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Surgical Endoscopy

, Volume 31, Issue 12, pp 5327–5341 | Cite as

What are the differences in the outcome of laparoscopic axial (I) versus paraesophageal (II–IV) hiatal hernia repair?

  • F. Köckerling
  • Y. Trommer
  • K. Zarras
  • D. Adolf
  • B. Kraft
  • D. Weyhe
  • R. Fortelny
  • C. Schug-Paß
Open Access
Article

Abstract

Introduction

Comparison of elective laparoscopic repair of axial vs paraesophageal hiatal hernias reveals relevant differences in both the patient collectives and the complexity of the procedures.

Materials and methods

The present uni- and multivariable analysis of data from the Herniamed Registry compares the outcome for 2047 (67.3%) (type I) axial with 996 (32.7%) (types II–IV) paraesophageal primary hiatal hernias following laparoscopic repair.

Results

Compared with the patients with axial hiatal hernias, patients with paraesophageal hiatal hernia were nine years older, had a higher ASA score (ASA III/IV: 34.8 vs 13.7%; p < 0.001), and more often at least one risk factor (38.8 vs 21.4%; p < 0.001). This led in the univariable analysis to significantly more general postoperative complications (6.0 vs 3.0%; p < 0.001). Reflecting the greater complexity of the procedures used for laparoscopic repair of paraesophageal hiatal hernias, significantly higher intraoperative organ injury rates (3.7 vs 2.3%; p = 0.033) and higher postoperative complication-related reoperation rates (2.1 vs 1.1%; p = 0.032) were identified. Univariable analysis did not reveal any significant differences in the recurrence and pain rates on one-year follow-up. Multivariable analysis did not find any evidence that the use of a mesh had a significant influence on the recurrence rate.

Conclusion

Surgical repair of paraesophageal hiatal hernia calls for an experienced surgeon as well as for corresponding intensive medicine competence because of the higher risks of general and surgical postoperative complications.

Keywords

Hiatal hernia Fundoplication Hiatoplasty Axial hiatal hernia Paraesophageal hiatal hernia 

Four anatomic patterns of hiatal hernia can be recognized. Axial or sliding (type I) hernia, in which the gastroesophageal junction migrates into the thorax, is the most common type of hiatal hernia (95%) and may predispose to gastroesophageal reflux [1]. Type II represents a true paraesophageal hernia with herniation of the gastric fundus anterior to a normally positioned esophagogastric junction [1]. Type III, with both elements of types I and II hiatal hernia, tends to be large with more than 50% of the stomach within the mediastinal sac [1]. In type IV hernias, the stomach, sometimes with other viscera such as the colon or spleen, migrates completely in the hernia sac, which may result in an “upside-down stomach” [1]. Patients with an axial/sliding or type I hernia and long-term treatment of gastroesophageal reflux disease and continuous reduced quality of life, persistent troublesome symptoms, and/or progression of disease despite adequate proton pump inhibitor therapy in dosage and intake are the best candidates for surgery [2]. Although paraesophageal hernias types II–IV account for only 5% of all hiatal hernias, their detection is important because of potentially life-threatening complications, such as obstruction, acute dilatation, perforation, or bleeding of the stomach mucosa [1]. In essence, no conventional options are available for the treatment of paraesophageal hernia, so surgical repair is recommended for relief of symptoms [1].

Laparoscopic hiatal hernia repair is as effective as open transabdominal repair, with a reduced rate of perioperative morbidity and with shorter hospital stays. It is the preferred approach for the majority of hiatal hernias [3, 4, 5, 6]. Laparoscopic posterior fundoplication is given preference over laparoscopic anterior fundoplication due to a lower recurrence rate [7] in the treatment of gastroesophageal reflux disease. Thirteen randomized controlled trials with 1564 patients showed for Toupet versus Nissen fundoplication significantly lower rates of adverse results involving dysphagia, gas-bloat syndrome, inability to belch, and reoperation due to severe dysphagia [8, 9]. Mesh application should be considered for large hiatal hernia repair because it reduces recurrences, at least in the midterm. Overall, procedure-related complications and mortality do not seem to be increased despite potential mesh-associated complications [10, 11, 12, 13, 14, 15, 16, 17].

In the literature, there is only one publication with a large case series which compares the patient collective, treatment, and the outcome of laparoscopic repair of type I hiatal hernias with those of paraesophageal hiatal hernias (types II–IV) [18]. In that study, most of the complications occurred in patients with paraesophageal compared with axial hernia (10 vs 1%, respectively) [18]. This variation reflects significant differences between patients with axial hiatal hernia, and gastroesophageal reflux disease, and those with paraesophageal hernia; it also highlights the increased complexity of the laparoscopic repair procedure used for paraesophageal hernia [18]. Based on data from the Herniamed Hernia Registry, this paper now explores the differences between these patients in terms of demographic characteristics, treatment, and outcome.

Materials and methods

The Herniamed quality assurance study is a multicenter, internet-based hernia register [19] into which 577 participating hospitals and surgeons engaged in private practice (Herniamed Study Group) in Germany, Austria, and Switzerland (status: October 10, 2016) have entered data prospectively on their patients who had undergone routine surgery and signed an informed consent agreeing to participate. As part of the information provided to patients regarding participation in the Herniamed Quality Assurance Study, all patients are informed that the treating hospital would like to be informed about any problems occurring after the operation and that the patient has the opportunity to attend for clinical examination. All postoperative complications occurring up to 30 days after surgery are recorded. On one-year follow-up, postoperative complications are once again reviewed when the general practitioners and patients complete a questionnaire. On one-year follow-up, general practitioners and patients are also asked about any recurrent symptoms, pain at rest, pain on exertion, and chronic pain requiring treatment. If recurrent symptoms or chronic pain are reported by the general practitioners or patients, patients can be requested to attend for clinical examination or radiologic tests. A recent publication has provided impressive evidence of the role of patient-reported outcomes in hernia surgery [20]. The present analysis compares the prospective data collected for all patients with a hiatal hernia (types I–IV) and laparoscopic repair. Inclusion criteria were minimum age of 16 years, primary elective laparoscopic operation, fundoplication or fundophrenicopexy, and availability of data on one-year follow-up. In total, 3043 patients were enrolled from 197 participating institutions with mean number of 15.4 (range 1–199) cases between September 1, 2009 and September 1, 2015 (Fig. 1). Of these patients, 2047 (67.3%) had an axial/sliding (type I) and 996 (32.7%) a paraesophageal (types II–IV) hiatal hernia (Table 1). No details of the diagnostic method used for classification of hernia type were included in the registry. The demographic parameters included age (years), gender, symptoms, ASA score (I, II, III, IV), body mass index (BMI) (kg/m2), and risk factors (COPD, diabetes, aneurysms, cortisone, immunosuppression, etc.). Risk factors were dichotomized, i.e., “yes” if a risk factor was positive and “no” otherwise.
Fig. 1

Flowchart of patient inclusion

Table 1

Distribution of cases based on hiatal hernia type

Type

N

%

Axial I

2047

67.3

Paraesophageal II

263

8.6

Mixed III

279

9.2

Upside-down IV

454

14.9

Total

3043

100

The second group of categorical influence variables reflecting surgery-related parameters included defect size, operation technique (Toupet vs Nissen vs fundophrenicopexy), and hiatoplasty (suture vs mesh vs suture and mesh).

The dependent variables were intra- and postoperative complication rates, complication-related reoperation rates, recurrence rates and rates of pain at rest, pain on exertion, and chronic pain requiring treatment.

All analyses were performed with the software SAS 9.4 (SAS Institute Inc. Cary, NC, USA) and intentionally calculated to a full significance level of 5%, i.e., they were not corrected in respect of multiple tests, and each p value ≤0.05 represents a significant result. To discern differences between the groups in unadjusted analyses, Fisher’s exact test was used for categorical outcome variables, and the robust t test (Satterthwaite) for continuous variables. To rule out any confounding of data caused by different patient characteristics, the results of univariable analyses were verified via multivariable analyses in which, in addition to hiatal hernia type, other influence parameters were simultaneously reviewed.

To access influence factors in multivariable analyses, the binary logistic regression model for dichotomous outcome variables was used. Estimates for odds ratio (OR) and the corresponding 95% confidence interval based on the Wald test were given. For influence variables with more than two categories, all pairwise odds ratios were given. For age (years), the 10-year OR estimate, for BMI (kg/m2), the five-point OR, and, for defect size, the ten-point OR estimate were given. For the procedure time (min) and hernia defect size (cm2), a logarithmic transformation was applied and re-transformed mean values and ranges specified. The results of multivariable analyses are presented in tabular form, sorted by descending impact.

Results

Univariable analyses

Patients with axial hiatal hernia (type I) and reflux disease compared with patients with paraesophageal hiatal hernia (types II–IV) were on average more than nine years younger, had a somewhat lower BMI, markedly shorter procedure time, and smaller hernia defects (Table 2).
Table 2

Comparison of mean age, mean BMI, mean procedure time, and mean defect size between axial and paraesophageal hiatal hernia types

  

Type I

Types II–IV

p

Age (years)

Mean ± STD

55.4 ± 14.0

65.0 ± 12.5

<.001

BMI

Mean ± STD

27.7 ± 4.3

28.7 ± 4.8

<.001

Duration of procedure (min)a

MW (range)

83.0 (81.5; 84.6)

104.4 (102.8; 106.0)

<.001

Defect size (cm2)a

MW (range)

12.6 (10.5; 14.8)

21.5 (19.2; 23.7)

<.001

aLogarithmic transformation; indication of re-transformed mean and range of dispersion (mean-STD; mean + STD)

As regards the axial hiatal hernias (type I), Toupet fundoplication (56.2 vs 41.0%; p < 0.001) as well as hiatoplasty with suture alone were performed more often (81.5 vs 64.1%; p < 0.001) (Table 3). Besides, axial hiatal hernia was associated with lower ASA scores and a greater number of male patients (Table 3). On the other hand, for the paraesophageal hiatal hernias (types II–IV), more cases of fundophrenicopexy (19.5 vs 2.5%; p < 0.001) and of hiatal closure with suture and mesh (35.2 vs 17.7%; p < 0.001) were observed (Table 3). For the paraesophageal hernias (types II–IV), higher ASA scores (ASA III/IV: 34.8 vs 13.7%; p < 0.001) as well as more female patients (67.2 vs 56.2%; p < 0.001) were identified. Besides, the proportion of patients with at least one risk factor was significantly higher for paraesophageal hernias at 30.8 vs 21.4% (p < 0.001). In terms of symptoms, only reflux (89.3 vs 66.0%; p < 0.001) was more common for axial hiatal hernias (Table 3).
Table 3

Comparison of demographic parameters, risk factors, and surgery-related parameters between axial and paraesophageal hiatal hernia types

 

Type I

Types II–IV

p

n

%

n

%

Procedure

 Fundophrenicopexy

51

2.49

194

19.48

<.001

 Nissen

845

41.28

394

39.56

 Toupet

1151

56.23

408

40.96

Hiatal repair technique

 Suture

1669

81.53

638

64.06

<.001

 Suture and mesh

363

17.73

351

35.24

 Mesh

15

0.73

7

0.70

ASA score

 I

464

22.67

88

8.84

<.001

 II

1302

63.61

561

56.33

 III

277

13.5

339

34.0

 IV

4

0.20

8

0.80

Gender

 Male

898

43.87

327

32.83

<.001

 Female

1149

56.13

669

67.17

Risk factor

 Total

  Yes

437

21.35

307

30.82

<.001

  No

1610

78.65

689

69.18

 COPD

  Yes

168

8.21

137

13.76

<.001

  No

1879

91.79

859

86.24

 Diabetes

  Yes

76

3.71

72

7.23

<.001

  No

1971

96.29

924

92.77

 Aortic aneurysm

  Yes

5

0.24

8

0.80

0.036

  No

2042

99.76

988

99.20

 Immunosuppression

  Yes

7

0.34

10

1.00

0.034

  No

2040

99.66

986

99.00

 Corticoids

  Yes

20

0.98

19

1.91

0.039

  No

2027

99.02

977

98.09

 Smoking

  Yes

162

7.91

58

5.82

0.037

  No

1885

92.09

938

94.18

 Coagulopathy

  Yes

13

0.64

16

1.61

0.015

  No

2034

99.36

980

98.39

 Antiplatelet medication

  Yes

62

3.03

68

6.83

<.001

  No

1985

96.97

928

93.17

 Anticoagulation therapy

  Yes

21

1.03

15

1.51

0.284

  No

2026

98.97

981

98.49

Symptoms

 Reflux

  Yes

1827

89.25

657

65.96

<.001

  No

220

10.75

339

34.04

 Regurgitation

  Yes

491

23.99

275

27.61

0.033

  No

1556

76.01

721

72.39

 Dysphagia

  Yes

392

19.15

454

45.58

<.001

  No

1655

80.85

542

54.42

 Pain

  Yes

763

37.27

484

48.59

<.001

  No

1284

62.73

512

51.41

 Anemia/bleeding

  Yes

81

3.96

212

21.29

<.001

  No

1966

96.04

784

78.71

 Affection of lung

  Yes

163

7.96

159

15.96

<.001

  No

1884

92.04

837

84.04

On overall assessment of the intraoperative complication rates no difference was detected between the axial (type I) and paraesophageal hiatal hernias (types II–IV) (Table 4). However, organ injuries were seen significantly more often with paraesophageal hiatal hernias (types II–IV) (3.7 vs 2.3%; p = 0.033).
Table 4

Comparison of intraoperative, postoperative, and general complications and 1-year follow-up outcome between axial and paraesophageal hiatal hernia types

 

Type I

Types II–IV

p

n

%

n

%

Intraoperative complications

 Total

  Yes

60

2.93

41

4.12

0.105

  No

1987

97.07

955

95.88

Intraop.: bleeding

  Yes

28

1.37

14

1.41

1.000

  No

2019

98.63

982

98.59

 Injuries

  Total

   Yes

47

2.30

37

3.71

0.033

  No

2000

97.70

959

96.29

  Esophagus

   Yes

1

0.05

0

0.00

1.000

   No

2046

99.95

996

100.0

  Stomach

   Yes

2

0.10

5

0.50

0.042

   No

2045

99.90

991

99.50

  Bowel

   Yes

0

0.00

1

0.10

0.327

   No

2047

100.0

995

99.90

 

  Liver

   Yes

8

0.39

3

0.30

1.000

   No

2039

99.61

993

99.70

  Spleen

   Yes

8

0.39

7

0.70

0.274

   No

2039

99.61

989

99.30

  Vessel

   Yes

3

0.15

2

0.20

0.665

   No

2044

99.85

994

99.80

  Others (pleura opening, diaphragm injury)

   Yes

26

1.27

21

2.11

0.086

   No

2021

98.73

975

97.89

Postoperative complications (Clavien–Dindo classification grades I–III)

 Total

  Yes

24

1.17

20

2.01

0.076

  No

2023

98.83

976

97.99

 Bleeding

  Yes

3

0.15

5

0.50

0.123

  No

2044

99.85

991

99.50

 Esophageal perforation

  Yes

10

0.49

5

0.50

1.000

  No

2037

99.51

991

99.50

 Infection

  Yes

3

0.15

6

0.60

0.067

  No

2044

99.85

990

99.40

 Stomach perforation

  Yes

5

0.24

0

0.00

0.180

No

2042

99.76

996

100.0

 Wound healing disorder

  Yes

3

0.15

6

0.60

0.067

  No

2044

99.85

990

99.40

 Ileus

  Yes

0

0.00

2

0.20

0.107

  No

2047

100.0

994

99.80

General complications

 Total

  Yes

61

2.98

60

6.02

<.001

  No

1986

97.02

936

93.98

 Fever

  Yes

6

0.29

7

0.70

0.137

  No

2041

99.71

989

99.30

 Urinary voiding problems

  Yes

4

0.20

5

0.50

0.163

  No

2043

99.80

991

99.50

 Diarrhea

  Yes

1

0.05

1

0.10

0.548

  No

2046

99.95

995

99.90

 Gastritis

  Yes

1

0.05

1

0.10

0.548

  No

2046

99.95

995

99.90

 Thrombosis

  Yes

2

0.10

0

0.00

1.000

  No

2045

99.90

996

100.0

 Pulmonary embolism

  Yes

1

0.05

3

0.30

0.106

  No

2046

99.95

993

99.70

 Pleural effusion

  Yes

10

0.49

17

1.71

0.001

  No

2037

99.51

979

98.29

 Pneumonia

  Yes

6

0.29

12

1.20

0.004

  No

2041

99.71

984

98.80

 COPD (clinical exacerbation)

  Yes

7

0.34

7

0.70

0.251

  No

2040

99.66

989

99.30

 Cardiac insufficiency

  Yes

4

0.20

10

1.00

0.003

  No

2043

99.80

986

99.00

 Coronary heart disease

  Yes

5

0.24

4

0.40

0.486

  No

2042

99.76

992

99.60

 Myocardial infarction

  Yes

1

0.05

2

0.20

0.251

  No

2046

99.95

994

99.80

 Renal insufficiency

  Yes

2

0.10

0

0.00

1.000

  No

2045

99.90

996

100.0

 Hypertensive crisis

  Yes

3

0.15

4

0.40

0.226

  No

2044

99.85

992

99.60

Complication-related reoperation (Clavien–Dindo classification grade III)

 Yes

22

1.07

21

2.11

0.032

 No

2025

98.93

975

97.89

Recurrence on 1-year follow-up

 Yes

105

5.13

40

4.02

0.204

 No

1942

94.87

956

95.98

Pain on exertion on 1-year follow-up

 Yes

222

10.85

102

10.24

0.661

 No

1825

89.15

894

89.76

Pain at rest on 1-year follow-up

 Yes

180

8.79

86

8.63

0.945

 No

1867

91.21

910

91.37

Pain requiring treatment on 1-year follow-up

 Yes

166

8.11

71

7.13

0.387

 No

1881

91.89

925

92.87

As regards the postoperative surgical complications, no significant difference was detected between the axial (type I) and paraesophageal hiatal hernias (types II–IV). However, more complication-related reoperations (Clavien–Dindo classification grade III) were noted for paraesophageal compared with axial hernias (2.1 vs 1.1%; p = 0.032) (Table 4). The main reasons for this were esophageal and gastric injuries, secondary bleeding, and abscesses.

For the general postoperative complications, a highly significant difference to the disadvantage of the paraesophageal hernias (types II–IV) was detected at 6.0 vs 3.0% (p < 0.001) (Table 4). Since one-year follow-up was a precondition for patient selection, analysis did not take account of deaths. In the hiatal hernia operation group up to 1 September, 2015, including among patients without one-year follow-up (n = 1.086) (Fig. 1), one death occurred in the axial (type I) hiatal hernia group (one out of 2792; 0.04%) and three deaths in the paraesophageal (types II–IV) group (three out of 1.333; 0.22%).

On one-year follow-up, no significant difference was identified in the recurrence rate or in the rates of pain at rest, on exertion or requiring treatment (Table 4). An additional analysis of patient outcome in relation to the individual hospital’s case load showed no significant differences for a case load of 1–49, 50–99, and ≥100 (Table 5).
Table 5

Outcome of patients depending on hospitals case load

 

1–49 OPs

50–99 OPs

>100 OPs

 

n

%

n

%

n

%

p

Intraoperative complications

 Yes

51

3.46

10

2.56

40

3.39

0.701

 No

1421

96.54

381

97.44

1140

96.61

Postoperative complications (Clavien–Dindo classification grade I–III)

 Yes

24

1.63

8

2.05

12

1.02

0.199

 No

1448

98.37

383

97.95

1168

98.98

General complications

 Yes

63

4.28

10

2.56

48

4.07

0.299

 No

1409

95.72

381

97.44

1132

95.93

Recurrence on 1-year follow-up

 Yes

82

5.57

11

2.81

52

4.41

0.053

 No

1390

94.43

380

97.19

1128

95.59

Multivariable analysis

Intraoperative complications

The results of the model used for analysis of influencing factors for intraoperative complications are illustrated in Fig. 2 (model matching: p < 0.001). The risk of intraoperative complications was primarily influenced by the ASA score (p = 0.001). A lower ASA score (I vs II: 0.195 [0.076; 0.497]; I vs III/IV: 0.144 [0.050; 0.409] reduced the risk of intraoperative complications. Likewise, age and operative technique had a significant influence on the intraoperative complications. Accordingly, by comparison, a 10-year-older patient had a significantly lower intraoperative complication risk (10-year OR 0.799 [0.676; 0.944]). On the other hand, the complication risk was increased when the Nissen compared with the Toupet method was used (OR 1.849 [1.202; 2.842]; p = 0.005).
Fig. 2

Forest plot: Multivariable analysis of influencing factors for intraoperative complications in hiatal hernia repair

Surgical postoperative complications

Model matching for analysis of the postoperative complications, which reflects the suitability of the influence parameters to explain the outcome variable scores, was not significant (p = 0.335). As such, there was no evidence of the individual variables having significantly influenced the postoperative complication rate.

Complication-related reoperations

Model matching for complication-related reoperations, which reflects the suitability of the influence parameters to explain the outcome variable scores, was not significant (p = 0.249). As such, there was no evidence of the individual variables having significantly influenced the complication-related reoperation rate.

General postoperative complications

The results of the model used for analysis of the general postoperative complication rate are shown in Fig. 3 (model matching: p < 0.001). Onset of general postoperative complications was primarily affected by the presence of risk factors (p = 0.006). The presence of at least one risk factor increased the general postoperative complication risk (OR 1.767 [1.180; 2.646]). Older patients, too, had an increased risk of general postoperative complications (10-year OR 1.255 [1.055; 1.494]). Conversely, the general postoperative complication risk was reduced in cases of hiatoplasty with suture alone compared with suture and mesh (OR 0.552 [0.371; 0.822]; p = 0.003).
Fig. 3

Forest plot: Multivariable analysis of influencing factors for general postoperative complications following hiatal hernia repair

Recurrence on one-year follow-up

Model matching for recurrence on one-year follow-up, which reflects the suitability of the influence parameters to explain the outcome variable scores, was not significant (p = 0.180). As such, there was no evidence of the individual variables having significantly influenced the recurrence rate.

Pain at rest on one-year follow-up

The results of the model used for analysis of pain at rest on one-year follow-up are summarized subsequently (model matching: p = 0.002). This was significantly impacted by risk factors, gender, and BMI. The rate was increased if there was at least one risk factor (OR 1.512 [1.135; 2.014]; p = 0.005). On the other hand, men (OR 0.664 [0.499; 0.864]; p = 0.005) and patients with higher BMI (5-point OR 0.821 [0.709; 0.951; p = 0.009) had a lower risk of pain at rest.

Pain on exertion on follow-up

Model matching for pain on exertion on one-year follow-up, which reflects the suitability of the influence parameters to explain the outcome variable scores, was not significant (p = 0.154). As such, there was no evidence of the individual variables having significantly influenced the pain on exertion rate.

Chronic pain requiring treatment on one-year follow-up

The results of the model used for analysis of chronic pain requiring treatment are summarized subsequently (model matching: p = 0.022). These, too, were significantly influenced by risk factors, gender, and BMI. The presence of at least one risk factor (OR 1.515 [1.119; 2.051]; p = 0.007) increased the risk of chronic pain requiring treatment. On the other hand, men (OR 0.712 [0.527; 0.961]; p = 0.026) and patients with higher BMI (5-point OR 0.839 [0.718; 0.981]; p = 0.028) had a lower risk of chronic pain requiring treatment.

Discussion

This paper analyzes prospective data from the Herniamed Registry for 3043 patients with primary, elective, and laparoscopic repair of a hiatal hernia. Only patients with complete one-year follow-up results were included in the analysis. Since the outcome for patients with axial hiatal hernia and reflux disease differs greatly from that of patients with paraesophageal hiatal hernia, due to divergent patient characteristics and complexity of the repair technique, the two patient collectives were compared in the analysis presented here.

First of all, significant differences were noted in the patient characteristics. Patients with paraesophageal hernia were on average almost 10 years older, had a somewhat higher BMI, larger hernia defect, and tended more often to be female. The chief determinant for onset of significantly more perioperative complications among patients with paraesophageal hiatal hernia was a higher proportion of patients with ASA scores III/IV (34.8 vs 13.7%; p < 0.0001) and of patients with risk factors (30.8 vs 21.4%; p < 0.001).

Both these factors help to explain the significantly more frequent onset of general postoperative complications after repair of paraesophageal compared with axial hiatal hernias (6.0 vs 3.0%; p < 0.001). Multivariable analysis clearly demonstrates that the presence of at least one risk factor and higher age significantly increases the risk of general postoperative complications.

The greater complexity of the procedures used for paraesophageal hiatal hernia repair is reflected in a significantly higher intraoperative organ injury rate (3.7 vs 2.3%; p = 0.033) and significantly higher rate of complication-related reoperations (2.1 vs 1.1%; p = 0.033) compared with axial hiatal hernias.

The recurrence rate on one-year follow-up for patients after laparoscopic repair of axial hiatal hernias was 5.1% and for paraesophageal hiatal hernias it was 4.0% (p = 0.204), with the proportion of mesh-augmented hiatoplasties being significantly higher (35.2 vs 17.7%; p < 0.001) for paraesophageal hiatal hernias. The indication for mesh use was decided by the individual surgeon or hospital. The specific reasons for using a mesh were not documented.

Multivariable analysis did not find any evidence that the use of a mesh or other factors had a significant influence on the recurrence rate on one-year follow-up. That concords with the meta-analysis of four randomized controlled trials with 406 patients by Memom et al. [16]. It can only be speculated whether the significantly more frequent use of meshes for types II–IV hiatal hernias with highly significantly larger hiatal defects had led to a non-significant difference in the recurrence rate. In less than 1% of cases, only a mesh and no suture was used for hiatal closure, as reported in the literature [21]. That practice is not recommended in the guidelines [4].

There was no significant difference in the rates of pain at rest, pain on exertion, or pain requiring treatment on one-year follow-up between the patients after laparoscopic repair of axial (type I) vs paraesophageal (types II–IV) hiatal hernia.

Multivariable analysis demonstrates that the risk of pain at rest and pain requiring treatment was higher in the presence of risk factors, and was lower among men and in patients with higher BMI.

In summary, patients with elective laparoscopic repair of primary paraesophageal (types II–IV) vs axial (type I) hiatal hernia were found to have a significantly higher risk of general postoperative complications because of higher age and higher ASA score as well as the higher proportion of patients with at least one risk factor. Reflecting the greater complexity of laparoscopic paraesophageal (types II–IV) hiatal hernia repair procedures, there is greater likelihood of significantly more intraoperative organ injuries and postoperative complication-related reoperations. Accordingly, laparoscopic procedures for repair of paraesophageal (types II–IV) hiatal hernias should only be undertaken by experienced surgeons. Because of the higher risk of general postoperative complications, corresponding intensive medicine resources are needed.

Notes

Acknowledgements

Ferdinand Köckerling—Grants to fund the Herniamed Registry from Johnson & Johnson, Norderstedt, Karl Storz, Tuttlingen, pfm medical, Cologne, Dahlhausen, Cologne, B Braun, Tuttlingen, MenkeMed, Munich and Bard, Karlsruhe.

Compliance with ethical standards

Disclosures

Y. Trommer, K. Zarras, D. Adolf, B. Kraft, D. Weyhe, R. Fortelny, C. Schug-Paß have no conflicts of interest or financial ties to disclose.

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Copyright information

© The Author(s) 2017

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  • F. Köckerling
    • 1
  • Y. Trommer
    • 2
  • K. Zarras
    • 3
  • D. Adolf
    • 4
  • B. Kraft
    • 5
  • D. Weyhe
    • 6
  • R. Fortelny
    • 7
  • C. Schug-Paß
    • 1
  1. 1.Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical SchoolVivantes HospitalBerlinGermany
  2. 2.Department of General, Visceral and Minimally Invasive SurgeryHelios HospitalGifhornGermany
  3. 3.Department of Visceral, Minimally Invasive and Oncologic SurgeryMarien HospitalDüsseldorfGermany
  4. 4.StatConsult GmbHMagdeburgGermany
  5. 5.Department of General and Visceral SurgeryDiakonie HospitalStuttgartGermany
  6. 6.Department of General and Visceral Surgery, Pius HospitalUniversity Hospital of Visceral SurgeryOldenburgGermany
  7. 7.Department of General, Visceral and Oncologic SurgeryWilhelminenhospitalViennaAustria

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