were significantly higher for open surgery (36% vs. 11%, P = 0.0007). Overall recurrence was 18% (27 patients), 9 after laparoscopic repair and 18 after open repair (P = 0.09). Moreover, shorter median LOS was found in the laparoscopic group (3 vs. 9 days, P < 0.0001). Using the NSQIP database, Kubasiak et al. ³² analyzed a cohort of 4470 patients with PEH, and found that laparoscopic repairs were associated with significant decrease in respiratory and cardiac complications, transfusion requirements, infection, episodes of sepsis and shock when compared to an open approach. Similarly, Schlottmann et al. ³³ analyzed the utilization of MIS and compared its outcomes with open procedures. From the 63,812 PEH analyzed, an abdominal approach was used in 60,087 (94.2%) of patients, from which 67.1% were operated by laparoscopy and 32.9% by laparotomy. Thoracic approach was utilized in 3725 patients mostly by open surgery (75.5%). Comparison of postoperative outcomes showed that MIS was associated with significantly lower morbidity (9.6% vs. 23.3%, P < 0.0001), mortality (0.3% vs. 2.4%, P < 0.0001), LOS (3 vs. 7 days, P < 0.0001) and overall costs ($50,000 vs. $55,000, P < 0.0001). For this reason, the authors concluded that MIS should be the standard of care for PEH repair. Moreover, Mungo and colleagues ³⁴ analyzed 8186 PEH repairs using the NSQIP database. Outcomes of laparoscopic, open transabdominal and open transthoracic approach were compared. Open transabdominal patients had the highest 30-day mortality rate (2.6%) compared with 0.5% in laparoscopic (P < 0.001) and 1.5% in transthoracic patients. Mean LOS was significantly longer for open transabdominal and transthoracic patients (7.8 and 6.5 days, respectively) compared with laparoscopic patients (3.3 days). In addition, open transabdominal and transthoracic approach had significantly increased overall and serious morbidity.

The 2013 SAGES guidelines ⁴ for the management of HH state that HH can be effectively managed either by a transthoracic or transabdominal approach. In addition, as the laparoscopic HH repair is as effective as the open transabdominal repair, but with reduced rates of perioperative morbidity and shorter LOS, laparoscopy is the preferred approach for the majority of HHs.

A well-known advantage of the transthoracic approach for PEH repair is enhanced esophageal exposure that favors extensive mobilization of the esophagus, and better visualization and therefore dissection of the hernia sac. Conversely, thoracotomy is associated with significant postoperative pain, morbidity and the technical difficulty of performing an adequate fundoplication. For instance, Subroto et al. ³⁵ analyzed 38,764 diaphragmatic hernia repairs using the USA National Inpatient Sample. Authors found that thoracotomy repair was associated with longer LOS and higher need of postoperative mechanical ventilation when compared to abdominal approach. In addition, the thoracotomy approach was an independent predictor for the development of pulmonary embolism. A promising alternative that could reduce the morbidity associated with open surgery while conserving transthoracic approach benefits has been described by Molena et al. ³⁶ Authors used a combined video-assisted thoracoscopic surgery (VATS)/laparoscopic approach for giant or complicated PEH with very good results. This procedure combines the technical advantages of transthoracic and transabdominal approach while preserving the benefits of MIS.

Paraesophageal hernia: to mesh or not to mesh

A tension-free hiatal closure is an essential step in the surgical treatment of PEH. Historically, a simple cruroplasty has been used. However, the high recurrence rates reported (up to 42%) prompted many surgeons to reinforce the hiatal closure. ³⁷ In 2012, Frantzides and colleagues ³⁸ performed a prospective randomized trial comparing simple cruroplasty to polytetrafluoroethylene (PTFE) patch repair for large (>8 cm) HHs. While similar LOS and complications were seen among groups, simple cruroplasty had significantly higher recurrence rates (22% vs. 0%, P < 0.006). A study conducted by Ganderath et al. ³⁹ randomized 100 patients to laparoscopic Nissen fundoplication with or without prosthetic reinforcement of hiatal closure. At 1 year of follow-up, functional outcomes improved significantly in both groups, but higher postoperative dysphagia rate was seen among mesh reinforcement group. On the other hand, intrathoracic wrap migration was significantly more frequent in simple cruroplasty group (26% vs. 8%, P < 0.001).

An argument against mesh reinforcement are the potential complications that may arise with its use. The most feared mesh-related complication is esophageal erosion. A meta-analysis by Muller-Stich et al. ⁴⁰ analyzed 5499 laparoscopic PEH repair with mesh reinforcement and found a 1.9% rate of mesh-associated complications. The more frequent mesh complications were erosions of the esophagus, the stomach or the aorta followed by stenoses and cardiac tamponades. Polypropylene (PP), PTFE and biologic meshes were used in 39.6%, 31.9% and 13.5% of the cases, respectively. Complication rates for specific type of mesh were: PP 0.8%, PTFE 2.5% and biologic 1.3%.

Potential serious complications related to the placement of a non-absorbable mesh in the hiatus brought the development of biologic and absorbable materials. Oelschlager et al. ⁴¹ performed another randomized trial in which recurrence rates after PEH repair was significantly lower with the use of biologic mesh when compared to primary repair (9% vs. 24%). However, the same group ⁴² reported long-term outcomes of the same trial showing no difference in recurrence rates between PEH with or without mesh reinforcement (54% vs. 59%).

The 2013 SAGES guidelines for the management of HH ⁴ stated that the use of mesh for reinforcement of large HH defects lead to a decreased short-term recurrence rate. However, there is inadequate long-term data on which to base a recommendation either for or against the use of mesh at the hiatus. Furthermore, the wide variety of materials and shape of prostheses makes the decision even more difficult. A recent meta-analysis ⁴³ analyzed outcomes after laparoscopic HH repair with simple suture, synthetic mesh or biologic mesh. Nine studies with 676 patients were included and authors found no significant difference in the incidence of complications between mesh and simple suture. Hernia recurrence was significantly lower using mesh (14.5% vs. 24.5%, P = 0.009), and synthetic mesh was more effective than biologic. Although there is no strong evidence to support its use, a study performed by Schlottmann et al. ⁴⁴ found that utilization rates of mesh for laparoscopic PEH repair remained high and stable between 2011 (39.4%) and 2014 (38.2%) in the USA. The authors stated that patients that could benefit the most by mesh reinforcement were those with giant PEH, redo operations or cases where the surgeon was unable to close the diaphragm.

Outcomes of PEH repair with mesh or simple suture in terms of recurrence and postoperative dysphagia are summarized in Table 1.

Table 1.

Reported outcomes of paraesophageal hernia repair with mesh or simple suture

Author (year)	N (mesh/SR)	Study type	Mesh type	Mean follow-up, months	Recurrence (%mesh/suture)	Dysphagia (% Mesh/SR)
Frantzides 38	72 (36/36)	Prospective RCT	PTFE	40	0/22	NR/NR
Kamolz 52	200 (100/100)	Retrospective	Polypropylene	12	0/5	2/2%
Ganderath 39	100 (50/50)	Multicenter RCT	Polypropylene	12	8/26	4/4%
Ringley 53	44 (22/22)	Prospective, case control	HACD	12	0/9	4.5/4.5%
Oelschlager 42	108 (51/57)	Multicenter RCT	Biologic (Surgisis)	58	54/59	NR/NR
Schmidt 54	70 (38/32)	Retrospective	Biologic	12	0/16	NR/NR
Watson 55	126 (83/43)	Multicenter RCT	Biologic (Surgisis)	12	BM: 30.8	BM: 5%
			Synthethic (TiMesh)		SM: 12.8	SM: 0%
					SR: 23	S: 2.5%
Asti 56	84 (41/43)	Observational cohort	Biosynthetic (GoreBio A)	24*	9.7/18.6	2.4/2.3%
Crespin 57	146 (110/36)	Retrospective	Biologic	9*	40.9/58	0.9/2.7%
Ilyashenko 58	98 (50/48)	Prospective RCT	ProGrip	48	2.9/22.8	20.5/48.5%
Oor 59	72 (36/36)	Multicenter RCT	Synthetic (TiMesh)	12	17.2/14.4	23.5/14.7%

^*median follow-up.

PTFE, polytetrafluoroethylene; HACD, human acellular cadaveric dermis; BM, biologic mesh; SM, synthetic mesh; SR, suture repair; NR, not reported.

Fundoplication: Yes or No

Arguments against performing a fundoplication during PEH repair are prolonged operative time, a variable prevalence of gastroesophageal reflux in PEH patients, risk of postoperative dysphagia and surgical complications associated with a fundoplication. On the other hand, a fundoplication aids the prevention of postoperative reflux due to the incompetence of LES, which is also favored by the extensive hiatal dissection during PEH repair. It is also thought that a fundoplication helps to support the anchoring of the cardia below the diaphragm, thereby reducing the chance of recurrence. The 2013 SAGES guidelines for the management of HH ⁴ stated that the fundoplication is an important step of PEH repair. However, the strength of this recommendation is weak. A trial by Muller-Stich et al. ⁴⁵ randomized 40 patients with PEH to laparoscopic mesh-augmented hiatoplasty with simple cardiophrenicopexy or to laparoscopic mesh-augmented hiatoplasty with fundoplication. At 1 year of follow-up reflux syndrome score and postoperative esophagitis (53% vs. 17%, P = 0.026) was higher in patients without fundoplication. In addition, dysphagia rates, quality of life, and postoperative complication rates did not differ between groups. Authors concluded that laparoscopic PEH repair should include a fundoplication to avoid postoperative gastroesophageal reflux and subsequent esophagitis.

Another controversial issue is what type of fundoplication to perform (i.e. partial vs. total). A previous study analyzing 17 clinical studies and 7 technical reports showed that the most common type of fundoplication after PEH repair was a total (Nissen or Nissen-Rossetti) fundoplication, and after analyzing the current evidence the authors concluded that a partial fundoplication (Toupet or Dor) should be reserved to those patients with significantly impaired esophageal motility. ⁴⁶

Table 2 summarizes outcomes of hernia repair with or without fundoplication in terms of postoperative reflux symptoms, esophagitis and recurrence.

Table 2.

Reported outcomes of paraesophageal hernia repair with or without fundoplication

Author (year)	N (Fundoplication: no/yes)	Study type	Fundoplication type	Mean follow-up, months	GERD	Esophagitis	Hernia recurrence
Williamson 60	No: 107	Retrospective	–	61.5	18%	NR	11%
Styger 61	No: 28	Retrospective	–	36	32%	10.7%	NR
Mattar 62	Yes: 136	Retrospective	NR	40	5–7%	NR	33%
Mark 63	Yes: 40	Retrospective	Nissen	12	7%	NR	NR
Muller-Stich 64	No: 306	Retrospective	–	52	34%	4.2%	5%
Morris-Stiff 65	12/11	Retrospective	Nissen	6	17% versus 0%	NR	0% versus 0%
van der Westhuizen 66	22/130	Retrospective	NR	13.9	18% versus 5.4%	NR	13.6% versus 12.3%
Linke 67	No: 55	Retrospective	–	72	34%	18%	10%
Muller-Stich 45	20/20	RCT	Nissen	12	24% vs 15%	53% versus 17%	33% versus 21%
Zhi-tong LI 68	61/61	RCT	Nissen	24	NR	44.6% versus 13.7%	5.4% versus 1.7%

RCT, randomized controlled trial; NR, not reported.

Use of gastropexy during paraesophageal hernia repair

Boerema first described anterior gastropexy for PEH repair in 1952. ⁴⁷ As this procedure was performed without other key components of actual PEH operation such as hernia sac reduction or cruroplasty, recurrence rates were very high and thereby the procedure was abandoned for years. Nevertheless, modified Boerema gastropexy reemerged in the last decades as an alternative option to reduce recurrence rates avoiding the potential long-term complications of mesh cruroplasty and routine fundoplication.

In 2003, Ponsky et al. ⁴⁸ presented a prospective series of 28 patients who underwent surgery for type III HHs. All operations included reduction of the hernia, sac excision, crural repair, anti-reflux procedure and anterior gastropexy. Authors reported no recurrences with up to 2 years of follow-up. Similarly, a study that included 89 patients with large HHs undergoing laparoscopic repair without mesh reported a recurrence rate of 15.7%. Three factors were associated with hernia recurrence: the absence of an anterior gastropexy, younger patients and history of abdominal surgery. Authors observed that 10.8% and 50% of recurrences occurred in patients with and without anterior gastropexy, respectively (P = 0.0028). ⁴⁹

A multicenter study by Daigle and colleagues ⁵⁰ analyzed 101 patients that underwent laparoscopic PEH repair using a modified Boerema anterior gastropexy without fundoplication. With a median follow-up of 12 months, reflux symptoms were absent in 70.3% of patients and pharmacotherapy alone was sufficient for the remaining symptomatic patients. Recurrence rate assessed by postoperative endoscopy/barium swallow was 16.8%, from which 9.9% were small and segmental recurrences. Authors concluded that this procedure demonstrated favorable results while avoiding the potential complications associated with mesh hiatoplasty or routine fundoplication.

The addition of a gastropexy was also studied in the emergency setting by Arevalo et al. ⁵¹ . Thirteen high-risk patients with acute gastric volvulus underwent laparoscopic PEH repair with adjunct gastropexy or gastrostomy tube placement with favorable outcomes. Authors stated that laparoscopic repair with gastropexy or gastrostomy tube placement successfully treats the acute gastric outlet obstruction and represents a safe, simple and less challenging approach which may be used to improve physician comfort with laparoscopy and expedite the repair in high-risk patients. Current guidelines ⁴ stated that a gastropexy could be safely used in addition to hiatal repair and a gastrostomy tube insertion may facilitate postoperative care in selected patients.

Conclusions

Elective surgery for PEH may be reasonable in some patients to avoid the morbidity associated with an emergent operation. Although acute complicated PEH are associated with a considerable morbidity and mortality, gastric decompression is often feasible to improve patient’s clinical condition. In addition, this allows for patients’ referral to a high-volume center, which results in better postoperative outcomes. Minimally invasive surgery, mainly by laparoscopy, is considered the gold standard for PEH repair. Controversies exist on technical aspects of the operation such as utilization of mesh, routine use of fundoplication or addition of an anterior gastropexy. Due to insufficient evidence, a case by case approach considering patient’s characteristics seems to be reasonable.

Most of the available evidence and recommendations for PEH management are based on prospective and retrospective reports with relatively low number of patients and lack of standardized surgical technique and outcomes report. Larger studies with long-term follow-up analyzing the potential benefits of the use of mesh and comparing fundoplication with gastropexy may be of interest for future research.

Authors contributions

Conception and design: Dreifuss, Schlottmann, Molena.

Data acquisition: Dreifuss, Schlottmann.

Analysis and interpretation of data: Dreifuss, Schlottmann.

Drafting of manuscript: Dreifuss, Schlottmann, Molena.

Critical revision of manuscript: Dreifuss, Schlottmann, Molena.

Conflicts of interest

Nicolás H. Dreifuss, Francisco Schlottmann and Daniela Molena have no conflict of interest, financial ties or funding/support to disclose.