Temporal patterns of hiatus hernia recurrence and hiatal failure: quality of life and recurrence after revision surgery

Abstract

Antireflux and paraesophageal hernia repair surgery is increasingly performed and there is an increased requirement for revision hiatus hernia surgery. There are no reports on the changes in types of failures and/or the variations in location of crural defects over time following primary surgery and limited reports on the outcomes of revision surgery. The aim of this study is to report the changes in types of hernia recurrence and location of crural defects following primary surgery, to test our hypothesis of the temporal events leading to hiatal recurrence and aid prevention. Quality of life scores following revision surgery are also reported, in one of the largest and longest follow-up series in revision hiatus surgery. Review of a single-surgeon database of all revision hiatal surgery between 1992 and 2015. The type of recurrence and the location of crural defect were noted intraoperatively. Recurrence was diagnosed on gastroscopy and/or contrast study. Quality of life outcomes were measured using Visick, dysphagia, atypical reflux symptoms, satisfaction scores, and Gastrointestinal Quality of Life Index (GIQLI). Two-hundred eighty four patients (126 male, 158 female), median age 60.8(48.2-69.1), underwent revision hiatal surgery. Median follow-up following primary surgery was 122.8(75.3-180.3) and 91.6(40.5-152.5) months after revision surgery. The most common type of hernia recurrence in the early period after primary surgery was 'telescope'(42.9%), but overall, fundoplication apparatus transhiatal migration was consistently the predominant type of recurrence at 1-3 years (54.3%), 3-5 years (42.5%), 5-10 years (45.1%), and >10 years (44.1%). The location of crural defects changed over duration following primary surgery as anteroposterior defects was most common in the early period (45.5% in <1 year) but decreased over time (30.3% at 1-3 years) while anterior defects increased in the long term with 35.9%, 40%, and 42.2% at 3-5 years, 5-10 years, and >10 years, respectively. Revision surgery intraoperative morbidity was 19.7%, mainly gastric (9.5%) and esophageal (2.1%) perforation. There was a 75% follow-up rate and recurrence following revision surgery was 15.4%(44/284) in unscreened population and 21%(44/212) in screened population. There was no difference in recurrence rate based on size of hiatus hernia at primary surgery, or at revision surgery. There were significant improvements in the Visick score (3.3 vs. 2.4), the modified Dakkak score (23.2 vs. 15.4), the atypical reflux symptom score (23.7 vs. 15.4), and satisfaction scores (0.9 vs. 2.2), but no difference in the various domains (symptom, physical, social, and medical) of the GIQLI scores following revision surgery. Revision hiatal surgery has higher intraoperative morbidity but may achieve adequate long-term satisfaction and quality of life. The most common type of early recurrence following primary surgery is telescoping, and overall is wrap herniation. Anterior crural defects may be strong contributor to late hiatus hernia recurrence. Symptom-s...

Protocol for Randomised Controlled Feasibility Study Comparing Cruroplasty with Circumferential DynaMesh-HIATUS® Versus Suture-Only Repair for Large Hiatus Hernias

“…This study aims to address potential methodological problems by using two validated quality of life questionnaires (GERD-QOL and EQ-5D) to quantify the patient's recovery and allow for comparative analysis between intervention and standard procedure groups. We deliberately prioritise patient-reported outcomes (PROMs) above objective clinical measures, as the former are rightly the most important outcomes from hiatal hernia surgery [10]. A challenge of this, and previous RCTs, has been that powering it to detect reduction in symptomatic recurrence would require a sample size in excess of 1000 participants.…”

“…Hernia recurrence rates can be as high as 50% with standard suture repair, though this does include both small and large hernia recurrences. Revisional surgery for symptoms thought to be due to recurrence occurs This article is part of the Topical Collection on Surgery in approximately 5% of patients [10,11]. To mitigate this, some surgeons have tried modifications to the suture technique.…”

Large hiatus hernia: time for a paradigm shift?

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The Controversial Role of Concurrent Crural Plasty in Bariatric Surgery: Where Is the Evidence?

“…33 Consequently, it is not realistic to count merely on the mechanical and biological properties of the mesh for the long-term success of HH repair, but other factors such as release of axial tension through systematic mediastinal dissection and hernia sac excision should be considered to prevent HH recurrence. 34,35 Over the past decade, the use of the falciform ligament flap has been revisited as a onlay crural buttress to prevent or repair primary and recurrent HH. 36 We found that the vascular supply of the flap originating from the middle hepatic and inferior phrenic arteries is constant.…”