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EAES Multidisciplinary Rapid Guideline: systematic review, meta-analysis, GRADE assessment and evidence-informed recommendations on the surgical management of paraesophageal hernias

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New evidence has emerged since latest guidelines on the management of paraesophageal hernia, and guideline development methodology has evolved. Members of the European Association for Endoscopic Surgery have prioritized the management of paraesophageal hernia to be addressed by pertinent recommendations.


To develop evidence-informed clinical practice recommendations on paraesophageal hernias, through evidence synthesis and a structured evidence-to-decision framework by an interdisciplinary panel of stakeholders.


We performed three systematic reviews, and we summarized and appraised the certainty of the evidence using the GRADE methodology. A panel of general and upper gastrointestinal surgeons, gastroenterologists and a patient advocate discussed the evidence in the context of benefits and harms, the certainty of the evidence, acceptability, feasibility, equity, cost and use of resources, moderated by a Guidelines International Network-certified master guideline developer and chair. We developed the recommendations in a consensus meeting, followed by a modified Delphi survey.


The panel suggests surgery over conservative management for asymptomatic/minimally symptomatic paraesophageal hernias (conditional recommendation), and recommends conservative management over surgery for asymptomatic/minimally symptomatic paraesophageal hernias in frail patients (strong recommendation). Further, the panel suggests mesh over sutures for hiatal closure in paraesophageal hernia repair, fundoplication over gastropexy in elective paraesophageal hernia repair, and gastropexy over fundoplication in patients who have cardiopulmonary instability and require emergency paraesophageal hernia repair (conditional recommendation). A strong recommendation means that the proposed course of action is appropriate for the vast majority of patients. A conditional recommendation means that most patients would opt for the proposed course of action, and joint decision-making of the surgeon and the patient is required. Accompanying evidence summaries and evidence-to-decision frameworks should be read when using the recommendations. This guideline applies to adult patients with moderate to large paraesophageal hernias type II to IV with at least 50% of the stomach herniated to the thoracic cavity. The full guideline with user-friendly decision aids is available in


An interdisciplinary panel provides recommendations on key topics on the management of paraesophageal hernias using highest methodological standards and following a transparent process.

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The authors acknowledge the contribution of Prof. Peter Grimminger for his contribution in prioritizing outcomes and defining minimal important differences.


This clinical practice guideline has been developed under the auspice of the European Association for Endoscopic Surgery (EAES). It is intended to be used primarily by health professionals (e.g., surgeons, anesthetists, physicians) and to assist in making informed clinical decisions on diagnostic measures and therapeutic management. It is also intended to inform individual practice of allied health professionals (e.g., surgical nurses, dieticians, physical rehabilitation therapists, psychologists); to inform strategic planning and resource management by health care authorities (e.g., regional and national authorities, health care institutions, hospital administration authorities); and to inform patients wishing to obtain an overview of the condition of interest and its management. The use of recommendations contained herein must be informed by supporting evidence accompanying each recommendation and by research evidence that might not have been published by the time of writing the present document. Users must thus base their actions informed by newly published evidence at any given point in time. The information in the guideline should not be relied upon as being complete or accurate, nor should it be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. With the rapid development of scientific knowledge, new evidence may emerge between the time the guideline is developed and when it is published or read. The guideline is not continually updated and may not reflect the most recent evidence. The guideline addresses only the topics specifically identified therein and is not applicable to other interventions, diseases, or stages of diseases. This guideline does not mandate any particular course of medical care. Further, the guideline is not intended to substitute the independent professional judgment of the treating provider, as the guideline does not necessarily account for individual variation among patients. Even if evidence on a topic suggests a specific diagnostic and/or treatment action, users and especially health professionals may need to decide against the suggested or recommended action in view of circumstances related to patient values, preferences, co-morbidities and disease characteristics; available human, financial and material resources; and healthcare infrastructures. EAES provides this guideline on an “as is” basis, and makes no warranty, express or implied, regarding the guideline.


This project was funded by the European Association for Endoscopic Surgery. The funding body had no influence on the development of this rapid guideline or its protocol. There is no grant number linked to this research.

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Correspondence to Stavros A. Antoniou.

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Sheraz R. Markar, Nainika Menon, Nadia Guidozzi, Katerina-Maria Kontouli, Dimitrios Mavridis, Alexandros Andreou, Felix Berlth, Luigi Bonavina, Alfred Cushieri, Lana Fourie, James Gossage, Caroline Gronnier, Eric J. Hazebroek, Sheila Krishnadath, Donald E. Low, Mimi McCord, Roos E. Pouw, David I. Watson, Francesco Maria Carrano, Monica Ortenzi and Stavros A. Antoniou declare no direct conflicts of interest related to this work. Indirect conflicts of external advisors were documented and managed as per Guidelines International Network Standards. Detailed conflict of interest statements of all contributors can be found in A patient version of this guideline is available in Supplementary File 1.

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Markar, S.R., Menon, N., Guidozzi, N. et al. EAES Multidisciplinary Rapid Guideline: systematic review, meta-analysis, GRADE assessment and evidence-informed recommendations on the surgical management of paraesophageal hernias. Surg Endosc 37, 9013–9029 (2023).

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