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Management of symptomatic, asymptomatic, and recurrent hiatal hernia: a systematic review and meta-analysis

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A Correction to this article was published on 26 April 2024

This article has been updated

Abstract

Background

The surgical management of hiatal hernia remains controversial. We aimed to compare outcomes of mesh versus no mesh and fundoplication versus no fundoplication in symptomatic patients; surgery versus observation in asymptomatic patients; and redo hernia repair versus conversion to Roux-en-Y reconstruction in recurrent hiatal hernia.

Methods

We searched PubMed, Embase, CINAHL, Cochrane Library and the ClinicalTrials.gov databases between 2000 and 2022 for randomized controlled trials (RCTs), observational studies, and case series (asymptomatic and recurrent hernias). Screening was performed by two trained independent reviewers. Pooled analyses were performed on comparative data. Risk of bias was assessed using the Cochrane Risk of Bias tool and Newcastle Ottawa Scale for randomized and non-randomized studies, respectively.

Results

We included 45 studies from 5152 retrieved records. Only six RCTs had low risk of bias. Mesh was associated with a lower recurrence risk (RR = 0.50, 95%CI 0.28, 0.88; I2 = 57%) in observational studies but not RCTs (RR = 0.98, 95%CI 0.47, 2.02; I2 = 34%), and higher total early dysphagia based on five observational studies (RR = 1.44, 95%CI 1.10, 1.89; I2 = 40%) but was not statistically significant in RCTs (RR = 3.00, 95%CI 0.64, 14.16). There was no difference in complications, reintervention, heartburn, reflux, or quality of life. There were no appropriate studies comparing surgery to observation in asymptomatic patients. Fundoplication resulted in higher early dysphagia in both observational studies and RCTs ([RR = 2.08, 95%CI 1.16, 3.76] and [RR = 20.58, 95%CI 1.34, 316.69]) but lower reflux in RCTs (RR = 0.31, 95%CI 0.17, 0.56, I2 = 0%). Conversion to Roux-en-Y was associated with a lower reintervention risk after 30 days compared to redo surgery.

Conclusions

The evidence for optimal management of symptomatic and recurrent hiatal hernia remains controversial, underpinned by studies with a high risk of bias. Shared decision making between surgeon and patient is essential for optimal outcomes.

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Acknowledgements

The authors would like to acknowledge Holly Ann Burt for her contribution in performing the literature search for all included studies. We would also like to acknowledge Sarah Colón for her help in organizing the guidelines committee meetings and communications.

Funding

No external funding was used for this study. SAGES provided partial salary support for the fellows, statistician, and librarian involved in the project.

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Authors and Affiliations

  1. Department of Surgery, Queen’s University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada

    Nader M. Hanna

  2. Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA

    Sunjay S. Kumar

  3. Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA

    Amelia T. Collings

  4. Department of Surgery, MetroWest Medical Center, Framingham, MA, USA

    Yagnik K. Pandya

  5. Department of Surgery, Providence Portland Medical Center, Portland, OR, USA

    James Kurtz

  6. Department of Surgery, Cooper University Hospital, Camden, NJ, USA

    Keshav Kooragayala

  7. Department of Surgery, University of Toledo College of Medicine, Toledo, OH, USA

    Meghan W. Barber

  8. Department of General Surgery, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine

    Mykola Paranyak

  9. Department of Surgery, NYU Langone Health, New York, NY, USA

    Marina Kurian

  10. AdventHealth Orlando, Orlando, FL, USA

    Jeffrey Chiu

  11. Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada

    Ahmed Abou-Setta

  12. Independent Researcher, Ottawa, ON, Canada

    Mohammed T. Ansari

  13. Department of Surgery, University of Chicago, Chicago, IL, USA

    Bethany J. Slater

  14. Department of Surgery, Monash University, Melbourne, Australia

    Geoffrey P. Kohn

  15. Melbourne Upper GI Surgical Group, Melbourne, Australia

    Geoffrey P. Kohn

  16. Department of Surgery, University of California Irvine, Irvine, USA

    Shaun Daly

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Correspondence to Nader M. Hanna.

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Disclosures

Geoff Kohn reports expert opinion fees from Avant Medical. Bethany J. Slater reports consulting fees from Hologic and from Cook Medical. Jeffrey Chiu reports consulting fees from Altrazeal Life Sciences Inc. Marina Kurian reports honoraria from WL Gore. Nader M. Hanna, Sunjay S. Kumar, Amelia T. Collings, Yagnik K. Pandya, James Kurtz, Keshav Kooragayala, Meghan W. Barber, Mykola Paranyak, Ahmed Abou-Setta, Mohammed T Ansari, and Shaun Daly have no conflicts of interest or financial ties to disclose.

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Hanna, N.M., Kumar, S.S., Collings, A.T. et al. Management of symptomatic, asymptomatic, and recurrent hiatal hernia: a systematic review and meta-analysis. Surg Endosc (2024). https://doi.org/10.1007/s00464-024-10816-9

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