No advantage of fundoplication in paraesophageal hernia repair: a retrospective multicenter study

Abstract

Paraesophageal hernia repair often includes both gastropexy and fundoplication. The fundoplication may cause persistent side effects, and the necessity of the procedure is uncertain. This study aimed to compare gastropexy with or without fundoplication. A retrospective multicenter study was conducted from three Scandinavian hospitals. Patients, with grade III-IV hiatal hernia, who had a laparoscopic repair with total hernia sack removal, closure of hiatus, gastropexy either with or without Nissen fundoplication were included. Outcomes were per- and postoperative complications, postoperative symptom control, and recurrence. A total of 320 patient cases were included in the study (72 patients with Nissen fundoplication and 248 patients without fundoplication). Baseline variables were comparable between the two groups. We found no difference in perioperative or postoperative events, reflux control or recurrence. Median operation time differed with 49 minutes (P < 0.001) in patients with fundoplication (Median: 108 minutes, interquartile range (IQR): 88-131 minutes) compared to patients without fundoplication (59 minutes, IQR = 46-78 minutes). We also found an increased risk for second repair in the fundoplication group (OR 4.3, 95% CI 1.4-13.3). This study shows no benefits of adding a Nissen fundoplication procedure to anterior gastropexy for paraesophageal hernia repair. It was not superior compared to gastropexy alone in terms of postoperative reflux control or preventing recurrence. In contrast, the fundoplication was associated with a four-fold increase of second repair, but the study design limits firm conclusions on this matter.

Keywords: anti-reflux surgery; foregut surgery; large hiatal hernia; nissen fundoplication; paraesophageal hernia.

Fig. 1

Flow chart of patient selection according to Consort guidelines. ^*Patients operated for paraesophageal hernia between year 2018 and 2023.

Fig. 2

Multivariate Cox proportional hazards for risk factors of recurrence. Cox regression model with potential confounding variables (age, fundoplication, subacute operation, type III or IV paraesophageal hernia, Charlson Comorbidity Index score ≥ 3, postoperative complications, mesh use) entered by backward, conditional method. Variables found to be significant to the risk of hiatal hernia recurrence are (a) Clavien-dindo score ≥ 3 HR 5.6 (2.8–11.3) P < 0.001. (b) Charlson co-morbidity index ≥3: HR 2.2 (1.0–5.0) P = 0.034.

Fig. 3

Kaplan Meyer analysis of hiatal hernia recurrence stratified by gastropexy with or without fundoplication.