Controversies in paraesophageal hernia repair; a review of literature

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Abstract
The surgical repair of paraesophageal hiatal hernias (PHH) can be performed by endoscopic means, but the procedure is not standardized and results have not been evaluated systematically so far. The aim of this review article was to clarify controversial subjects on the surgical approach and technique, i.e., recurrence rate after conventional versus laparoscopic PHH treatment, results of mesh reinforcement of the cruroplasty, the necessity for additional antireflux surgery, and indications for an esophageal lengthening procedure. An electronic Medline search was performed to identify all publications reporting on laparoscopic and conventional PHH surgery. The computer search was followed by additional hand searches in books, journals, and related articles. All types of publications were evaluated because of a lack of high-level evidence studies such as randomized controlled trials. Critical analysis followed for all articles describing a study population of >10 patients and those reporting postoperative outcome. A total of 32 publications were reviewed. Randomized controlled trials comparing laparoscopic and open techniques could not be identified. Nineteen of the publications described the results of retrospective series. Therefore, most of the studies retrieved were low in hierarchy of evidence (level II-c or lower). The overall median hospital time as published was 3 days for patients operated laparoscopically and 10 days in the conventional group. Postoperative complications, such as pneumonia, thrombosis, hemorrhage, and urinary and wound tract infections, appeared to be more frequent after conventional surgery. Follow-up was longer for conventional surgery (median 45 months versus 17.5 months after the laparoscopic technique). Recurrence rates reported were higher in patients operated conventionally (median 9.1% versus 7.0% for patients operated laparoscopically). Recurrences after PHH repair may decrease with usage of mesh in the hiatus, although uniform criteria for this procedure are lacking. No conclusions could be drawn regarding the necessity for an additional antireflux procedure. Furthermore, uniform specific indications for the need of an esophageal lengthening procedure or preoperative assessment methods for shortened esophagus could not be detected. Treatment based on standardized protocols for preoperative assessment and postoperative follow-up is required to clarify the current controversies.