Hiatal hernia

Hiatal hernia (HH) is such a common endoscopic finding (reported prevalence 20 per cent) that it is, by definition, a normal variant and not a disease1. HH denotes the upward displacement of the stomach or other organs into the thoracic cavity via the diaphragmatic hiatus, and is classified into four subtypes depending on the position of the gastro-oesophageal junction (GOJ) and whether other organs are involved. The distance between the GOJ (the upper limit of the gastric folds) and the diaphragmatic incisura, the impression of the diaphragmatic hiatus on the gastric wall, also called the ‘pinch', gives an idea of the size of HH’, gives the starting point for measurement of distance (GOJ) but not the end point. Barrett’s oesophagus and/or wide crurae can make the assessment of the junction difficult. Contrast swallow tests may be useful if operative management is being considered, but are not needed routinely. Oesophageal manometry is not mandatory, and can be challenging in large hiatus hernias, but may deem surgery contraindicated if there is significant dysmotility. Minor motility issues may lead the surgeon to proceed, if surgery is absolutely required, with a partial plication (Dor wrap) of the fundus or gastropexy rather than a complete (Nissen) fundoplication, but definitive evidence for any particular approach is sparse. Similarly, pH studies are not needed routinely, although it is sensible to record abnormal reflux if surgery is to be considered in patients intolerant of medical therapy or those choosing surgery to reduce the need for lifelong acid suppression. Surgery should be reserved for very selected patients with symptomatic type 2 to 4 HH only2, but the risks of recurrence (approximately one-third) and need for antacid therapy (50 per cent at least) are very high. There are few robust data comparing surgery with conservative management of asymptomatic paraoesophageal hernias. The annual risk of emergency surgery was 1.1 per cent per year, with a worrying mortality rate of 5.4 per cent (elective mortality risk 1.4 per cent), in a 1997 registry study. A 2019 National Surgical Quality Improvement Project (NSQIP) study on elective and emergency ‘complex’ paraoesophageal hernias concluded that outcomes were superior in patients suitable for a laparoscopic approach3. Emergency surgery for acute gastric volvulus can be challenging and a heavily co-morbid patient with physiological compromise may not survive protracted surgery. Acute gastric volvulus with no features of gastric necrosis may be decompressed endoscopically with nasojejunal tube placement to avoid emergency surgery. Unfit patients may benefit from the placement of a percutaneous endoscopic gastrostomy to help prevent revolving4. One controversy that has not been resolved is the question of augmenting crural repair to see whether the very high risk of recurrence after surgery could be improved. Options include use of pledgeted sutures, synthetic meshes, bioprostheses (most are not mesh but composed of decellularized animal dermis), or anatomical space fillers (ligamentum teres or left lobe of liver). Routine use of prosthetic mesh is very controversial, practice varies hugely (for example, some advocate only for large HH but others for small HH), and disadvantages include dysphagia, chronic infection, fibrosis, and the deeply worrying risks of mesh erosion and migration. Meanwhile, it appears that mesh does not prevent recurrence. A 5-year follow-up of an RCT (absorbable or non-absorbable mesh or crural suture repair only)5 found no significant difference in recurrence rates, yet (somewhat illogically) worse symptoms in the absorbable mesh group. These findings were supported by a meta-analysis (7 RCTs)6 which found no difference in short- or long-term recurrence rates for mesh repair or suture alone. As in all fields of surgery, there are those who have an opposing opinion with data to support their assertion7. Practical advice is to use prosthetic material highly selectively, when suture or other simple methods are not working for the patient. Quality-of-life measurement, in a systematic review8 of 4404 patients, found postoperative improvement in only three-quarters. That is a startling statistic for an operation designed to rearrange the anatomy to specifically improve quality of life—it is rare for elective HH surgery to improve mortality; clearly more work is needed. The limitations of reporting and standardization may have limited studies and their interpretation in the field9. Standardization of patient-reported outcome measures with quality, long-term follow-up data would be required to resurrect enthusiasm for elective HH surgery. It should be carried out only in the very symptomatic patient who is intolerant of medical therapy, and who consents to a 50 : 50 chance of being back on antacids and a 1 in 3 risk of a recurrent hernia within a decade, a 15 per cent chance of some new functional symptom (gas bloat, dysphagia, diarrhoea, satiety, etc.), and a 10 per cent perioperative morbidity risk (wound problems, respiratory tract infections, pneumothorax, incisional/port-site hernia, etc.). The authors have no funding to declare. The authors declare no conflict of interest in the writing of this editorial.