Revisional surgery at the esophageal hiatus—a Scandinavian single-center retrospective review of 59 operations

Introduction

The prevalence of gastroesophageal reflux disease (GERD) is high (1-3). In most cases, laparoscopic anti-reflux surgery for GERD is associated with a high degree of symptom relief and low rates of short-term morbidity and mortality (4-7). Anti-reflux procedures and repair of paraesophageal hernias (PEH) are complex operations requiring advanced skills in minimally invasive surgery. In the last decades, centralization of these procedures has occurred worldwide (8,9).

Revisional surgery after operations for GERD or PEH is indicated in 3–6% of patients (10-12). Indications for surgical revision include slipped fundoplication, too tight or loose wrap or recurrent herniation of abdominal contents through the esophageal hiatus (10,13). Revisional surgery at the esophageal hiatus is associated with increased risk for complications and lower patient satisfaction compared to primary procedures (13).

Following the marked reduction in primary anti-reflux operations, the volume of revisional surgery has also declined (14,15). In Norway, surgeons with experience from the high-volume era of laparoscopic anti-reflux surgery are fewer. Consequently, several institutions refer these patients to regional centers with larger operative volumes and greater experience in surgery at the gastroesophageal junction. The aim of this study is to assess the results from a Norwegian tertiary care hospital regarding indications and outcome after revisional surgery at the esophageal hiatus after previous surgery for non-malignant conditions. We present this article in accordance with the STROBE reporting checklist (available at https://aoe.amegroups.com/article/view/10.21037/aoe-24-21/rc) (16).

Methods

Study population

The study population included all adult patients who underwent revisional surgery after a previous anti-reflux procedure or PEH repair at Oslo University Hospital (OUS) from January 1, 2014, to June 1, 2022. This study is a retrospective cohort study. Repair of PEH was defined as repair of a hiatal hernia grade II to IV, i.e. more than repair of a simple sliding hernia during anti-reflux surgery (17). OUS is a referral regional university hospital for upper gastroesophageal surgery in South-East Norway. The population of South-East Norway is approximately 2.9 million. Patients were identified by manually reviewing the charts of all patients with Norwegian Code for Surgical Procedure (NCSP) codes addressing surgery at the esophageal hiatus (18), as well as all patients admitted with the ICD-10 diagnosis K44.X (hiatal hernia) and a corresponding procedure code (19).

Follow-up

The hospital’s routine follow-up after revisional surgery included an appointment at the outpatient clinic, either by telephone or physically, two to three months after surgery, as well as a CT scan of the diaphragm after approximately one year. Except for this, there was no systematic follow-up. As a referral hospital for these patients, it is most unlikely that subsequent related surgery occurred elsewhere. The end of the follow-up was set to August 1st, 2023 by reviewing the latest follow-up reports.

Study variables

Patient journals were reviewed (J.H. and E.B.) and demographic data, patient comorbidities, previous operations, indications for surgery, perioperative information, later interventions, and predefined outcome measures were registered. If data were not available in the patient journal, the variables were set to missing. Patient comorbidity was classified according to the Charlson Comorbidity Index (20). Aspects of the operations and subsequent re-interventions were reviewed. Complications and mortality during the first 30 days after surgery were categorized according to the Clavien-Dindo classification (21). Secondary operations in patients who had staged procedures were not classified as complications. Radiological hernia recurrence was defined as gastric or other organ herniation beyond 20 mm above the diaphragm. Isolated herniation of the gastrojejunal or esophagojejunal anastomosis in cases of Roux-en-Y reconstruction was not defined as recurrence. Patient satisfaction was defined as the yes/no answer to the question: “Are you satisfied with the surgery?” asked at the outpatient follow up three months after revisional surgery.

Ethics

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013) (22). The use of data was in agreement with Oslo University Hospital Data Protection Officer (22/09352) and the need for informed consent was waived in accordance with institutional guidelines.

Statistical analysis

SPSS version 29 (IBM Corp.) was used for statistical computations. Baseline characteristics were reported as counts, percentages, means (standard deviations) and medians (range), as appropriate. To calculate differences of proportions, Chi-square or Fisher’s exact test was used, as appropriate. For continuous variables, the Mann-Whitney’s non-parametric test was applied.

Results

During the study period 431 patients were identified through NCSP procedure codes and 132 through ICD-10 diagnosis codes with a corresponding surgical procedure. A total of 59 patients were eligible for inclusion in the study. Forty-seven (77%) of these were referred from other hospitals. All patients had at least one previous operation at the esophageal hiatus with a median of 4 (range, 0–35) years since the last surgery. The indications for previous surgery were PEH in 31 (48%) and GERD in 31 (53%). The median follow up after revisional surgery was 67.5 months (range, 0–114 months). Further characteristics of the study population are given in Table 1.

Pre-operative work up

Ten (17%) patients underwent emergency surgery, while 49 patients (83%) had planned operations. Emergency surgery was indicated for paraesophageal herniation with obstruction and/or suspicion of circulatory compromise of the herniated ventricle. CT was performed in 51 (86%) patients and upper endoscopy in 48 (81%) patients. An upper gastrointestinal X-ray with per oral contrast was performed in 34 (58%), a 24-hour pH-measurement in 29 (49%), esophageal manometry in 34 (58%), and gastric emptying study in 14 (25%).

The main subjective symptom preoperatively was GERD in 12 (20%), dysphagia in 23 (39%), chest and or epigastric pain in 13 (22%), and other symptoms in 11 (19%).

The main anatomical pathological finding following pre-operative work up was herniated fundoplication in 45 (74%), disrupted fundoplication in 2 (3%), tight fundoplication in 11 (18%) and slipped fundoplication in 1 (2%).

Surgery

The median duration of surgery was 232 (range, 84–430) minutes. All operations were attempted laparoscopically and 55 (93%) were completed this way. No procedures were robotically assisted. Details on surgical technical aspects are shown in Table 2. There were no significant differences in the procedure duration, need of gastric resection or type of anti-reflux construction created among patients operated emergently or electively.

A mesh was implanted around the esophageal hiatus in 21 (36%) of patients. Biodesign^® Hiatal Hernia Graft (Cook^® Biotech) was used in 8 and BIO-A^® Tissue Reinforement (GORE^®) was used in 13 (22%).

A gastrostomy tube was placed in seven (12%) of patients. In three (5%) of these patients, the gastrostomy tube was placed without an anti-reflux procedure. In four (7%), the gastrostomy was placed in combination with fundoplication to further fixate the ventricle, or as a possibility for venting of the gastric contents. There was no difference in the use of gastrostomy between elective (5/49) and emergency (2/10) patients (P=0.34). The gastrostomy tube was removed after six to eight weeks at the outpatient clinic.

Roux-en-Y reconstruction

Thirteen (22%) patients received a Roux-en-Y reconstruction during the revisional operation. Eight of these were operated with Roux-en-Y gastric bypass (RYGB). Six of the RYGB procedure were prescheduled because of obesity or poor esophageal motility, two were performed at the discretion of the surgeon based on intraoperative findings. Five patients had a Roux-en-Y esophagojejunostomy reconstruction following resection of the gastric cardia. Three patients required resection for gastric wall necrosis caused by the herniation and two needed resection of the gastric cardia following injuries after mobilisation from extensive adhesions or mesh erosion. One additional patient received a Roux-en-Y esophagojejunostomy reconstruction during early reoperation due to esophageal perforation. The cardia region was resected and an esophagojejunostomy was made.

Early postoperative outcomes (<30 days)

The median postoperative hospital stay was 7 (range, 2–54) days. Nine (15%) patients were reoperated within 30 days; three were planned reoperations in staged procedures, three patients had early reherniations and three patients were reoperated for other reasons. Serious complications (Clavien-Dindo ≥ IIIb) occurred in 9 (15%) patients, of which six were unplanned reoperations and three were medical complications requiring intensive care. Ten (17%) patients were readmitted within 30 days after discharge. Three (21%) of the 14 patients with Roux-en-Y reconstruction had serious complications. Early postoperative course following elective and emergency procedures is described in Table 3.

Late postoperative outcomes (>30 days)

Fifty-six (95%) patients were followed up with an outpatient appointment after a median of 67 (range, 23–448) days after surgery. Twenty-seven (46%) had a physical appointment and 25 (42%) were contacted by telephone. Thirty-seven (65%) patients were satisfied with the outcome of surgery. The proportion of patients with anemia, nausea, dysphagia, dyspnea, chest pain, reflux and regurgitation was lower after, than before surgery (Figure 1). Postoperative nausea and dysphagia were associated with patient dissatisfaction (P<0.01). The proportion of patients with feeling of bloating increased after surgery. Proton pump inhibitors were used by 31 (53%) before and 26 (44%) after surgery, respectively (P=0.19).

Figure 1 Prevalence (%) of symptoms before and after (2–3 months) revisional hiatal surgery in 59 patients.

Six (10%) patients underwent subsequent revisional surgery, after a median of 16 (range, 5–65) months. The indications for these procedures were transhiatal herniation of the fundoplication or other abdominal organs in five and dysphagia in one.

Radiological hiatal herniation

CT imaging of the diaphragm was performed in 49 (83%) patients during follow up. Twenty-three (39%) of all patients had a proven radiological recurrence. The recurrences were detected after a median of 12 (range, 0–103) months. There was no association between radiological recurrence and later revisional surgery (P=0.09), or between radiological recurrence and patient satisfaction measured 3 months after surgery (P=0.14). Patients with and without mesh implantation had similar radiological recurrence rates (P=0.15).

Discussion

In this population of patients receiving emergency and elective revisional surgery at the esophageal hiatus, there was low perioperative mortality, but a relatively high rate of serious complications for elective and acute surgery combined. This reflects the complexity of the procedures. Following surgery, most patients were satisfied with the procedural outcome. Of note, the high rate of radiological recurrent hiatal herniation was not translated into need of further revisional surgery for most of the patients.

The preoperative assessment of patients considered for redo surgery at the esophageal hiatus is a crucial step in ensuring optimal outcomes (23). In the present study, most patients were assessed by CT and upper endoscopy, detailing the anatomical disturbances of the esophagogastric junction. Upper gastrointestinal contrast X-ray series are useful to assess mechanical and functional obstruction related to the hiatal hernia repair and fundoplication if present. In patients with new onset reflux symptoms, or symptoms persisting after previous surgery, 24-hour pH measurement may support any indication for surgery (24). High resolution manometry can help to determine the operative strategy, as the finding of dysmotility might suggest that a partial, rather than a complete fundoplication should be made as a new reflux-procedure (23).

A recent estimate of rate of surgery for reflux disease from Denmark was 3.5 anti-reflux procedures per 100,000 people per year, translating to a need for around 200 anti-reflux procedures per year in Norway (25), and some 6–12 revisional anti-reflux procedures per year. Furthermore, a low and undefined number of hiatal hernia repairs may be required that also includes anti-reflux procedures. Today fewer surgeons are experienced in hiatal gastroesophageal surgery likely due to centralization of cancer surgery and a low rates of reflux surgery. In the current study, almost 80% of patients were referred from other hospitals. To ensure institutional experience in handling complex revisional procedures with potentially serious complications, centralization to few centers experienced in hiatal gastroesophageal surgery should be encouraged.

Similar retrospective series from the last decade report rates of perioperative complications between 4% and 7% (12,26-28). A recent meta-analysis of 2095 revisional anti-reflux procedures found an overall complication rate (Clavien-Dindo III/IV) of 5% (3.3–7%) (29). In the present study, the rate of serious complications was close to 15%. This difference across reports may be explained by several factors. First, most studies included in the review by Schlottman et al. consisted of revisions after anti-reflux surgery. In a recent study detailing 190 revisional PEH repairs, the 30-day morbidity rate was 16.5% with a readmission rate of 9.5%, reoperation rate of 4.7%, and mortality rate of 1.1% (12). Further, a considerable proportion of our patients underwent emergency surgery. A recent study by Sorial et al. showed a complication rate (Clavien-Dindo ≥ III) of 28% in emergency hiatal hernia repair, compared to 5% in elective repair (30). Lastly, in the present study, a total of 14 patients were in need of a Roux-en-Y reconstruction, which was rarely described in similar materials (12,26-29), and is associated with a higher rate of complications than fundoplication.

In line with most other studies of revisional hiatal surgery most preoperative gastroesophageal symptoms improved after surgery (26-28). Nausea and dysphagia were associated with patient dissatisfaction with surgery, indicating a need for preoperative information and postoperative follow up. However, the assessment of symptoms pre- and postoperatively is subject to bias. The symptoms were assessed 3 months after revisional surgery by patient chart review, which might in itself lead to bias.

Radiological hiatal reherniation is a difficult concept in hiatal hernia surgery. Currently, the most used definition of radiological recurrence is a ≥2.0 cm axial herniation of the fundoplicate above the diaphragm (31,32). After primary surgery for hiatal hernia, the radiological recurrence rate is high, Oelschlager et al. found a recurrence rate of over 50% after 58 months in their randomized trial of resorbable mesh for hiatal hernia repair (32). However, the radiological recurrence rate did not translate to a high rate of revisional surgery, with only two patients (3%) reoperated during follow-up. Similarly, in the present study, a 39% radiological recurrent hiatal herniation rate observed over median 67 months, translating into a rate of re-redo surgery at 10%.

Experience with Roux-en-Y reconstruction is relevant for revisional hiatal surgery. First, the failure rate of primary anti-reflux surgery is higher among patients with overweight and obesity (33,34). In a systematic review of 874 patients a GERD resolution rate of 93% with RYGB was reported after failed anti-reflux surgery (35). Thus, RYGB may ensure both sustained weight reduction and resolution of GERD in patients with overweight and failed anti-reflux surgery. The procedure may also reduce the risk for re-herniation (35). Secondly, in a study of 152 revisional hiatal procedures improved outcomes were observed in patients with four or more “symptom risk factors” (preoperative dysphagia, preoperative heartburn, esophageal dysmotility, short esophagus, delayed gastric emptying, multiple failed hiatal surgeries, reflux-related respiratory symptoms) who underwent RYGB compared to redo fundoplication (36). We applied the Roux-en-Y reconstruction in patients with overweight, esophageal and gastric motility problems, perioperative technical difficulties and gastric ischemia requiring resection in line with similar previous series (36,37).

The risk of complications appears higher in revisional Roux-en-Y reconstruction compared to redo fundoplication. Management of these complications requires experience and support from dedicated endoscopists and interventional radiologists (35-37). In the review by Chiappetta et al. the 30-day complication rate was 16.7%. Supporting this, in a case series of 50 conversions from Nissen fundoplication to RYGB Landreneau et al. describe a 30-day complication rate of 24% comparable to the complication rate of 21% in our series after Roux en Y reconstruction (37).

The preferred or optimal fundoplication procedure during PEH repair remains controversial and without adequate evidence to support any strict guidelines. In our institution, the standard procedure for several years has been the Toupet fundoplication that quite robustly fixates the fundoplication to the crura, reduces the risk of reflux, and may also reduce the risk for dysphagia. Alternative techniques include the anterior 180 degree fundoplication although not applied in our series.

Little evidence supports the routine placement of mesh augmentation in hiatal hernia surgery (38). In the current study, there was no obvious benefit, i.e., a lower rate of radiological recurrence in the use of biosynthetic mesh in the revisional surgery. A systematic review by Laxague et al. suggests that mesh can be considered in complicated hiatal hernias, including revisional operations (38). However, further investigations are needed, and at the present time point, routine use of mesh in hiatal hernia repair is not advised (38).

The use of gastropexy or gastrostomy as the sole intervention in repair of hiatal hernia elderly or frail patients is sometimes advocated (39,40). Furthermore, some authors argue that in cases of high risk for recurrence, an anchoring gastropexy can be added to a standard operation for hiatal hernia (41). There is no clear guidelines as for when or how a gastropexy or gastrostomy should be used in this context. In our practice we have used an anchoring gastrostomy in selected patients in an attempt to reduce risk of reherniation. We typically remove the gastrostomy six to eight weeks postoperatively.

This study has inherent limitations, primarily due to the lack of systematic follow up beyond the initial hospital stay. This may restrict the ability to evaluate long-term outcomes. Additionally, relying solely on patient charts for data collection may introduce biases in information, which can potentially skew the results. The absence of standardized follow-up can reduce this study’s validity and applicability to broader patient populations.

Conclusions

Although revisions after previous surgery for GERD or PEH are associated with a relatively high rate of complications, overall patient satisfaction and symptom improvement was high. A radiological recurrence of hiatal herniation was common after surgery, but did not translate into a high rate of reoperations. Revisional surgery at the esophageal hiatus is a complex procedure that should be performed at centers which routinely perform reconstructive techniques at the gastroesophageal junction.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://aoe.amegroups.com/article/view/10.21037/aoe-24-21/rc

Data Sharing Statement: Available at https://aoe.amegroups.com/article/view/10.21037/aoe-24-21/dss

Peer Review File: Available at https://aoe.amegroups.com/article/view/10.21037/aoe-24-21/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoe.amegroups.com/article/view/10.21037/aoe-24-21/coif). The authors have no conflicts of interests to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The use of data was in agreement with Oslo University Hospital Data Protection Officer (22/09352) and the need for informed consent was waived in accordance with institutional guidelines.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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