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. 2023 Jun;37(6):4555-4565.
doi: 10.1007/s00464-023-09933-8. Epub 2023 Feb 27.

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

Stephan Gerdes  1 , Sebastian F Schoppmann  2 , Luigi Bonavina  3 , Nicholas Boyle  4 , Beat P Müller-Stich  5 , Christian A Gutschow  6 ; Hiatus Hernia Delphi Collaborative Group
Collaborators, Affiliations

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

Stephan Gerdes et al. Surg Endosc. 2023 Jun.

Abstract

Aims: There is considerable controversy regarding optimal management of patients with paraesophageal hiatus hernia (pHH). This survey aims at identifying recommended strategies for work-up, surgical therapy, and postoperative follow-up using Delphi methodology.

Methods: We conducted a 2-round, 33-question, web-based Delphi survey on perioperative management (preoperative work-up, surgical procedure and follow-up) of non-revisional, elective pHH among European surgeons with expertise in upper-GI. Responses were graded on a 5-point Likert scale and analyzed using descriptive statistics. Items from the questionnaire were defined as "recommended" or "discouraged" if positive or negative concordance among participants was > 75%. Items with lower concordance levels were labelled "acceptable" (neither recommended nor discouraged).

Results: Seventy-two surgeons with a median (IQR) experience of 23 (14-30) years from 17 European countries participated (response rate 60%). The annual median (IQR) individual and institutional caseload was 25 (15-36) and 40 (28-60) pHH-surgeries, respectively. After Delphi round 2, "recommended" strategies were defined for preoperative work-up (endoscopy), indication for surgery (typical symptoms and/or chronic anemia), surgical dissection (hernia sac dissection and resection, preservation of the vagal nerves, crural fascia and pleura, resection of retrocardial lipoma) and reconstruction (posterior crurorrhaphy with single stitches, lower esophageal sphincter augmentation (Nissen or Toupet), and postoperative follow-up (contrast radiography). In addition, we identified "discouraged" strategies for preoperative work-up (endosonography), and surgical reconstruction (crurorrhaphy with running sutures, tension-free hiatus repair with mesh only). In contrast, many items from the questionnaire including most details of mesh augmentation (indication, material, shape, placement, and fixation technique) were "acceptable".

Conclusions: This multinational European Delphi survey represents the first expert-led process to identify recommended strategies for the management of pHH. Our work may be useful in clinical practice to guide the diagnostic process, increase procedural consistency and standardization, and to foster collaborative research.

Keywords: Delphi survey; Fundoplication; Hiatus hernia; Mesh; Paraesophageal hernia; Surgical technique.

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Conflict of interest statement

Christian A. Gutschow received consulting fees and/or honoraria from Medtronic, B. Braun, BD/Bard medical and Micro-Tech Europe GmbH, and third party funding for his institution from B.Braun. Stephan Gerdes, Sebastian F. Schoppmann and Beat P. Müller-Stich have no conflict of interest or financial ties to disclose. Nicholas Boyle received consulting fees and/or honoraria from Johnson & Johnson and BD/Bard medical. Luigi Bonavina received third party funding for his institution from BD/Bard medical and participated on data safety boards with BD/Bard medical and Johnson & Johnson.

Figures

Fig. 1
Fig. 1
Expert recommendations for diagnostic work-up for pHH
Fig. 2
Fig. 2
Expert recommendations for techniques for hiatoplasty in pHH repair
Fig. 3
Fig. 3
Expert agreements for indications for LES augmentation in pHH repair
Fig. 4
Fig. 4
Expert recommendations for antireflux procedures in pHH repair
Fig. 5
Fig. 5
Expert recommended diagnostic procedures to exclude recurrence after pHH repair
See this image and copyright information in PMC

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