Differentiated approach to hernioplasty of paraesophageal hernias

Authors

DOI:

https://doi.org/10.30978/GS-2024-2-38

Keywords:

paraesophageal hernia, hiatal surface area, crurorraphy, allohernioplasty, recurrence, prediction, surgical tactics

Abstract

The results of surgical treatment of paraesophageal hernias indicate a high recurrence rate, from 15% to 66%, with an average follow‑up period of 12 to 40 months. The main options for repairing the defect of the esophageal hiatus in the presence of paraesophageal hernia are crurorraphy and mesh‑reinforced crurorraphy. Both methods have their own advantages and disadvantages. The criteria for choosing a method have not been specified.

Objective — to develop a differentiated approach to the surgical treatment of paraesophageal hernias, taking into account the size of the esophageal hiatus, and to determine its effectiveness.

Materials and methods. The study included 157 patients who were operated on for paraesophageal hernias. They were divided into two groups. The patients in both groups did not exhibit any statistically significant differences in terms of mean age, body mass index, sex ratio, type, frequency of complaints, or results of the endoscopic and radiological examination.

In Group I, hiatoplasty was performed using crurorraphy (61 (38.9%) patients). In this group, the threshold values of the esophageal hiatus dimensions were calculated using the developed device and methodology, which allowed predicting hernia recurrence during the follow‑up period of up to 18 months. In Group II (96 (61.1%) patients), the hernioplasty technique (crurorraphy or mesh‑reinforced crurorraphy) was chosen on the basis of the obtained threshold values.

Results. In Group I, the mean hiatal surface area was 86.8±18.2 mm2 (53 to 161 mm2) and the width of the esophageal hiatus was 29.3±3.3 mm (24 to 38 mm). In Group II, they were 95.6±23.2 mm2 (51 to 212 mm2) and 31.1±3.7 mm (24 to 43 mm), respectively. The threshold hiatal surface area, at which the probability of recurrence after crurorraphy was >50%, was 90 mm2 (AUC — 0.926 (95% confidence interval — 0.827—1.000), with a sensitivity and specificity of 87.5% and 97.8%, respectively. The width of the esophageal hiatus was measured at a cut‑off point of 32 mm (AUC — 0.864 (95% confidence interval — 0.733—0.995), with a sensitivity and specificity of 75.0% and 78.0%. In Group II, posterior crurorraphy was performed in the case of a hiatal surface area <90 mm2 and a distance between the crura diaphragmatis <32 mm. In other cases, mesh‑reinforced crurorraphy was conducted. The recurrence rate in Groups I and II was 26.2% and 7.3% (p=0.001).

Conclusions. The device and methodology that have been developed are capable of measuring the dimensions (length, width, and area) of the esophageal hiatus intraoperatively. These measurements can be taken for the entire area within the esophageal hiatus contour, independent of its shape, even when using laparoscopic methods. The study found that there was a probability of recurrence after crurorraphy >50% when the threshold hiatal surface area was 90 mm2, and the width of the esophageal hiatus was 32 mm. A differentiated approach to hiatoplasty involves using crurorraphy for hiatal surface areas <90 mm2 or distances between the crura diaphragmatis <32 mm. For larger hiatal surface areas or widths, mesh‑reinforced crurorraphy is indicated. This approach has resulted in a significant reduction in the recurrence rate from 26.2% to 7.3% (p=0.001) and has prevented complications associated with the use of implants for up to 18 months after surgery.

 

Author Biographies

O. Y. Ioffe, Bogomolets National Medical University, Kyiv

MD, Prof., Head of the Department of General Surgery No2

T. A. Tarasov, Bogomolets National Medical University, Kyiv

-

L. Y. Markulan, Bogomolets National Medical University, Kyiv

PhD, Assoc. Prof.

M. M. Bagirov, Shupyk National Healthcare University of Ukraine, Kyiv

-

References

Aiolfi A, Cavalli M, Saino G, Sozzi A, Bonitta G, Micheletto G, Campanelli G, Bona D. Laparoscopic posterior cruroplasty: a patient tailored approach. Hernia. 2022 Apr;26(2):619-626. http://doi.org/10.1007/s10029-020-02188-5. Epub 2020 Apr 25. PMID: 32335756.

Alicuben ET, Luketich JD, Levy RM. Laparoscopic repair of giant paraesophageal hernia. J Thorac Cardiovasc Surg Tech. 2021;10:497-502. http://doi.org/10.1016/j.xjtc.2021.04.037.

Alicuben ET, Worrell SG, DeMeester SR. Impact of crural relaxing incisions, Collis gastroplasty, and non-cross-linked human dermal mesh crural reinforcement on early hiatal hernia recurrence rates. J Am Coll Surg 2014;219:988-92. http://doi.org/10.1016/j.jamcollsurg.2014.07.937.

Analatos A, Håkanson BS, Lundell L, Lindblad M, Thorell A. Tension-free mesh versus suture-alone cruroplasty in antireflux surgery: a randomized, double-blind clinical trial. Br J Surg. 2020 Dec;107(13):1731-1740. http://doi.org/10.1002/bjs.11917. Epub 2020 Sep 16. PMID: 32936951.

Angeramo CA, Schlottmann F. Laparoscopic Paraesophageal Hernia Repair: To Mesh or not to Mesh. Systematic Review and Meta-analysis. Ann Surg. 2022 Jan 1;275(1):67-72. http://doi.org/10.1097/SLA.0000000000004913. PMID: 33843796.

Antiporda M, Veenstra B, Jackson C, Kandel P, Smith DC, Bowers SP. Laparoscopic repair of giant paraesophageal hernia: are there factors associated with anatomic recurrence? Surg Endosc. 2018;32:945-54. http://doi.org/10.1007/s00464-017-5770-z.

Antoniou SA, et al. Laparoscopic augmentation of the diaphragmatic hiatus with biologic mesh versus suture repair: a systematic review and meta-analysis. Langenbecks Arch Surg. 2015;400(5):577-83. http://doi.org/10.1007/s00423-015-1312-0.

Barrett NR Hiatus hernia: a review of some controversial points. Br J Surg 1954;42:231-43. PMID: 13219304.

Batirel HF, Uygur-Bayramicli O, Giral A, et al. The size of the esophageal hiatus in gastroesophageal reflux pathophysiology: outcome of intraoperative measurements. Journal of Gastrointestinal Surgery. 2009;14(1):38-44. http://doi.org/10.1007/s11605-009-1047-8.

Borraez-Segura B, et al. Mesh migration after hiatal hernia repair. Indian J Gastroenterol. 2019;38(5):462-4. http://doi.org/10.1007/s12664-019-00993-0.

Boru CE, Rengo M, Iossa A, et al. Hiatal surface area’s CT scan measurement is useful in hiatal hernia’s treatment of bariatric patients. Minim Invasive Ther Allied Technol. 2021 Apr;30(2):86-93. http://doi.org/10.1080/13645706.2019.1683033.

Brandalise A, Herbella FAM, Luna RA, Szachnowicz S, Sallum RAA, Domene CE, Volpe P, Cavazzolla LT, Furtado ML, Claus CMP, Farah JFM, Crema E. Brazilian hernia and abdominal wall Society statement on large hiatal hernias management. Arq Bras Cir Dig. 2024 Feb 5;36:e1787. http://doi.org/10.1590/0102-672020230069e1787.

Campos V, Palacio DS, Glina F, Tustumi F, Bernardo WM, Sousa AV. Laparoscopic treatment of giant hiatal hernia with or without mesh reinforcement: A systematic review and meta-analysis. Int J Surg. 2020 May;77:97-104. http://doi.org/10.1016/j.ijsu.2020.02.036. Epub 2020 Mar 3. PMID: 32142902.

Chan EG, Sarkaria IS, Luketich JD, Levy R. Laparoscopic approach to paraesophageal hernia repair. Thorac Surg Clin. 2019;29:395-403. http://doi.org/10.1016/j.thorsurg.2019.07.002.

Cole W, Zagorski S Intramural gastric abscess following laparoscopic paraesophageal hernia repair. Endoscopy. 2015;47(Suppl1):E227-E228. http://doi.org/10.1055/s-0034-1365439.

Dallemagne B, Kohnen L, Perretta S, Weerts J, Markiewicz S, Jehaes C. Laparoscopic repair of paraesophageal hernia. Longterm follow-up reveals good clinical outcome despite high radiological recurrence rate. Ann Surg. 2011;253:291-6. http://doi.org/10.1097/SLA.0b013e3181ff44c0.

De Moor V, et al. Complications of mesh repair in hiatal surgery: about 3 cases and review of the literature. Surg Laparosc Endosc Percutan Tech. 2012;22(4):e222-e225. http://doi.org/10.1097/SLE.0b013e318253e440.

Dutta S. Prosthetic esophageal erosion after mesh hiatoplasty in a child, removed by transabdominal endogastric surgery. J Pediatr Surg. 2007;42(1):252-6. http://doi.org/10.1016/j.jpedsurg.2006.09.043.

Frantzides CT, Madan AK, Carlson MA, Stavropoulos GP. A prospective, randomized trial of laparoscopic polytetrafluoroethylene (PTFE) patch repair vs simple cruroplasty for large hiatal hernia. Arch Surg. 2002 Jun;137(6):649-52. http://doi.org/10.1001/archsurg.137.6.649. PMID: 12049534.

Granderath FA, Schweiger UM, Kamolz T, Pasiut M, Haas CF, Pointner R. Laparoscopic antireflux surgery with routine meshhiatoplasty in the treatment of gastroesophageal reflux disease. J Gastrointest Surg. 2002;6:347-53. http://doi.org/10.1016/s1091-255x(01)00025-7.

Granderath FA, Schweiger UM, Pointner R. Laparoscopic antireflux surgery: tailoring the hiatal closure to the size of hiatal surface area. Surg Endosc. 2007 Apr;21(4):542-8. http://doi.org/10.1007/s00464-006-9041-7. Epub 2006 Nov 14. PMID: 17103275.

Grubnik VV, Malynovskyy AV. Laparoscopic repair of hiatal hernias: new classification supported by long-term results. Surg Endosc. 2013 Nov;27(11):4337-46. http://doi.org/10.1007/s00464-013-3069-2.

Hashemi M, Peters JH, DeMeester TR, et al. Laparoscopic repair of large type III hiatal hernia: objective follow-up reveals high recurrence rate. J Am Coll Surg. 2000;190:553-60. http://doi.org/10.1016/s1072-7515(00)00260-x.

Hutter MM, Rattner DW Paraesophageal and other complex diaphragmatic hernias. In: Yeo CJ (ed) Shackelford’s surgery of the alimentary tract. Saunders Elsevier, Philadelphia; 2007. P. 549-562.

Koch OO, Schurich M, Antoniou SA, Spaun G, Kaindlstorfer A, Pointner R, Swanstrom LL. Predictability of hiatal hernia/defect size: is there a correlation between pre- and intraoperative findings? Hernia. 2014;18(6):883-8. http://doi.org/10.1007/s10029-012-1033-z. Epub 2013 Jan 6. PMID: 23292367.

Kohn GP, Price RR, DeMeester SR, Zehetner J, Muensterer OJ, Awad Z, Mittal SK, Richardson WS, Stefanidis D, Fanelli RD; SAGES Guidelines Committee. Guidelines for the management of hiatal hernia. Surg Endosc. 2013 Dec;27(12):4409-28. http://doi.org/10.1007/s00464-013-3173-3. Epub 2013 Sep 10. PMID: 24018762.

Latorre-Rodríguez AR, Rajan A, Mittal SK. Cruroplasty with or without mesh? A systematic literature review with a novel time-organized proportion meta-analysis. Surg Endosc. 2024 Apr;38(4):1685-708. http://doi.org/10.1007/s00464-024-10683-4. Epub 2024 Feb 13.

Le Page PA, Furtado R, Hayward M, et al. Durability of giant hiatus hernia repair in 455 patients over 20 years. Ann R Coll Surg Engl. 2015 Apr;97(3):188-93. http://doi.org/10.1308/003588414X14055925060839.

Luketich JD, Nason KS, Christie NA, et al. Outcomes after a decade of laparoscopic giant paraesophageal hernia repair. J Thorac Cardiovasc Surg. 2010;139:395-404. 404.e1. http://doi.org/10.1016/j.jtcvs.2009.10.005.

Lundell LR, Dent J, Bennett JR, et al. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut. 1999 Aug;45(2):172-80. http://doi.org/10.1136/gut.45.2.172.

Mattar SG, Bowers SP, Galloway KD, et al. Long-term outcome of laparoscopic repair of paraesophageal hernia. Surg Endosc 2002;16:745-9. http://doi.org/10.1007/s00464-001-8194-7.

Memon MA, Siddaiah-Subramanya M, Yunus RM, Memon B, Khan S. Suture cruroplasty versus mesh hiatal herniorrhaphy for large hiatal hernias (HHs): An updated meta-analysis and systematic review of randomized controlled trials. Surg Laparosc Endosc Percutan Tech. 2019 Aug;29(4):221-32. http://doi.org/10.1097/SLE.0000000000000655.

Morino M, Giaccone C, Pellegrino L, Rebecchi F. Laparoscopic management of giant hiatal hernia: factors influencing long-term outcome. Surgical Endoscopy. 2006;20(7):1011-6. http://doi.org/10.1007/s00464-005-0550-6.

Müller-Stich BP, Kenngott HG, Gondan M, et al. Use of Mesh in laparoscopic paraesophageal hernia repair: a meta-analysis and risk-benefit analysis. PLoS One. 2015 Oct 15;10(10):e0139547. http://doi.org/10.1371/journal.pone.0139547.

Oelschlager BK, Pellegrini CA, Hunter J, et al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair: long-term follow-uw from a multicenter, prospective, randomized trial. J Am Coll Surg. 2011;213:461-8. https://doi.org/10.1016/j.jamcollsurg.2011.05.017.

Petric J, Bright T, Liu DS, Wee Yun M, Watson DI. Sutured versus Mesh-augmented hiatus hernia repair: a systematic review and meta-analysis of randomized controlled trials. Ann Surg. 2022 Jan 1;275(1):e45-e51. http://doi.org/10.1097/SLA.0000000000004902.

Rancourt M, Pare A, Comeau E. Intraoesophageal migration of Tefon pledgets used for hiatal hernia repair: a serious adverse event. BMJ Case Rep. 2019;12(4):224383. http://doi.org/10.1136/bcr-2018-224383.

Schlottmann F, Strassle PD, Farrell TM, et al. Minimally invasive surgery should be the standard of care for paraesophageal hernia repair. J Gastrointest Surg. 2017;21:778-84. http://doi.org/10.1007/s11605-016-3345-2.

Siboni S, Asti E, Milito P, et al. Impact of Laparoscopic repair of large hiatus hernia on quality of life: observational cohort study. Dig Surg. 2019;36(5):402-8. http://doi.org/10.1159/000490359.

Spiro C, Quarmby N, Gananadha S. Mesh-related complications in paraoesophageal repair: a systematic review. Surg Endosc. 2020 Oct;34(10):4257-80. http://doi.org/10.1007/s00464-020-07723-0.

Tam V, Winger DG, Nason KS. A systematic review and meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair. Am J Surg. 2016 Jan;211(1):226-38. http://doi.org/10.1016/j.amjsurg.2015.07.007. Epub 2015 Sep 18. PMID: 26520872; PMCID: PMC5153660.

Tarasov TA. Ukrainian utility model patent No. 154379(46) was issued for this laparoscopic tool: Publication of information 08.11.2023, Bulletin No. 45 on state registration: (54) Laparoscopic instruments.

Wade A, Dugan A, Plymale MA, Hoskins J, Zachem A, Roth JS. Hiatal hernia cruroplasty with a running barbed suture compared to interrupted suture repair. Am Surg. 2016 Sep;82(9):e271-4. PMID: 27670546.

Watson DI, Davies N, Devitt PG, et al. Importance of dissection of the hernial sac in laparoscopic surgery for large hiatal hernias. Arch Surg 1999;134:1069-73. http://doi.org/10.1001/archsurg.134.10.1069.

Watson DI, Thompson SK, Devitt PG, et al. Five year follow-up of a randomized controlled trial of laparoscopic repair of very large hiatus hernia with sutures versus absorbable versus nonabsorbable mesh. Ann Surg. 2020;272:241-7. http://doi.org/10.1097/SLA.0000000000003734.

World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2012;310(20):2191-4. http://doi.org/10.1001/jama.2013.281053.

Wu JS, Dunnegan DL, Soper NJ. Clinical and radiologic assessment of laparoscopic paraesophageal hernia repair. Surg Endosc. 1999 May;13(5):497-502. http://doi.org/10.1007/s004649901021. PMID: 10227951.

Downloads

Published

2024-06-30

How to Cite

1.
Ioffe O, Tarasov T, Markulan L, Bagirov M. Differentiated approach to hernioplasty of paraesophageal hernias . ЗХ [Internet]. 2024Jun.30 [cited 2024Oct.6];(2):38-46. Available from: http://generalsurgery.com.ua/article/view/308060

Issue

Section

Original Research