Association between hiatal hernia and Barrett’s esophagus: an updated meta-analysis with trial sequential analysis

Abstract

Background: Barrett’s esophagus (BE) is a precursor of esophageal adenocarcinoma. It is critical to recognize the risk factors associated with BE. Objectives: The present meta-analysis aims to systematically estimate the association of hiatal hernia with the risk of BE. Design: A meta-analysis with trial sequential analysis. Data sources and methods: The PubMed, EMBASE, and Cochrane Library databases were searched. The pooled odds ratios (ORs) and adjusted ORs (aORs) with their 95% confidence intervals (CIs) were calculated for the combined estimation of unadjusted data and data adjusted for confounders, respectively. Heterogeneity was quantified using the Cochrane Q test and I² statistics. Subgroup, meta-regression, and leave-one-out sensitivity analyses were employed to explore the sources of heterogeneity. Results: Forty-seven studies with 131,517 participants were included. Based on the unadjusted data from 47 studies, hiatal hernia was significantly associated with an increased risk of any length BE (OR = 3.91, 95% CI = 3.31–4.62, p < 0.001). The heterogeneity was significant ( I² = 77%; p < 0.001) and the definition of controls ( p = 0.014) might be a potential contributor to heterogeneity. Based on the adjusted data from 14 studies, this positive association remained (aOR = 3.26, 95% CI = 2.44–4.35, p < 0.001). The heterogeneity was also significant ( I² = 65%; p < 0.001). Meta-analysis of seven studies demonstrated that hiatal hernia was significantly associated with an increased risk of long-segment BE (LSBE) (OR = 10.01, 95% CI = 4.16–24.06, p < 0.001). The heterogeneity was significant ( I² = 78%; p < 0.001). Meta-analysis of seven studies also demonstrated that hiatal hernia was significantly associated with an increased risk of short-segment BE (OR = 2.76, 95% CI = 2.05–3.71, p < 0.001). The heterogeneity was not significant ( I² = 30%; p = 0.201). Conclusion: Hiatal hernia should be a significant risk factor for BE, especially LSBE. Registration: PROSPERO registration number CRD42022367376.