Management of paraesophageal hiatus hernia: recommendations following a European expert Delphi consensus

Abstract

Aims There is considerable controversy regarding optimal management of patients with paraesophageal hiatus hernia (pHH). This survey aims at identifying recommended strategies for work-up, surgical therapy, and postoperative follow-up using Delphi methodology. Methods We conducted a 2-round, 33-question, web-based Delphi survey on perioperative management (preoperative work-up, surgical procedure and follow-up) of non-revisional, elective pHH among European surgeons with expertise in upper-GI. Responses were graded on a 5-point Likert scale and analyzed using descriptive statistics. Items from the questionnaire were defined as “recommended” or “discouraged” if positive or negative concordance among participants was > 75%. Items with lower concordance levels were labelled “acceptable” (neither recommended nor discouraged). Results Seventy-two surgeons with a median (IQR) experience of 23 (14–30) years from 17 European countries participated (response rate 60%). The annual median (IQR) individual and institutional caseload was 25 (15–36) and 40 (28–60) pHH-surgeries, respectively. After Delphi round 2, “recommended” strategies were defined for preoperative work-up (endoscopy), indication for surgery (typical symptoms and/or chronic anemia), surgical dissection (hernia sac dissection and resection, preservation of the vagal nerves, crural fascia and pleura, resection of retrocardial lipoma) and reconstruction (posterior crurorrhaphy with single stitches, lower esophageal sphincter augmentation (Nissen or Toupet), and postoperative follow-up (contrast radiography). In addition, we identified “discouraged” strategies for preoperative work-up (endosonography), and surgical reconstruction (crurorrhaphy with running sutures, tension-free hiatus repair with mesh only). In contrast, many items from the questionnaire including most details of mesh augmentation (indication, material, shape, placement, and fixation technique) were “acceptable”. Conclusions This multinational European Delphi survey represents the first expert-led process to identify recommended strategies for the management of pHH. Our work may be useful in clinical practice to guide the diagnostic process, increase procedural consistency and standardization, and to foster collaborative research.

Comment on “Laparoscopic Paraesophageal Hernia Repair: to Mesh or Not to Mesh”

“… 5 , 6 At present, this topic remains open to debate and consensus is limited due to the complexity of factors involved in paraesophageal hernia recurrence and the lack of standardization of current surgical techniques. 7 We believe that, in selected patients, use of a resorbable synthetic mesh as an adjunct to adequate distal esophageal dissection, standard cruroplasty, fundic mobilization, and posterior partial fundoplication has the potential to reduce early recurrence rates and improve quality of life outcomes. 8 , 9 …”

Evaluation of the frequency of hiatal hernia in patients undergoing upper gastrointestinal system endoscopy

“…If the herniation concerns only the esophagogastric junction, it is called sliding. If the fundus and other parts of the stomach herniate through the hiatus, it is called paraesophageal hiatus herniation [6]. Although congenital and acquired causes are blamed for the development of hiatus hernia, its etiology has not been fully explained.…”

Morbidity and mortality following hiatal hernia repair in geriatric patients: a multicenter research network study

“…As data accumulates, a reevaluation of recommendations addressing whether to operate on the asymptomatic hiatal hernia in the senior or geriatric population may be warranted. A European expert Delphi consensus published in 2023 sought to answer the question of indications for surgical repair of paraesophageal hernia and may signal a change in surgeons’ perspective [ 16 ]. They labeled surgery the “recommended” therapeutic strategy for symptomatic patients regardless of age and considered surgery “acceptable” for patients with no or minor symptoms.…”