What Is the Reality of Hiatal Hernia Management?—A Registry Analysis

Abstract

Introduction: To date, the guidelines for surgical repair of hiatal hernias do not contain any clear recommendations on the hiatoplasty technique with regard to the use of a mesh or to the type of fundoplication (Nissen vs. Toupet). This present 10-years analysis of data from the Herniamed Registry aims to investigate these questions. Methods: Data on 17,328 elective hiatal hernia repairs were entered into the Herniamed Registry between 01.01.2010 and 31.12.2019. 96.4% of all repairs were completed by laparoscopic technique. One-year follow-up was available for 11,280 of 13,859 (81.4%) patients operated during the years 2010-2018. The explorative Fisher's exact test was used for statistical calculation of significant differences with an alpha = 5%. Since the annual number of cases in the Herniamed Registry in the years 2010-2012 was still relatively low, to identify significant differences the years 2013 and 2019 were compared Results: The use of mesh hiatoplasty for axial and recurrent hiatal hernias remained stable over the years from 2013 to 2019 at 20 and 45%, respectively. In the same period the use of mesh hiatoplasty for paraesophageal hiatal hernia slightly, but significantly, increased from 33.0 to 38.9%. The proportion of Nissen and Toupet fundoplications for axial hiatal hernia repair dropped from 90.2% in 2013 to 74.0% in 2019 in favor of "other techniques" at 20.9%. For the paraesophageal hiatal hernias (types II-IV) the proportion of Nissen and Toupet fundoplications was 68.1% in 2013 and 66.0% in 2019. The paraesophageal hiatal hernia repairs included a proportion of gastropexy procedures of 21.7% in 2013 and 18.7% in 2019. The recurrent hiatal hernia repairs also included a proportion of gastropexies 12.8% in 2013 and 15.1% in 2019, Nissen and Toupet fundoplications of 72.7 and 62.7%, respectively, and "other techniques" of 14.5 and 22.2%, respectively. No changes were seen in the postoperative complication and recurrence rates. Conclusion: Clear trends are seen in hiatal hernia repair. The use of meshes has only slightly increased in paraesophageal hiatal hernia repairs. The use of alternative techniques has resulted in a reduction in the use of the "classic" Nissen and Toupet fundoplication surgical techniques.

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

“…Augmentation of the lower esophageal sphincter is a frequently performed adjunct to pHH repair and was formally "recommended" by our participants. Our results confirm recent data from the multi-institutional HERNIAMED registry reporting additional sphincter augmentation in paraesophageal hernia repair in 60-70% [8,21]. However, routine and selective sphincter augmentation is performed by 64% and 35% of our participants, respectively, which contrasts the 84% (routine) and 9% (selective) sphincter augmentation rates in the EAES survey [3].…”

Reversal of unstable atrial fibrillation after surgical correction of hiatus hernia: A case report

“…The use of a mesh in the correction of hernia, according to Köckerling et al, is necessary in about 20% of cases of type I hiatal hernia, without a major change in this percentage between 2013 and 2019. In relation to hernias types II to IV, the use of meshes increased from 33% to 38.9% of cases [10] .…”

Mesh or no mesh in anti-reflux surgery

“…In registry analyses including the second half of the last decade, however, results conflicted. In an NSQIP analysis between 2010-2017 of over 25,000 cases, mesh utilization decreased from 46.2% to 35.2% [9] . In a European analysis between 2010 -2019, mesh utilization for axial HHR was stable at ~20%, for paraesophageal HHR mesh increased from 33% to 38.9%, and was stable for recurrent HHR at around 45% [10] .…”

“…Similar results were found in a survey of the European Association for Endoscopic Surgery (EAES) in 2015, with higher use of mesh at 92.1% of European surgeons at least selectively using mesh although mesh types differed with most surgeons preferring either polypropylene, polyester or PTFE meshes and only 27.9% using biologic meshes [6] . In registry analyses, these survey results are further expanded: mesh is used frequently but in less than half of ARS cases overall [7][8][9][10] . As for trends over time, in two National Surgery Quality Improvement Program (NSQIP) analyses between 2010-2015, the use of mesh remained stable over time at around 38%-43% [7,8] .…”

“…Little data exists comparing mesh-and non-mesh-based repairs of reoperative ARS. Many surgeons consider reoperation an indication of mesh usage, and so perhaps the lack of data owes to the suspected lack of equipoise [4,9] . Nevertheless, in the only comparative study of mesh use in reoperative ARS -essentially a case series that discusses the use of mesh or not in reoperative ARS -Desai et al found similar re-reoperation rates (16% vs. 20%) in mesh-based and non-mesh-based repairs of failed HHR (n = 82) [36] .…”