Surgical reconstruction of functional and anatomical defects in the diaphragmatic hiatus

Gastroesophageal reflux disease (GERD) is characterized mainly by heartburn and acid regurgitation but in the more severe forms even organic manifestations can occur. Proton pump inhibitors (PPIs) is the main medical treatment of GERD but antireflux surgery should be looked upon as an effective long-term therapeutic option. The hiatus hernia (HH) is an important factor in the pathogenesis of GERD since it may disrupt both the anatomy and physiology of the antireflux barrier. The overall aim of this thesis was to critically assess important components in the surgical repair confined to the diaphragmatic hiatus, in patients with HH and with or without GERD.

Study I was a double-blind randomized clinical trial in which 159 patients with GERD and HH > 2cm allocated to closure of the hiatal defect with simple crural sutures or with nonabsorbable mesh. The aim of the study was to assess the anatomical and functional outcomes of the use of a mesh for the repair of HH in patients with GERD. Similar anatomical recurrence rates of the HH were noted in the two study groups at 1 year (mesh; 9%, sutures; 3%) and at 3 years (mesh; 13%, sutures; 10%) after the surgery. Both procedures controlled reflux equally well and quality of life scores were comparable. However, more patients had dysphagia for solid food after mesh closure. Study II contained long-term follow up observations of the study I, and assessed the risk for recurrence of HH as well as differences in functional results between the two procedures when assessed more than 10 years later. The mean (SD) follow up of the study was 13 (1.1) years. The radiological recurrence of the HH was 46% in the mesh and 28% in the suture group (p=0.175) but most of the recurrences were small. No differences emerged over time in quality of life between the two procedures but we observed a maintained higher dysphagia scores for solid food items in the mesh group (p=0.011). Study III was a long-term follow up of a randomized double-blind clinical trial of patients with GERD allocated to a total (3600) or partial posterior (2700) fundoplication. The aim of the study was to assess the long-term functional outcomes of these two procedures (>15 years after the operation). The mean (SD) follow up of this study was 16 (1.3) years. The study found that both procedures controlled GERD and quality of life equally well at the time of the follow up with only minor differences in mechanical side effects. Study IV was a double-blind randomized clinical trial conducted in two centers. The aim of the study was to identify any differences between two different types of fundoplication (1800 or 3600) in patients with paraesophageal hernia in terms of early postoperative functional outcomes. In total, 70 patients were included in the study and the follow up was 6 months. Dysphagia was assessed by the Ogilvie and the Dakkak dysphagia scores. The study found that during the follow-up, Ogilvie dysphagia scores were stable in the total fundoplication group but significantly improved in the Toupet group at 3 and 6 months after the operation ( p=0.003 and 0.001, respectively). Moreover, at 6 months, Dakkak dysphagia scores were significantly higher in the total fundoplication group (p=0.003). Finally, there was no difference in reflux control or HH recurrence between the two procedures at the time of the follow-up.

In conclusion, tension-free crural repair with non-absorbable mesh in patients with GERD undergoing a Nissen fundoplication does not reduce the risk for radiological recurrence of the HH in the short- or the long-term. In addition, the finding of maintained higher dysphagia scores at 13 years postoperatively in the mesh group, implies that PTFE mesh closure cannot be recommended for routine use in HH repair associated with antireflux surgery. Both the total and the partial posterior fundoplication control GERD and quality of life well when assessed as long as 15 years after surgery. The addition of a total fundoplication in patients with paraesophageal hernia undergoing surgery, may be burdened by higher risk for postoperative dysphagia.

List of scientific papers

I. 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. British Journal of Surgery. 2020 Dec;107(13):1731-1740.
https://doi.org/10.1002/bjs.11917

II. Analatos A, Ansorge C, Lindblad M, Lundell L, Håkanson BS, Thorell A. Hiatus hernia repair with tension-free mesh or crural sutures alone in antireflux surgery. More than 10 years follow-up of a randomized, double-blind clinical trial. [Manuscript]

III. Analatos A, Håkanson BS, Ansorge C, Lindblad M, Lundell L, Thorell A. Comparable clinical outcomes of a laparoscopic total vs a 2700 posterior partial fundoplication in Chronic Gastroesophageal Reflux Disease. A Randomized Clinical Trial. JAMA Surgery. 2022.
https://doi.org/10.1001/jamasurg.2022.0805

IV. Analatos A, Lindblad M, Ansorge C, Lundell L, Thorell A, Håkanson BS. Total versus partial posterior fundoplication in the surgical repair of para-oesophageal hernias: a randomized clinical trial. British Journal of Surgery Open. 2022.
https://doi.org/10.1093/bjsopen/zrac034