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

Abstract

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.

INTRODUCTION

Giant hiatus hernia (GHH) is primarily a disease of the elderly with increased reported incidence over the last two decades.[1,2] This trend is attributed to the ageing population, centralisation of upper gastrointestinal (UGI) services and greater incidental findings of GHH in asymptomatic patients with the increased utilisation of imaging.[1,3,4,5] GHH is associated with a significantly reduced quality of life (QoL) and increased risk of complications such as volvulus of the stomach if left untreated.[6] Surgical repair for all patients with symptomatic GHH has therefore been recommended.[6,7,8,9,10] Watchful waiting is advocated in asymptomatic patients.[9,11,12]

Over the last two decades, careful patient selection and advances in perioperative care have led to significant reduction in post-operative mortality of this condition (0%–5.2%).[3,13,14] Improved survival in GHH surgery patients has changed the focus of study outcomes from mortality to that of recurrence and QoL measures, with the reported recurrence rate varying between 9% and 66%.[15,16,17] The elderly demographic of GHH patients presents clinicians with challenge in the management of symptomatic GHH, where the improvement in QoL must be weighed against the risks of undergoing surgery.

After the first report by Velanovich et al. in 2001, a number of studies addressing the QoL following the repair of GHH have been published.[18] Some studies have compared QoL outcomes with or without mesh, some have assessed QoL in elderly population and some have compared QoL after two different operations.[19,20,21,22,23,24,25] There remains a lack of clarity on the impact of such variables on QoL outcomes after GHH surgical repair. The aim of this study is to systematically review the literature assessing QoL following elective repair of GHH.

METHODOLOGY

Literature search

A systematic review of the literature was performed using the following databases: Medline (1946–May 2020) via OvidSp, Ovid Embase (1947–20 May 2020) and Cochrane Library. The search aimed to identify original studies evaluating outcomes following repair of GHH with specific emphasis on post-operative improvement in QoL. Three strings using the following search terms were used: Paraoesophageal; hiatus hernia; giant hiatus hernia and quality of life. All variations in spelling including a truncated search term using wild card characters and ‘related articles’ function were used in combination with the Boolean operators ‘AND’ and ‘OR’. Reference lists of the identified articles were also searched to identify other potentially relevant studies.

Two independent reviewers (YMG and AD) screened the titles and abstracts of all studies identified by a primary electronic search. The full texts of potentially relevant articles were retrieved to assess eligibility for inclusion. Included studies were those reporting surgical and QoL outcomes in patients undergoing GHH or large paraoesophageal hernia (PEH) repair. Different variants of definitions of GHH were accepted, including. (1) paraoesophageal hernia (PEH),[5] (2) GHH >30% or 50% of the stomach in the chest and (3) >2-cm hiatus hernia on radiology or endoscopy. Studies were excluded if they reported on animal or in vitro studies; used non-validated questionnaires; were not published in English language; did not report on QoL outcomes and were review articles, conference abstracts and case reports. A third reviewer (RD) was consulted in the case of a disagreement.

Assessment of quality of studies

The quality of studies was assessed with the ‘Quality assessment tool for case series studies’, devised by the National Heart, Lung, and Blood Institute.[26] Each study was assessed utilising the 9-point criteria, with 1 point given for each criterion fulfilled. A study’s quality rating was subsequently graded as good, fair or poor based on the total score from these points.

Outcome measures

The following data items were extracted from the included publications: year of publication, country of origin, study design, hernia type and size, total number of patients in each study, QoL assessment as the primary study outcome, mean age, use of mesh, type of surgery performed, recurrence, mortality and morbidity, length of follow-up and type of questionnaire used in the study.

RESULTS

Literature search and study characteristics

A systematic literature search identified a total of 208 studies, of which 45 remained after applying the exclusion criteria and removal of duplicates [Figure 1]. After reviewing full-text articles, a final total of 38 studies comprising a total of 4404 subjects who underwent surgery for GHH were included in the review, with follow-up using questionnaires achieved in over 3000 patients [Table 1a and b]. There were 36 studies that were either retrospective or prospective case series, with an additional two randomised controlled trials. All studies were graded as ‘good’ (score of ≥8) by both adjudicators except for Kang et al.,[27] which scored ‘fair’ with 6 points. Based on Quality assessment tool for case series studies, there were no exclusions and all the 38 studies were reviewed in this paper. Of note, Tam et al.[28] and Nason et al.[29] reported on different outcomes from the same patient group; Tam et al. reported multiple outcomes including QoL improvement after surgery, recurrence and significance of mesh, whereas the data from Nason et al. were relevant for Collis gastroplasty.

Figure 1.

PRISMA chart

Table 1.

Included studies and study characteristics

Authors	Study type	Prospective/retrospective	Definition of hernia in the study	Total number of patients	Number of patients followed up	Length of follow-up (months)	Recurrence (symptomatic)	Recurrence endoscopic (E) or radiological (R) (%)	Mean age in years	Types of surgery	Mortality	Questionnaire used
Asti et al., 2016	Case series	Retrospective	Type III and >5 cm	84	75	24	n/a	12E (4 mesh, 8 no mesh)	65	NF or Toupe and mesh versus no mesh	0	GERD-HRQL
Chen et al., 2018	Case series	Retrospective	>50%	69	54	114	n/a	12 (34) R	66	Dor, 270F, NF +mesh	n/a	GIQLI
Dallemagne et al., 2011	Case series	Retrospective	>50%, Type II or III, Type IV	85	64	118	2 (3%) redo	23 (66) R	66	NF, Toupe CR, CR with pledgets, mesh, emergency	0	GIQLI
Ferri et al., 2004		Prospective	PEH	60	23 (78% open) 34 (91% lap)	45	n/a	8 (44 open) 7 (31 lap)	n/a	emergency, open, lap, NF gastrostomy, GP	n/a	GERD-HRQL; SF-12
Furtado et al., 2016	Case series	Retrospective	>50%	100	85	27	n/a	24 (24%) R	71	NF + CR	1	GIQLI; Visick; DSS
Gibson et al., 2013	Case series	Retrospective	>30%, 10% Type IV	100	92	24	9 (9%) 2 redo and 7 dilatation	7 (7) R, 2 (2) redo	69.1	NF, GP	0	GIQLI; Visick
Hall et al., 2018	Case series	Retrospective	PEH II, III, IV	314	188	24	n/a	n/a	69.1	NF versus Toupe	1	GERD-HRQL; RSI; DSS; SF-36
Hazebroek et al., 2008 (ANZ Journal of Surgery)	Case series	Retrospective	PEH	40	37	12	n/a	1 R	65.2	CR, 270F over 56 Fr Bougie+mesh	0	QOLRAD
Hazebroek et al., 2008 (Diseases of the Oesophagus)	Case series	Retrospective	PEH Type II or III	35	30	43	1	0	77	CR, 270F	0	QOLRAD
Huerta et al., 2018	Case series	Retrospective	PEH Type III and IV	179	77	54 (Nissen); 25 (Toupet)	n/a	5 (4) NF, 2 (3) T (R and symptomatic)	64	NF versus Toupe	n/a	GERD-HRQL
Ilyashenko et al., 2018	Case series	Retrospective	PEH Type III	98	95	48	5 non-mesh; 2 redo	1 mesh, 8 no mesh	63	Mesh versus no mesh, anterior CR	0	GERD-HRQL
Kang et al., 2014	Case series	Prospective	>1/3rd of the stomach	89	29	69.7	1 re do	6 (6.7) E or R	62.7	CR, mesh	n/a	QLSGR
Karmali et al., 2008	Case series	Retrospective	>1/3rd of the stomach	93	71	17 lap 21 open	3 redo (2 lap, 1 open)	4 (9) lap 4 (9) open	64 Lap 72 open	Lap versus open, NF, 180F 270F, CG, PEG	0	GERD-HRQL
Koetje et al., 2015	Randomised controlled trial	Prospective	Large hiatus hernia >50%	126	105	24	9	29	68	CR versus non-absorbable mesh versus absorbable mesh	1	SF-36
Laan et al., 2018	Case series	Retrospective	>50%	236	193	120	5 NF; 3 BM IV	NF12 R 9 E BMIV 9 R 8 E	71	NF versus BMIV, CG	1	GERD-HRQL
Lidor et al., 2015	Case series	Prospective	PEH Type III	111	89	36	1	19 (27) R	61	NF and mesh±GP	0	n/a
Louie et al., 2011	Case series	Retrospective	PEH Type II	58	55	15	n/a	6 (10) or R	78	NF, Hill, NF + Hill, mesh, emergency	0	GERD-HRQL; QOLRAD
Marano et al., 2014	Case series	Prospective	PEH	13	13	12	0	0	67	CR and NF, mesh	0	GERD-HRQL; SF-36
Merzilikin et al., 2017	Case series	Retrospective	PEH	59	38	60	n/a	5	74	NF with 56-60 Fr bougie or Hill with 43 bougie or NF-Hill	2	GERD-HRQL; QOLRAD; DSS
Ng et al., 2009	Case series	Prospective	n/a	28	28	6	n/a	n/a	70.83 (bougie), 62.29 (non-bougie)	270F bougie versus no bougie	0	QOLRAD
Oelschlager et al., 2011	Randomised controlled trial	Prospective	PEH	108	72	58	0 in mesh, 2 (3.5) in non-mesh	20 (59) no mesh 14 (54) mesh	64	Mesh versus no mesh	0	SF-36
Parameswaran et al., 2006	Case series	Retrospective	PEH >50% of the stomach into the chest	49	31	19	4 (12.9)	4 (14.8) R	68	NF, GP, CG, emergency	0	GERD-HRQL; GSRS
Parker et al., 2015	Case series	Retrospective	PEH Type III, IV	267	n/a	15.8 11.3 11.3	3 (1.1)	6 (4.3) 4 (5) 0 (0)	58 (<69 y) 75 (70-79 y) 83 (>80 y)	NF, Dor, CG, mesh, emergency	1 1 0	QOLRAD
Pierre et al., 2002	Case series	Retrospective	>1/3rd of the stomach	203	152	18	2 re do	4	67	NF, CG+NF,180 F.CG+180F, Roux-enY	1	GERD-HRQL
Qureshi et al., 2013	Case series	Prospective	Giant PEH	21	14	13	0	2 R and E	n/a	NF, Hill	0	GERD-HRQL; QOLRAD; DSS
Shreshtha et al., 2019	Case series	Retrospective	>5 cm or 30%	60	60	60	5 (8)	4 (7)	71	NF and GP, emergency	2	GERD-HRQL
Siboni et al., 2019	Case series	Retrospective	>50%, PEH Type III or IV	49	37	24	0	2 (5.4) E and R	61	CR and Toupe	n/a	GERD-HRQL; SF-36
Stiven et al., 2013	Case series	Prospective	PEH	114	94	12	n/a	n/a	67	CR+ 180F with bougie	1	QOLRAD
Stringham et al., 2017	Case series	Prospective	>30%	106	101	12	37 (36.6)	33 (32.7) R	68	Lap open NF, BMIV	1	GERD-HRQL
Tam et al., 2017	Case series	Retrospective	PEH >30%	795	606	25	Redo mesh 9 (9), non-mesh 21 (3)	mesh 15 (22), non-mesh 86 (17)	>70, <70	CR, mesh, CG	14 (1.8%) from Nason, 2011	GERD-HRQL; SF-36
Taragona et al., 2013	Case series	Retrospective	PEH <50% (39), >50% (31), 100 (7%)	77	37	108	12 (22)	R 20 (46)	64	NF	1	GIQLI
Velanovich et al., 2001	Case series	Prospective	Type II and III PEH	44	39	24	3	n/a	66	CR+GP. BMIV, lap or open NF/Toupe, CG-NF, open repair with gastrectomy, emergency	1	SF-36
Wang et al., 2019	Case series	Retrospective	PEH	65	65	25 mesh; 43 no mesh	n/a	no mesh 12 (37.5), mesh 8 (24.2)	65	Mesh versus no mesh, lap open, thoracotomy, recurrent hernias	n/a	GERD-HRQL; SF-36
Whitson et al., 2006	Case series	Retrospective	GHH	61	52	24	0	2 (4.7)	62	CG-NF, NF	1	GERD-HRQL
Zahiri	Case series	Retrospective	PEH	317	167	12	2	n/a	64.6 NF; 60.2 Toupe	Nissen, Toupet	0	GERD-HRQL
Zehetner et al., 2009	Case series	Retrospective	PEH >50%	35	23	14	1	2	70	NF	0	GERD-HRQL
Zhu et al., 2011	Case series	Prospective	PEH >50%	30	30	24	0	5 (17) R	70	NF	0	GIQLI
Zugel et al., 2009	Case series	Prospective	Large PEH	26	20	24	0	0 mesh; 3 non-mesh	70	CR, NF, mesh	0	GIQLI

PEH: Paraoesophageal hernia, Lap: Laparoscopic, O: Open; NF: Nissen fundoplication, BM IV: Belsey Mark IV, CR: Crural repair, PEG: Percutaneous gastrostomy, Fr: French, GP: Gastropexy, CG: Collis gastroplasty, 270F: 270° posterior fundoplication, GERD-HRQL: Gastro-Oesophageal Reflux Disease-Health-Related Quality of Life, QOLRAD: Quality of Life in Reflux and Dyspepsia, QOL: Quality of life, GIQLI: Gastrointestinal Quality of Life Index, SF: Short Form health surveys, GSRS: Gastrointestinal Symptom Rating Scale, DSS: Dysphagia Severity Scale, n/a: Not available, y: Years, RSI: Reflux severity index; QLSGR: Quality of life scale for gastroesophageal reflux disease to key please

The definitions of GHH varied within the included studies due to the lack of consensus in the field. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines classify hiatus hernias in accordance to anatomical classification (Types I–IV).[10] Although most studies have used the SAGES classification,[10] nine authors defined GHH in their study using modified SAGES criteria, as either a Type II or III hernia (four studies),[18,24,29,30] or large PEH (five studies).[31,32,33,34,35]

Seventeen studies have defined GHH by size; six studies defined GHH as >30% or one-third of the stomach present in the chest[13,23,27,29,32,36] and thirteen defined this as >50%.[16,28,33,37,38,39,40,41,42,43,44] There is another subset of authors that describe size of GHH in accordance with the size measured on radiography, in centimetres.[13,16,24,29,31,36,38,40] There is an agreed endoscopic definition of PEHs, >2-cm separation of the upward displacement of the gastro-oesophageal junction and diaphragmatic impression.[45] Three authors did not clearly define their definition of GHH included in their study.[46,47,48]

Assessment tools and reporting of quality of life

There were a variety of QoL questionnaires used in the studies; these included QoL in Reflux and Dyspepsia (QOLRAD), Gastro-Oesophageal Reflux Disease-Health Related QoL (GERD-HRQL), Gastrointestinal QoL Index (GIQLI), Gastrointestinal Symptom Rating Scale (GSRS), Short-Form health surveys SF-12 and SF-36, Reflux Symptom Index (RSI), Dysphagia Severity Scale (DSS), Gastro-Oesophageal Reflux Symptom Scale (GERSS) and Visick scores [Table 2]. The majority of studies (n = 25, 66%) used QoL questionnaires specific for gastro-oesophageal reflux disease (GERD), such as the QOLRAD and GERD-HRQL questionnaires. GIQLI and GSRS are more general for the entire gastrointestinal tract and were used in eight studies.[49] Seven studies used SF-12 and SF-36, which are generic questionnaires assessing physical and mental scores across eight multi-item dimensions, namely physical functioning (PF), role-physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional (RE) and mental health (MH).[50] SF-12 and SF-36, alongside the RSI, GERSS, DSS and Visick scores, were used mainly post-operatively in conjunction with GERD disease-specific tools.

Table 2.

Description of the commonly used quality of life assessment tools and how to interpret their scores

Tool	Components	Scoring and clusters	Overall score	Interpretation of results
Reflux disease specific questionnaires
QOLRAD	A total of 25 questions making up 5 dimensions  Emotional distress (6 items)  Sleep disturbance (5 items)  Food or drink problems (six items)  Physical or social functioning (five items)  Vitality (three items)	Each question is awarded a maximum score of 7 and patients are asked to rate the symptoms they have experienced over the preceding week on a 7-point scale	The total score for each domain is then calculated as an average of the total number of questions in each domain. The overall total score is the average of 25 questions	A higher score indicates better QoL
GERD-HRQL	A total of 10 items: 6 items measure satisfaction with degree of heartburn symptoms, two measure dysphagia or odynophagia and one assesses the impact of medication on daily life. The final item measures overall QoL	Each of the ten items is given a score out of 5, whereby 5 is for poor symptom control or satisfaction	The maximum score possible is 45. Composite responses are grouped as excellent (0-5), good (6-10), fair (11-15) and poor (15)	A higher score reflects worse patient symptoms and QoL
Questionnaires specific for gastrointestinal tract
GIQLI[16]	A total of 36 items scored on a 5-point Likert scale[49]	Score range can be between 0 and 144	A maximum score of 144	A higher score indicates better QoL[16]
GSRS	A total of 15 items with 5 dimensions  Reflux,  Abdominal pain,  Indigestion,  Diarrhoea  Constipation	Each question is rated on a 7-point scale	1 represents absence of troublesome symptoms and 7 represents very troublesome symptoms	A higher score indicates poorer QoL
Generic questionnaires
SF-36	A total of 36 items measured over 8 multi-item dimensions: PF, RP, BP, GH, VT, SF, RE and MH	All questions scored on a scale of 0-100, where 100 represents the highest level of functioning possible. A final score of each of the eight dimensions is obtained from averaging the scores The scores form two clusters resulting in total scores for physical and mental health summary measures. PF, RP, BP and GH contribute to the final PCS score. VT, MH, RE and SF form the MCS score	0-100	Norm-based scoring, where mean is standardised to 50. A score higher than 50 indicates better functioning and a score of 100 would indicate the highest possible level of functioning
SF-12[50]	A total of 12 items and a practical version of SF-36. This uses the same eight domains as SF-36	PCS and MCS scores calculated using the scores from the 12 questions	0-100	Norm-based scoring, where mean is standardised to 50. A score higher than 50 indicates better functioning and a score of 100 would indicate the highest possible level of functioning

GERD-HRQL: Gastro-Oesophageal Reflux Disease-Health-Related Quality of Life, QOLRAD: Quality of Life in Reflux and Dyspepsia, QOL: Quality of life, GIQLI: Gastrointestinal Quality of Life Index, SF: Short Form health surveys, GSRS: Gastrointestinal Symptom Rating Scale, MCS: Mental component summary, PCS: Physical component summary, PF: Physical functioning, RP: Role-physical, BP: Bodily pain, GH: General health, VT: Vitality, SF: Social functioning, RE: Role-emotional, MH: Mental health, n/a: Not available

QOLRAD and GERD-HRQL, though disease specific for reflux, can be applied for many other UGI disorders. GERD-HRQL is validated for measuring the disease severity of GERD and to assess response to medications, endoscopic procedures and surgery. QOLRAD has a high validity and internal reliability in each dimension and composite score. For ease of understanding and interpretation of results of the studies to the readers, the most frequently used tools (QOLRAD, GERD-HRQL, GIQLI, GSRS and SF-36) are described briefly in Table 2; their full details can be found elsewhere.[51]

Quality of life improvement after surgery

A total of 31 studies compared the pre-operative and post-operative QoL after GHH surgery [Table 3]. Some studies used multiple questionnaires and reported findings for each questionnaire separately. GERD-HRQL and GIQLI questionnaires have been reported in two different ways; some authors report pre-operative and post-operative scores and any statistical significance between them, whereas others report percentage of patients showing ‘excellent’ or ‘good’ improvement in QoL after surgery. Two of the 31 studies[9,48] did not report statistical analysis in post-operative QoL improvement, but we have included the absolute score values in Table 3 for reference. Of the remaining 29 studies, 22 (76%) reported either a significant increase in post-operative QoL following GHH surgery, or an ‘excellent’ or ‘good’ score post-operatively in at least 83% of patients. The follow-up time of the studies ranged from 6 months to 118 months, with a median follow-up time of 22.5 months.

Table 3.

Pre- and post-operative quality of life improvement after giant hiatus hernia surgery, using a variety of questionnaires

Authors	Total number of patients (number of patients followed up)	Length of follow-up (months)	Pre-operative score	Post-operative score	Improvement in QoL (P)	Additional follow-up
GERD-HRQL
Stringham et al., 2017	106	12	22.5	3	P<0.001	Score 7 (P<0.001*)
Asti et al., 2016	84 (84)	24	15.5 (MU), 18 (NM)	1 (MU), 3 (NM)	P<0.001 for both	n/a
Shreshtha et al., 2019	60 (60)	60	27 (Veritas), 27 (Strattice)	0 (Veritas), 0 (Strattice)	P<0.005	n/a
Zahiri et al., 2017	317	12	20.9 (initial), 21.1 (re-do)	6.5 (initial), 8 (re-do)	P=0.175	n/a
Zehetner et al., 2009	35 (21)	14	n/a	5	91.3% satisfied, 4.3% neutral, 4.3% dissatisfied	n/a
Parameswaran et al., 2006	49 (31)	19	18	1	P<0.001	n/a
Louie et al., 2011	58 (55)	15	14.7	7.6	P<0.001	P<0.001*
Merzilikin et al., 2017	137 (59)	60	11	5	P=0.03	n/a
Hall et al., 2018	314 (188)	24	14.4	6.6	P<0.0001	At 1 year - 5.7 (P<0.0001) At 2 years - 5.8 (P<0.0001)
Marano et al., 2014	13	12	37.4	3.2	P<0.0001	n/a
Siboni et al., 2019	49 (37)	24	11	2	P<0.001	n/a
Qureshi et al., 2013	21 (14)	13	22.9	6.9	P<0.03	n/a
Ilyashenko et al., 2018	98 (69)	48	17.5 (MU, n=50); 16.3 (NM, n=48)	3.8 (MU, n=34); 5.9 (NM, n=35)	P<0.0001 for both	n/a
Whitson et al., 2006	61 (52)	24	n/a	1.15	Excellent 96.2%, Good 1.9%	n/a
Karmali et al., 2008	93 (71)	17 (LS) 21 (OS)	n/a	n/a	Excellent result in 89% (LS) and 77% (OS)	n/a
Pierre et al., 2002	203	18	n/a	2.4	84% Excellent, 8% good, 7% fair, 3% poor	n/a
Tam et al., 2017	795 (606)	25	n/a	Good to Excellent QoL (n=522, 88%)	P=0.978	n/a
QOLRAD
Louie et al., 2011	58 (55)	15	5	6	P<0.001	P<0.001*
Qureshi et al., 2013	21 (14)	13	4.09	6.04	P<0.0001	n/a
Merzilikin et al., 2017	137 (59)	60	4	6.5	P=0.0005	n/a
Hazebroek et al., 2008 (ANZ Journal of Surgery)	40 (37)	12	3-4	5-6	P<0.001	P<0.001†
Hazebroek et al., 2008 (Diseases of the Oesophagus)	35 (30)	43	3.98	6.04	P<0.001	P<0.001‡
Stiven et al., 2013	114 (94)	12	3.7	5.5	P<0.001	n/a
Ng et al., 2009	28	6	3.65§ 3,72¦	5.29§ 6.27¦	n/a	n/a
Parker et al., 2015	267	15.8 11.3 n/a	4.07 (mean)	7 (mean)	P<0.001	n/a
GIQLI
Chen et al., 2018	69 (54)	114	n/a	117	Excellent or good in 83%	n/a
Dallemagne et al., 2011	85 (64)	118	n/a	NRCR 114 RCR 120	n/a	n/a
Targarona et al., 2013	77 (37)	108	n/a	NR 127 CR 97.5 RR 112	P=0.005	n/a
Zhu et al., 2011	30 (30)	24	85.7	107.9	P<0.001	n/a
Zugel et al., 2009	26 (20)	12 (24 radiological)	87	111	NS (111)	n/a
Gibson et al., 2013	100 (92)	24	87.8	109.1	P=0.03	n/a
Furtado et al., 2016	100	27	89	108	P<0.001	n/a
SF-36
Tam et al., 2017	795 (606)	25	n/a	Good to excellent QoL (n=522, 88%)	P=0.005 (PCS) P=0.264 (MCS)	n/a
Koetje et al., 2015	126 (91)	24	n/a	Improvement across all groups	P<0.001	PCS: P<0.001-0.044‡ MCS: variable significance‡
Velanovich et al., 2001	44 (39)	24	n/a	Quality of results not suitable to display	PCS (P=0.02, significant) in LS group	n/a
GSRS
Parmeswaran et al., 2006	49 (31)	19	Pain 3.67 Reflux 4.53 Indigestion 3.74	Pain 1.79 Reflux 1.41 Indigestion 2.69	P<0.001 for all	n/a

*At 1 year, ^†at all post-operative time periods 5 weeks, 6 months, 12 months, ^‡at all post-operative time periods 3 months, 6 months, 12 months, 18 months, 24 months, ^§Bougie, ¦No bougie. NS: Not significant at 3 months, MU: Mesh used, NM: No Mesh, NR: No recurrence, LS: Laparoscopic surgery, OS: Open surgery, CR-:Clinical recurrence; RR: Radiological recurrence, NRCR: Non-reinforced crural repair, RCR: Reinforced crural repair, GERD-HRQL: Gastro-Oesophageal Reflux Disease-Health-Related Quality of Life, QOLRAD: Quality of Life in Reflux and Dyspepsia, QOL: Quality of life, SF: Short Form health surveys, GIQLI: Gastrointestinal Quality of Life Index, GSRS: Gastrointestinal Symptom Rating Scale, n/a: Not available

Eight studies used QOLRAD for assessment of QoL [Table 3]. Seven authors reported a significant improvement in QoL after GHH surgery (P < 0.001).[24,25,30,31,35,47,48] Ng et al. found an improvement in QoL after surgery but did not assess for significance.[48]

GERD-HRQL was used in 17 studies [Table 3]; ten studies[19,20,24,32,38,42,47,52,53,54] using GERD-HRQL reported a significant increase in QoL after surgery, with an additional five studies reporting >83% of patients with ‘excellent’ or ‘good’ outcomes.[23,28,39,46,55] Two studies found that there was no significant increase in post-surgical QoL.[56,57]

The GIQLI tool was used by seven studies [Table 3]; three studies reported a significant improvement in post-operative QoL,[37,44,58] three found no statistical significance[33,36,40] and one did not assess for significance.[16] Zhu et al. and Furtado et al. reported a significant improvement in post-operative GIQLI scores (24 to 85.7 and 27 to 89, respectively; P < 0.001).[36,58] Chen et al. reported ‘good’ or ‘excellent’ GIQLI score in 83% (45/54) of patients at follow-up, with a mean post-operative score of 117.[44] Two studies using GIQLI compared post-operative scores with a control population;[37,40] Zhu et al. reported that a post-operative score of 107.9 was still lower than the scores of healthy individuals (118.2).[36] Targarona et al., on the contrary, felt that successfully operated patients reached a GIQLI value comparable to that of the standard population.[40]

The SF-36 score was used by nine studies, of which three looked at both pre-operative and post-operative QoL.[18,28,41] Tam et al. found no significant improvement in QoL in both PCS (P = 0.005) and MCS (P = 0.264) components.[28] Koetje et al. reported a significant improvement across all groups post-operatively (P < 0.001) and at 3 months, 6 months, 12 months and 24 months (range, P < 0.001–P < 0.044).[41] Velanovich et al., using SF-36, compared post-operative improvement in laparoscopic group with that of open group.[18] Post-operatively, the PF score improved in the laparoscopic group (P = 0.02) and RP worsened in the open group (P = 0.0001). However, when comparing the laparoscopic group to the open group, there were significantly better scores in the laparoscopic group in the domains of PF, RP, RE, VT and SF.

One study utilising GSRS found significant improvement in pain, reflux and indigestion (P < 0.001), which supports the findings based on the GERD-HRQL questionnaire used in the same study.[38] Lidor et al. did not use a standardised questionnaire, however reported significant improvement in all symptoms at 12 months and significant overall satisfaction at 36 months.[59]

Age and quality of life

Five studies[5,24,25,30,57] looked at QoL after repair of GHH with focus on the age demographic of patients [Table 4]. Parker et al. compared three different age groups and demonstrated significant improvement in QOLRAD scores in all the three groups.[25] There was no significant difference in either the pre-operative or post-operative QOLRAD scores between the young and older cohorts, and the overall improvement in QOLRAD scores in the three groups was 2.1, 2.3 and 2.4, respectively (P = 0.9032).[25] Similarly, Jalilvand et al. reported comparable differences in QoL improvement between patients above and below 80 years.[60] However, the authors also reported that older patients are more likely to suffer post-operative complications and significantly greater length of hospital stay (P < 0.005). Merzlikin et al., in carefully selected patients, showed improved QoL that sustained at 5 years and beyond.[57] The data from the study by Louie et al. also support repair of symptomatic GHH in patients aged 70 years or more;[24] the authors conclude that GHH in the elderly can be repaired with minimal surgical mortality and acceptable morbidity in both elective and urgent settings. A significant number of their patients had symptom resolution and improvements in both short- and long-term QoL. Improvement was noted in patients who presented urgently as well as in those with small recurrent herniation.[24]

Table 4.

Pre-operative and post-operative quality of life scores with focus on elderly patient demographics

Authors	Total number of patients (number of patients followed up)		Mean age in years	Length of follow-up (months)	Mortality	Questionnaire used	Pre-operative score	Post-operative score	Improvement in QoL (P)
Louie et al., 2011	58 (55)		78§	15	Nil	QOLRAD GERD-HRQL	5* 14.7†	6* 7.6†	P<0.001* P=0.01†
Merzilikin et al., 2017	137 (59)		74	60	2	QOLRAD GERD-HRQL	4* 11†	6.5* 5†	P=0.0005* P=0.03†
Hazebroek et al., 2008 (Diseases of Oesophagus)	35 (30)		76.6	43	Nil	QOLRAD	3.98	6.04	P<0.001¦
Jalilvand et al., 2019 (years)	<80	162	62.8	1	n/a	GERD-HRQL GERSS	20‡ 113†	0‡ 3†	No significant difference between groups (P=0.84 and 0.48‡; P=0.58 and 0.54†)
	>80s	23	85.3				22‡ 119†	0‡ 3†
Parker et al., 2015 (years)	<69	267	58	15.8	n/a	QOLRAD	4.2	7	P<0.001 (across all) no significant difference in QoL improvement between groups
	70-79		75	11.3			4	7
	>80		83	11.3			4	7

*QOLRAD, ^†GERD-HRQL, ^‡GERSS, ^§median, ^¦ at all post-operative time periods. GERSS: Gastro-Oesophageal Reflux Symptom Scale, GERD-HRQL: Gastro-Oesophageal Reflux Disease-Health-Related Quality of Life, QOLRAD: Quality of Life in Reflux and Dyspepsia, QOL: Quality of life, n/a: Not available

Recurrence of hernia and quality of life

As with the definition of GHH, the assessment and definition of recurrence varies in the literature; this has been done in three different ways: symptomatic, radiological or endoscopic (or a combination of the two or more methods). From a total of 38 studies reviewed, 9 studies assessed the impact of recurrence on QoL outcomes in GHH surgery. The range of recurrence varied from 9% to 66% [Table 5]. The nine studies together included a total of 1516 patients, of which 225 (14.8%) were shown to have recurrence of hiatus hernia using one or more assessment methods. The median follow-up length ranged from 1 month to 118 months after surgery; due to inconsistency of data, the mean length of follow-up post-operatively could not be assessed in this review. Four studies found a significant difference in the QoL between the recurrence and no-recurrence groups.[40,41,44,52] The remaining five studies failed to demonstrate any significant differences in QoL.[16,24,28,36,58] Small and large recurrences were compared in one study;[52] from a total 33 (32.7%) recurrences, 14 (13.9%) were small and 19 (18.8%) were large (>2 cm). They found similar post-operative QoL and patient satisfaction scores in both groups, and the authors conclude that clinically, small recurrences may be as important as large ones.

Table 5.

Impact of recurrence on post-operative quality of life scores

Authors	Total number of patients (number of patients followed up)	Mean age (years)	Length of follow-up (months)	Recurrence rate (%)	Questionnaire used	QoL score (recurrence)	QoL score (without recurrence)	Impact of recurrence on QoL (P)
Stringham et al., 2017	106	68	12	18.8	GERD-HRQL	13	3.5	SS
Louie et al., 2011	58 (55)	78 (median)	15	10	GERD-HRQL QOLRAD	6.8*; 3.5†	6.6*; 4†	NS
Tam et al., 2017	795 (606)	n/a	25	17-22	GERD-HRQL SF-36	n=70†, 84%§ 48¦ 53**	n=336†, 89%§ 50¦ 52**	P=0.247† 0.51¦ 0.29**
Targarona et al., 2013	77 (37)	64	108	46	GIQLI	110	122	P<0.01
Dallemagne et al., 2011	85 (64)	66	118	66	GIQLI	115	116	P=0.36
Chen et al., 2018	69 (54)	66	114	34	GIQLI	92	122	P<0.01
Gibson et al., 2013	100 (92)	69.1	24	9	GIQLI Visick	110‡	94‡	P=0.03‡
Furtado et al., 2016	100	71	27	24	GIQLI; Visick; DSS	108‡	106‡	P=0.089‡
Koetje et al., 2015	126 (91)	n/a	24	31	SF-36	46.9¦; 48.8**	51.2¦; 50.7**	P<0.001

*QOLRAD, ^†GERD-HRQL, ^‡GIQLI, ^§Good to excellent score, ^¦SF-36 PCS, **SF-36 MCS. NS: Not statistically significant, no P provided, SS: Significantly improved post-operative QoL score in both groups compared to pre-operative scores and ‘higher QoL scores in patients without recurrence’, no P provided. GERD-HRQL: Gastro-Oesophageal Reflux Disease-Health-Related Quality of Life, SF: Short Form health surveys, MCS: Mental component summary, GIQLI: Gastrointestinal Quality of Life Index, QOL: Quality of life, QOLRAD: Quality of Life in Reflux and Dyspepsia, DSS: Dysphagia Severity Scale

Mesh and quality of life

Six of the 38 included studies compared QoL after reinforcement of crural repair with mesh versus no mesh [Table 6]. Ilyashenko et al. reported a significant difference in QoL between mesh and no-mesh groups (P <0.0001),[19] however the remaining five studies found no statistically significant difference in the two groups.[16,20,41,61,62] Two studies used mesh in all the patients;[31,39] At 2 years follow up with barium examination and endoscopy, Hazebroek et al.[31] found no mesh erosion and only one asymptomatic recurrent hernia of <2 cms.[31] The rest of the patients in this study had improvement in post-operative QoL. Zehetner et al. also used Vicryl^® mesh and BioGlue^® in all patients;[39] two of their 35 patients had recurrences on objective testing. One was symptomatic and dissatisfied, whereas the other patient had a GERD-HRQL score 28 and was satisfied with the surgery.

Table 6.

Impact of using mesh compared with no mesh on quality of life outcomes

Authors	Total number of patients (number followed up)	Mean age (years)	Length of follow-up (months)	Questionnaire used	Mesh type	Number of patients with mesh n (score)		Number of patients without mesh n (score)		Impact of mesh on post-operative QoL (P)
						Pre-operative score	Post-operative score	Pre-operative score	Post-operative score
Asti et al., 2016	84 (84)	65	24	GERD-HRQL	Pre-shaped biosynthetic (Gore Bio™)	41 (15.5)	2	43 (18)	3	P<0.306
Ilyashenko et al., 2018	98 (69)	63	48	GERD-HRQL	Non-absorbable self-fixating (ProGrip™)	50 (17.5)	3.8	48 (16.3)	5.9	P<0.0001
Wang et al., 2019	55	65	n/a	GERD-HRQL; SF-36	Porcine urinary bladder matrix	n/a	32 (13.2*; 15†)	n/a	33 (11.2*; 14†)	P=0.5235* P=0.7182†
Dallemagne et al., 2011	85 (64)	66	118	GIQLI	Variable	n/a	120	n/a	114	P=0.075
Koetje et al., 2015	126 (91)	x	24	SF-36	Absorbable (Surgisis; n=41), Non-absorbable (Timesh; n=42)	n/a	83	n/a	43	Not significant
Oelschlager et al., 2011	108 (72)	64	58	SF-36	Biologic mesh Group (Surgisis)	n/a	44‡ 47§	n/a	44‡ 49§	P=1.0‡ P=0.6§

*GERD-HRQL, ^†SF-36, ^‡PCS, ^§MCS. GERD-HRQL: Gastro-Oesophageal Reflux Disease-Health-Related Quality of Life, SF: Short Form health surveys, PCS: Physical component summary, MCS: Mental component summary, GIQLI: Gastrointestinal Quality of Life Index, QOL: Quality of life, n/a: Not available

Gibson et al. did not use mesh in any patient and reported symptomatic recurrence of hiatus hernia in two (2%) patients, both involving a recurrent fundal herniation.[36] Another seven (7%) patients in this study had asymptomatic recurrence of <2 cms on radiological imaging and the most recent QoL score (questionnaire not specified) was significantly higher in those patients without recurrence compared with those with recurrence (110 [±21.8] vs. 94 [±24.6]; P = 0.03).[36]

Zugel et al. reported a serious complication in their case series;[33] one patient had mesh erosion in the aorta, requiring three surgeries at weekly intervals after the first operation. However, the patient was still satisfied at the end of 3-year follow-up and had no gastro-oesophageal symptoms (GIQLI: 127) or radiological recurrence (with CT scan).

Quality of life outcomes compared between two surgical techniques

Most studies used one method of repair, however there were five studies[21,22,23,43,48] comparing two different surgical methods and their improvement in QoL [Table 7]. There were five studies comparing the impact of surgical techniques on improvement in quality of life. Two studies compared laparoscopic versus open surgery, one study compared Nissen and Belsey Mark,[4] one study compared Nissen and Toupet and one study compared bougie and non bougie. None of the studies showed any difference in post-operative improvement in QoL between the two groups, however QoL still improved after surgery in both groups.

Table 7.

Impact of surgical technique on post-operative quality of life scores

Authors	Total number of patients (number of patients followed up)	Mean age (years)	Length of follow-up (months)	Questionnaire used	Surgical technique compared (1); post- operative QoL score	Surgical technique compared (2); post-operative QoL score	Impact of surgical technique on QoL (P)
Karmali et al., 2008	93 (71)	64 (L) 72 (O)	17 (L) 21 (O)	GERD-HRQL	L 4	O 4	P=0.861
Laan et al., 2018	236 (193)	71	n/a	GERD-HRQL	N 83.7%§	BM 88.4%	P=0.52
Huerta et al., 2018	179 (77)	64	54 (N) 25 (T)	GERD-HRQL	N 2	T 4	P=0.551
Ferri et al., 2004	60 (57)	n/a	45	GERD-HRQL; SF-12	L 4* 46.1† 53.9‡	O 1* 49.7† 53.3‡	P=0.4* P=0.4† P=0.3‡
Ng et al., 2009	28	B 70.83 NB 62.29	6	QOLRAD	B 5.3	NB 6.3	P=0.14

*GERD HRQL score, ^†SF-12 PCS score, ^‡SF-12 MCS score ^§excellent or good results. L: Laparoscopic, O: Open, N: Nissen, T: Toupet, BM: Belsey Mark, B: Bougie, NB: No Bougie, GERD-HRQL: Gastro-Oesophageal Reflux Disease-Health-Related Quality of Life, QOLRAD: Quality of Life in Reflux and Dyspepsia, QOL: Quality of life, SF: Short Form health surveys, MCS: Mental component summary

A further four studies[18,23,52,55] used more than two procedures, however did not directly compare their impact on QoL. The procedures used included partial wrap, full wrap, Belsey Mark IV, emergency surgery, gastropexy, laparoscopic procedure, open procedure and Collis gastroplasty. Velanovich et al. reported one death of emergency patient.[18] They had 11.5% symptomatic recurrences in the laparoscopic group and 0% in the open group. Pierre et al. had high rate of complications (n = 57, 28%); there were four recurrent PEHs, of which one died and two required re-operation.[55] There were also six (3%) oesophageal leaks. Karmali et al. performed 270° partial wrap in their majority of patients (31/47) in the open group and 360-fundoplication in 38 out of 46 patients in the laparoscopic group.[23] Collis gastroplasty was performed in 2/46 (4%) and 1/47 (2%) patients in laparoscopic and open groups, respectively. The authors reported low symptomatic recurrence (9%) in each group.[23] The QoL outcomes from these four studies are summarised in Table 8.

Table 8.

Impact of Collis gastroplasty on quality of life outcomes

Authors	Total number of patients (number of patients followed up)	Mean age (years)	Length of follow-up (months)	Mortality (absolute number)	Recurrence (percentage of patients)	Questionnaire used	Pre-operative Score	Post-operative score (%)	Improvement in QOL (P)
Stringham et al., 2017	106	68	12	1	18.8	GERD-HRQL	22.5	3	P<0.001
Karmali et al., 2008	93 (71)	L 64 O 72	17 (L) 21 (O)	0	9	GERD-HRQL	n/a	L 89‡ O 77§	n/a
Pierre et al., 2002	203	67	18	1	9.3	GERD-HRQL	n/a	2.4 84‡ 8§	n/a
Whitson et al., 2006	61 (52)	61.9	24	1	4.7	GERD-HRQL	n/a	1.15 96.2‡ 1.9§	n/a
Merzilikin et al., 2017	137 (59)	74	60	23	8.4	QOLRAD GERD-HRQL	4† 11*	6.5† 5*	P=0.0005† P=0.03*
Nason et al., 2011	795 (606)	392 (<70) 403 (>70)	n/a	14	18.2	GERD-HRQL SF-36	n/a	88‡,§	n/a
Velanovich et al. 2001	44 (39)	66.1	24	1	7.6	SF-36	n/a	n/a	PF (P=0.02) in L group

*GERDHRQL, ^†QOLRAD, ^‡patients had excellent results, ^§patients had good results. PF: Physical functioning component of PCS score, L: Laparoscopic, O: Open, GERD-HRQL: Gastro-Oesophageal Reflux Disease-Health-Related Quality of Life, QOLRAD: Quality of Life in Reflux and Dyspepsia, QOL: Quality of life, SF: Short Form health surveys, PCS: Physical component summary

Collis gastroplasty and quality of life

Seven studies[18,23,29,46,52,55,57] used Collis gastroplasty in many of their patients to reduce the chance of recurrence [Table 8]. All studies showed improvement in QoL, with >77% excellent or good outcomes reported in four studies[23,29,46,55] and statistical significance in a further three studies.[18,52,57] The recurrence rate varied from 4.7% to 18.8%.

Nason et al.[29] performed Collis gastroplasty if 2 cm of intra-abdominal length of oesophagus was not achieved, whereas other studies[23,52,57] used 3 cm as the cut-off point. Pierre et al. used Collis gastroplasty if the gastro-oesophageal junction could not be brought below the hiatus without tension.[55] Tringham et al. diagnosed short oesophagus pre-operatively on barium if the gastro-oesophageal junction was >5 cm above the hiatus or intra-operatively if the length of the oesophagus below the hiatus was <2 cm.[52] Whitson et al. mainly used Collis gastroplasty in combination with various other procedures, including some emergencies.[46] The authors found this technique useful in reducing recurrences and reported only two radiological recurrences. A univariate analysis by Laan et al. revealed that the performance of a wedge gastroplasty was protective of recurrence.[43]

Nason et al. found no correlation with any independent variables and recurrent PEH on radiographic follow-up.[63] However, they suggest a possibility of increased incidence of recurrence in patients with pre-operative pulmonary diseases such as asthma, chronic obstructive pulmonary disease, emphysema, bronchiectasis or interstitial fibrosis (odds ratio [OR]: 2.6; 95% confidence interval [CI]: 1.0, 7.0).[29] A total of 15 patients had radiological recurrence in this study. The authors performed Collis gastroplasty in 86% (160/187) of the patients and did not find oesophageal-lengthening procedure useful in reducing the incidence of recurrence (OR: 0.7; 95% CI: 0.2, 2.2). The QoL scores were excellent or good in 84% in those with radiographic recurrence compared to 85% in those without radiographic recurrence.

DISCUSSION

To the best of our knowledge, this is the first review exclusively looking at the post-operative QoL in patients undergoing surgical repair of GHH. The most outstanding finding of this review is that all studies demonstrated improvement in absolute QoL score after surgical GHH repair, with statistical significance found in 76% of studies. This was despite variation in key areas of reporting, including definition of GHH, type of surgical procedure (fundoplication 360° or partial, gastropexy and Collis gastroplasty), follow-up methods (radiological vs. endoscopic vs. symptomatic) and questionnaires used for assessing QoL. Patient age did not impact QoL improvement, and surgery was shown to improve QoL in both younger and older patient groups comparably. From the studies that compared the impact of two different surgical techniques on QoL, no significant difference was found. Similarly, only one out of six studies comparing mesh versus no mesh reported significantly improved QoL in patients where mesh was used. The impact of post-operative recurrence of GHH on QoL remains open to debate, with four out of nine studies finding significant differences in QoL between recurrence and non-recurrence groups.

In patients with GHH, dysphagia and shortness of breath are the most common presenting complaints due to intermittent partial volvulus. This contrasts with reflux disease, where heartburn is the predominant symptom. GERD-specific questionnaires such as GERD-HRQL and QOLRAD assessing these symptoms appear to be most useful in this cohort. The QOLRAD tool has been proven to have high validity and internal reliability in each dimension, as well as in composite score.[51] QOLRAD and GERD-HRQL scores also appear to be easy to understand and interpret. Furthermore, GERD-HRQL is claimed to be sensitive to treatment interventions.[51]

There are two different ways in which improvement in QoL is reported in GERD-HRQL and GIQLI questionnaires: (1) absolute scores and (2) percentage of patients having excellent, good, fair or poor results. This variation makes it difficult to assess the cumulative results of different studies or compare them. We believe that reporting absolute scores using these two questionnaires would be easier for readers and for data analyses. Alternatively, reporting both the results may also be acceptable.

SF-36 is a more generic tool, but we did not find it as an appropriate questionnaire for assessment of QoL after repair of GHH. Furthermore, it has often been reported in more than two ways – graphs, charts, component scores and separate PCS and MCS scores – making it difficult for meaningful collation of results. Xiao Li Guan et al. have compared QoL questionnaires in patients with GERD and contrary to our opinion, the authors felt that GERD-HRQL focuses on disease symptoms but ignores the importance of social function and psychological status in QoL, which is covered well by the SF-36.[50,51] The authors suggest use of GERD-specific scales in conjunction with a generic questionnaire.

The decision to offer major surgery for GHH to prevent gastric volvulus has been debated for long time. In 2002, Stylopoulos et al. reported that a mortality of 1.4% for elective repair should be weighed against a 1.1% annual risk of complication through ‘watchful waiting’ management.[64] However, with advancing age, the risk of mortality increases and the cumulative annual risk of complications decreases with a reducing life span, thus changing the risk–benefit ratio. All the five studies in this review specifically looking at age and post-operative QoL have shown low mortality and sustained QoL improvement post-operatively in older patient cohorts. Two studies further report no significant differences in QoL improvement between older and younger patient groups, justifying the need to offer surgery to symptomatic elderly patients.[25,60] Notably, data from one of the studies suggest that although QoL and symptom burden is comparable, older patients may experience higher post-operative morbidity than that of younger patients.[60] Collis gastroplasty and use of mesh have been the two commonly recommended adjuncts to reduce recurrence, used in addition to standard fundoplication or gastropexy. Collis gastroplasty adds the risk of leak from suture line to the conventionally ‘clean’ operation, and use of a mesh adds the risk of erosion to the viscera. The risks of these serious complications have prevented the general acceptance of these adjuncts in clinical practice. All studies using Collis gastroplasty in this review showed recurrence of 4.7%–18.8% and post-operative improvement in QoL with good or excellent outcomes in 77%–96.2% patients, and significant improvement in a further three studies [Table 8]. These figures are comparable to that of other studies in this review, suggesting that the influence of Collis gastroplasty on recurrence does not seem to affect post-operative QoL adversely.

The value of mesh in preventing recurrence is another contentious issue in the field of GHH surgery. The use of mesh did not appear to affect QoL in this review except in one study by Ilyashenko et al., who found significantly better post-operative QoL in mesh group compared to that of simple hiatal repair.[19] However, the outcome in the non-mesh group in this study was still a ‘good’ outcome as per the GERD-HRQL tool (16.3 pre-operative to 5.9 post-operative score).

Zugel et al. reported a serious complication in their case series; one patient had mesh erosion in aorta, requiring three surgeries at weekly intervals after the first operation. However, the patient was still satisfied at the end of 3-year follow-up and had no gastro-oesophageal symptoms (GIQLI score: 127) and no radiological recurrence (computed tomography scan). This anecdotal case exemplifies the fact that presence of complications does not necessarily correlate with poorer QoL. Findings from this review furthermore highlight that complications such as recurrence after GHH surgery do not equate to poor QoL scores. Five studies out of nine which directly compared QoL in patients with and without recurrence showed no difference between the two groups, whereas the other four studies showed significant difference in the improvement of QoL. Notably, length of follow-up may influence the rate of recurrence; for example, Dallemagne et al. had the longest follow-up period of 118 months and the highest recurrence of 66%. Furthermore, using more rigorous follow-up methods with multiple modalities of assessing recurrence would increase the chances of identifying recurrence. Therefore, we cannot draw confident conclusions regarding the impact of recurrence of QoL from the data included in this review.

Limitations

This review identified shortfalls in the reporting of studies addressing post-operative QoL after repair of GHH. A large heterogeneity of studies with wide variation between the types of QoL assessment tools used, surgical techniques, follow-up times and periodic QoL assessments made it difficult to ‘normalise’ and collate data, however within these constraints, we have summarised the outcomes with the best of our ability. There may also be an element of publication bias as all studies reveal positive QoL outcomes after surgery. In addition, only two randomised controlled trials were included in this review article and we identify a need for higher level of evidence in the literature.

CONCLUSION

This review of the literature showed that elective repair of GHH offers significant improvement in QoL irrespective of age, surgical technique or use of mesh. The effect of recurrence on QoL is not answered by this review, and further study is required. Elective laparoscopic repair of GHH has low mortality and should be offered to symptomatic patients not just to prevent complications such as volvulus but also to improve QoL. A consensus statement in uniform reporting of surgical outcomes following repair of GHH is recommended.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.