Postoperative follow-up strategies for recurrence monitoring after paraesophageal hernia repair: a narrative review

Introduction

Background

Surgical repair for paraesophageal hernia (PEH) is the gold standard treatment for symptomatic PEH, aimed at reducing herniation and restoring normal anatomy. The application of minimally invasive surgery techniques to PEH repair has improved patient outcomes leading to lower blood loss, fewer intraoperative complications, shorter time to oral intake, less opioid use, lower length of stay (1,2), and in some reports, lower recurrence rates (3,4). Nevertheless, recurrence rates of PEH remain high and depend on the length of follow-up (5).

Rationale and knowledge gap

Most available meta-analyses addressing recurrence rates following PEH repair have failed to identify conclusive evidence of factors affecting recurrence rates due to the heterogeneity of reported data related to various definitions of hernia and hernia recurrence, and various subjective assessments of recurrence (6). While current guidelines advise against routine radiologic follow-up after surgery, there has not been any recommendation regarding the timing of post-operative follow-up for patients after PEH repair (7). The main reason for the lack of guidance in this area is that studies have not specifically assessed what the optimal follow-up duration after PEH is to detect recurrences.

Objective

This narrative review aims to summarize the current state of knowledge regarding recurrence rates after minimally invasive PEH repair. The review will focus on determining which postoperative follow-up strategies maximize recurrence detection and what the ideal imaging modalities and diagnostic tools are for postoperative recurrence monitoring. The review also discusses the clinical implications of recurrence detection and its impact on patient management. We present this article in accordance with the Narrative Review reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-23-71/rc).

Methods

A comprehensive and systematic literature review was performed utilizing the PubMed database to identify studies pertinent to our objective. Keywords and MeSH terms used in the search strategy included “Hiatal Hernia”, “paraesophageal hernia”, “recurrence”, “follow-up”, “postoperative period”, and variations thereof (Table 1). The search was refined using the database’s filtering function to include comparative studies, meta-analyses, randomized control trials, systematic reviews, and observational studies. Only human studies, articles in English, and those involving an adult population were considered. Titles and abstracts of the retrieved articles were screened by authors W.S.L. and Q.A. individually to exclude reports without recurrence data, unrelated to PEH/hiatal hernia (HH) repair, studies of non-surgical intervention, as well as duplicate publications. After this preliminary exclusion, the full texts of the remaining articles were reviewed to ensure the inclusion of both objective and subjective follow-up data. Studies with overlapping populations and those not exclusively dedicated to minimally invasive PEH/HH repair were omitted (Table 1). Ultimately 67 studies, with a total of 8,766 participants reported, met the inclusion criteria for final review (Figure 1). Data extraction was performed independently by two authors, focusing on study design, patient population, surgical techniques, follow-up protocols, definition of recurrence, diagnostic approach, rates of recurrence, reoperation, and primary outcomes.

Figure 1 Flow chart summarizing literature review process. PEH, paraesophageal hernia; HH, hiatal hernia.

Discussion

Impact of surgical technique on recurrence and other outcomes

The goals of PEH repair include reduction and excision of the hernia sac, mediastinal esophageal mobilization to create adequate intra-abdominal esophageal length, primary crural repair, and the addition of a fundoplication (7,8). Additional techniques have been proposed when these goals cannot be achieved via standard techniques and include the creation of gastroplasty, the use of crural relaxing incisions, and mesh reinforcement.

The use of mesh has proven useful in abdominal hernias; mesh reinforcement during PEH has been proposed as a method of reducing the tension of crural repair (9). However, it has not been standard practice in the repair of HHs. The majority of comparative studies and randomized clinical trials included in this review did not report any difference between classic suture repair and the use of mesh in terms of recurrence rates or symptoms at long-term follow-up (10-14), with Watson et al. and Jacobs et al. reporting worse symptomatic outcomes in patients who had an absorbable mesh used for repair (11,15). Oelschlager et al. have found mesh reinforcement was able to achieve a lower recurrence rate at short-term follow-up (6 months) compared to primary repair (16), but results were comparable at 5 years (17). In contrast, Wang et al. found that PEH repair with mesh yielded lower recurrence rates and better symptoms control in long-term follow-up. Additionally, they showed that different levels of mesh reinforcement had better outcomes. The use of a 6-ply mesh had lower recurrence rate compared to 4-ply, albeit not statistically significant (13.6% vs. 30%) (18). The current body of evidence does not provide strong supportive evidence for the incorporation of mesh in PEH repair as a routine procedure. In addition, concerns about permanent mesh erosion in the esophagus require further study of alternative types of mesh especially for larger hiatal defects.

The addition of a fundoplication, particularly Nissen fundoplication, gained traction as a part of HH repair due to its benefits in treating gastroesophageal reflux disease (GERD) symptoms and potentially preventing recurrence. Müller-Stich et al. compared laparoscopic repair of PEH with and without Nissen fundoplication and found that reflux symptoms were significantly better with the fundoplication, but no difference in recurrence rates was noted (19), while Furnée et al. recommended routine fundoplication selectively for patients with large HHs and preoperative GERD, and reported no additional benefit of fundoplication during PEH repair (20,21). Other studies explored other fundoplication types, including the Nissen-Hill hybrid fundoplication and Belsey Mark IV (BM-IV) repair. The Nissen-Hill hybrid method of PEH repair showed better quality of life (QoL) and reflux symptom control with decreased postoperative proton pump inhibitor (PPI) use (22); in addition, patients had lower hernia recurrence rates compared with Nissen fundoplication alone (23). Laan et al. found that BM-IV had lower rates of reoperation and leak compared to Nissen fundoplication, however, the recurrence rates were comparable (24). Additionally, the Collis-Nissen gastroplasty was found to reduce recurrence rates in patients with large HH and short esophagus (25,26), and other adjuncts such as gastropexy were also found to have beneficial outcomes (27).

The overall body of reviewed evidence, however, has not demonstrated that a specific technique leads to consistently lower recurrence rates. Adequately powered quality studies are needed that compare head-to-head various employed techniques of PEH repair to determine the ideal technique to optimize patient outcomes.

Recurrence definition and method of diagnosis

The majority of available studies used radiologic evaluation to detect recurrences, however, the definitions used varied; 38.8% of the papers defined recurrence as any evidence of stomach above the level of the diaphragm, while 35.8% defined it as >2 cm of stomach above the diaphragm, and the other 25.4% did not provide a clear definition of recurrence criteria. The latter definition has been used by landmark papers of Oelschlager et al. and Mittal et al. (17,28) and has since been adopted by multiple newer studies. Nevertheless, recurrence rates identified by studies using these two different definitions of PEH recurrence do not seem to differ significantly (21.7% vs. 17%, respectively; P=0.41).

Fluoroscopic imaging of the upper gastrointestinal (GI) tract remains the preferred mode of diagnosis, with over 90% of studies using esophagram to detect PEH recurrence. Esophagogastroduodenoscopy (EGD) has been used in the remaining studies, with a significant number of studies opting to use both methods in conjunction more recently. The diagnosis of sliding HHs has been debated in the literature, with many studies suggesting that high-resolution manometry is superior to both esophagram and EGD (29,30). Granderath has described hiatal surface area (HSA) to be a more sensitive measurement (31). Grubnik et al. have stratified patients based on HSA preoperatively and have found recurrence is highly dependent upon HSA (32). Koch et al. used HSA similarly for their postoperative assessment and found those with symptomatic recurrence had a larger HSA (33). In our review, a few studies also used standard manometry for preoperative and postoperative assessment, in addition to 24-hour pH monitoring (25,34,35).

To determine whether PEH recurrences were symptomatic, studies used different methods to evaluate patients’ symptoms including subjective symptom reporting, or a range of tools including institution-based questionnaires, the GERD-Health Related Quality of Life (HRQL) (36), and Visick score (37). A total of 19 studies reported the percentage of symptomatic patients among those with objective recurrence, while the rest of the studies reported symptomatic and objective recurrence separately and/or discussed the correlation between the two.

The lack of standardization of recurrence objective and subjective definitions is a barrier to conducting meaningful comparisons. Future studies reporting PEH outcomes should use a standardized definition of recurrence; to minimize heterogeneity in outcome reporting and enable comparisons, we suggest that studies should specify the size of anatomic recurrence, the modality used to make the diagnosis, and the presence or not and type of patient symptoms.

Relationship between symptomatic and anatomic recurrence

The relationship between symptomatic recurrence and anatomical failure in PEH repair is complex and has led to challenges in accurately determining the true recurrence rate and comparing results across studies. This discrepancy was first highlighted by Wu et al., who found hiatal defects in patients without any reported symptoms (38).

Numerous studies including Mattar et al.’s long-term postoperative analysis, found no clear correlation between anatomical recurrence and symptom severity. Despite a higher rate of anatomical recurrence (33%), only a minority experienced more than mild symptoms (39). Hashemi et al. also reported a poor correlation between symptoms and the presence of a recurrent hernia, with some symptom-free patients showing radiologic evidence of hernia or wrap disruption and patients with persistent symptoms having no evidence of recurrence on imaging (40). Furthermore, studies that focused on anatomical recurrence as the primary outcome failed to observe any significant differences in symptom reporting compared to patients without recurrence (17,28,39,41-44). This suggests that anatomical failure may not be a reliable indicator for symptom recurrence or severity.

Conversely, several studies, such as those by Oor et al. and White et al., have identified a significant correlation between anatomical recurrence and higher heartburn scores, more so than other symptoms like chest pain, regurgitation, or dysphagia (13,45). Nason et al. observed a correlation between chest discomfort and regurgitation with radiographic recurrence, although it did not necessarily predict poorer outcomes (46). Jobe et al. found a link between symptoms and size of recurrence, with 75% of those with a larger type 3 anatomic recurrence experiencing more symptoms unlike those with small sliding hernias who were all asymptomatic (47). Lastly, Wang et al. noted higher symptom severity in recurrence patients who had their hiatus repaired primarily without mesh reinforcement compared with those who had mesh placement (12). Thus, the literature reporting on the correlation between anatomic and symptomatic recurrence is mixed without a consistent relationship having been demonstrated.

The inconsistency in the literature raises questions about the necessity of obtaining confirmation of anatomical failure as the primary outcome in the absence of symptoms. It is therefore crucial to better understand the association between symptoms and anatomical failure as it impacts clinical decision-making. Future research should focus on clarifying this relationship to better guide clinical management strategies.

QoL after recurrence

QoL has been increasingly incorporated in patient-centered outcome research. It may aid healthcare providers to gain a more comprehensive understanding of the impact of any intervention. Incorporating the QoL assessment considers physical and mental well-being, daily function, and extending beyond traditional physiologic measures. Validated questionnaires such as GERD-HRQL, Gastrointestinal Quality of Life Index (GIQLI), and Short Form Health Survey (SF-36) are utilized by most studies to assess patients’ satisfaction and overall quality of living (48,49). Generally, these studies suggest that PEH repair improves QoL compared to preoperative assessment (50,51). Koetje et al. found similar improvement in QoL following both primary cruroplasty and those with mesh reinforcement (14). Furnée et al. reported that 88.6% of patients with fundoplication experienced symptom relief and overall enhancement in general QoL (20). Karmali et al. and Aiolfi et al. also indicated excellent and satisfactory postoperative results as well in their study population (2,52,53).

In contrast, the influence of recurrence on QoL has yielded mixed findings. Some studies suggest that recurrence negatively impacts QoL. Khaitan et al. found that patients with an anatomically intact fundoplication wrap had higher Quality of Life in Reflux and Dyspepsia (QoLRAD) scores compared to those with a herniated wrap (54). Watson et al. demonstrated that 31% of patients with symptomatic anatomic recurrence had lower Physical Component Scores (PCS) in SF-36 than those without recurrence (11). Wang et al. reported no difference in symptom severity or satisfaction between mesh reinforcement and primary repair but noted higher dissatisfaction in patients with recurrence in the primary repair cohort (12). Stringham et al. found that only 57.1% of patients with radiologic recurrence were still satisfied with their surgery after 12 months, significantly lower than those without radiographic recurrence (55). Targarona et al. similarly found that QoL was lower in patients with recurrence but could not find changes in QoL based on whether recurrences were symptomatic, anatomic, or combined (56).

Conversely, other studies found no significant correlation between QoL surveys and radiologic recurrence (57,58), or even an association with higher QoL in the recurrence group (46,59). The size of hernia recurrence was also not a significant factor in QoL outcome (17,55).

While initial PEH repair clearly improves patient QoL, no clear relationship has been demonstrated between PEH recurrence and QoL based on the current literature reviewed. Future studies should aim to further explore this relationship, including QoL after reoperation, as it can be crucial for improving clinical management strategies, ensuring that patient well-being is prioritized alongside traditional clinical outcomes.

Indications, timing, and outcomes of reoperation

Given the mixed findings on the impact of PEH recurrence on patient symptoms and QoL, further exploration of the primary factors prompting patients to undergo a reoperation is needed. Current management for recurrence varies by the degree of symptoms and size of hernia (60). For patients with minimal or no symptoms and a small radiographic recurrence of their hernia, observation with imaging is often sufficient (47). In cases of recurrence of small sliding hernia with mild to moderate symptoms, medication management was often used to alleviate symptoms (53,61,62), those requiring surgical intervention are mostly driven by the severity of clinical symptoms.

In the reviewed literature, 43 out of the 65 studies (66.15%) reported reoperation information. From these reports, the average overall reoperation rate was low at 5.24% [defined as (reoperations for recurrence)/total study population ×100]. Those with documented anatomic recurrence, 36.7% of those underwent reoperation. The majority of studies identified symptoms as the primary reason for reoperation rather than anatomic recurrence. Studies by Grubnik et al. and other large retrospective reviews predominantly found that reoperations were driven by symptomatic recurrence and confirmation of anatomic failure using objective imaging (14,25,32,42,44,63). A study by Levy et al. reported one reoperation purely due to the anatomic breakdown in Hill-Nissen hybrid repair (23). Andujar et al.’s review revealed that 80% of their patient cohort underwent reoperation primarily due to reflux recurrence and dysphagia issues, with only two cases involving both anatomical and symptomatic recurrence (64).

Emergent interventions for complications like strangulation or gastric volvulus have also been reported, necessitating more extensive procedures such as partial gastrectomy, which carries a higher risk of morbidity and mortality (61,63,65). Additionally, reoperations were also associated with their own set of issues, including second hernia recurrences (24,25,66-68), severe gastroesophageal complications (64), inferior symptomatic outcomes (69), and sometimes larger hernia size upon recurrence (46). Thus, early diagnosis of recurrence and reoperation may be crucial in optimizing outcomes.

Reoperations can occur early after surgery (0–30 days) or years later. Figure 2 illustrates the reported timing of reoperations by identified studies along with their follow-up period. In the majority of studies, reoperations occurred well before their longest follow-up time and most within 4 years of the index operation.

Figure 2 Relationship between reoperation period and follow-up duration (years). *, Pomar, 2009 had reoperation during the 9th month.

Future research should specify the indication for reoperation, its timing, and associated patient outcomes. In addition, studies should document the etiology of recurrence based on intraoperative findings as this may aid in improving our understanding of technical factors that contribute to recurrences. Importantly, prospective studies with adequate follow-up reporting on recurrence rates after reoperations are needed to determine the effectiveness and longevity of this approach.

Recurrence timing and its relationship to follow-up duration

The analysis of follow-up times across various studies shows significant variation, potentially impacting the proper identification of recurrences. Notably, since 2007–2008, an increase in average follow-up times reported has been observed, likely due to the availability of more longitudinal data. Post-2020, follow-up periods commonly extend to at least 2 years postoperatively (10,26,52). Jones et al. found that the rate of recurrence stabilizes after 24 months, with the most significant increase (16.4% to 32.8%) occurring between 12–24 months. Subsequently, follow-up rates tend to drop off at 24 months and the percentage of participants’ follow-up remains about the same from years 3–5 (43). Mittal et al. and Jobe et al. observed an increase in recurrence rates over long-term follow-up, which may be high due to a reduction in the number of participants remaining in follow-up (28,47).

Le Page et al.’s retrospective study indicated that PEH recurrence rates rose steadily with follow-up time, a similar trend seen by Zehetner et al. where no peak or plateau was seen with recurrence incidents across the follow-up time (4,44). Zaninotto et al. reported a bimodal distribution of recurrence; among the 8 patients with recurrence identified 50% had developed recurrence greater than 60 months out from their initial operation (62), suggesting that there could be a potential population of patients who get missed if the follow-up duration is shorter than 5 years (4,44).

The timing of PEH recurrence in relationship with the follow-up period is illustrated in Figure 3. As shown, some studies reported PEH recurrence occurred within 1 year postoperatively, even with an extended follow-up period (66,67,70-73), while others reported the presence of recurrence beyond the first year. Notably, the majority of studies identified recurrence occurring around the 2-year mark (26,28,32,42,44,52).

Figure 3 Hernia recurrence range with respect to the follow-up dates (years).

The optimal follow-up period post-PEH repair for meaningful surveillance seems to be around 2 years, as most recurrences are detected and typically stabilize beyond this point. Clinically, this suggests the importance of diligent monitoring in the initial 2 years post-surgery by offering a 2-year follow-up to patients after PEH repair for an evaluation.

Limitations of this review

While the review provides extensive coverage of the current literature on postoperative outcomes and follow-up for minimally invasive PEH repair, it is important to acknowledge certain limitations. Despite a comprehensive literature search, there remains a possibility that relevant studies may have been overlooked. Additionally, a formal quality assessment was not done for the review, which could lead to potential biases in the results. Furthermore, the focus of the review was primarily on the technical aspects of postoperative follow-ups, potentially neglecting other important factors such as lifestyle or demographic variables that may also influence recurrence rates and patient outcomes.

Conclusions

Accurately recording the long-term outcomes of PEH repair is crucial to determining initial repair effectiveness, as short-term follow-ups of reporting studies may miss recurrences that occur in the long term. A clear, universally accepted definition of PEH recurrence encompassing both clinical and anatomical criteria would allow for easier study result pooling and interpretation. Studies should include clear reporting on patient symptoms and incorporate QoL assessments and other patient-centered outcomes to determine the relationship of anatomic recurrence with symptoms and aid reoperation decisions. There is also a need to establish a set goal for the follow-up period after surgery and work preoperatively with patients regarding expectations and the need for follow-up to reduce attrition rates postoperatively. Our review findings suggest that the optimal follow-up duration may be 2 years postop.

Acknowledgments

The authors would like to acknowledge medical librarian Hannah Craven, MLIS for assistance with the literature search process.

Funding: None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-23-71/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-23-71/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-23-71/coif). D.S. serves as an unpaid editorial board member of Annals of Laparoscopic and Endoscopic Surgery from May 2022 to April 2024. D.S. receives research support from Intuitive and Beckton Dickinson, and is a consultant at J&J and applied medical. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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