Management of paraesophageal hiatus hernia: recommendations following a European expert Delphi consensus
Stephan Gerdes, Sebastian F. Schoppmann, Luigi Bonavina, Nicholas Boyle, Beat P. Müller‐Stich, Christian A. Gutschow, the Hiatus Hernia Delphi Collaborative Group, Suzanne S. Gisbertz, Ferdinand Köckerling, Thorsten Lehmann, Dietmar Lorenz, Frank A. Granderath, Riccardo Rosati, C. Wullstein, Lars Lundell, Edward Cheong, Philippe Nafteux, Stefano Olmi, Stefan Mönig, Matthias Biebl, Jessica M. Leers, Joerg Zehetner, Ivan Kristo, Richard George Berrisford, Ognjan Skrobić, Aleksandar Simić, Manuel Pera, Peter Grimminger, Ines Gockel, K. Zarras, Vincent Bernard Nieuwenhuijs, James Gossage, Mark i. van Berge Henegouwen, H. J. Stein, Sheraz R. Markar, Willem E. Hueting, Eduardo M. Targarona, Jan Johansson, Graeme D. Macaulay, Bas P. L. Wijnhoven, Frank Benedix, Stephen Attwood, Arnulf H. Hölscher, Pablo Priego, Karl–Hermann Fuchs, Misha Luyer, Ewen A. Griffiths, Torgeir T. Søvik, Dimitrios Theodorou, Bruno Sgromo, Jarmo Salo, Rishi Singhal, Anders Thorell, Giovanni Zaninotto, Marko Bitenc, Xavier Benoît D’Journo, Grant Fullarton, Thomas Horbach
Abstract
AIMS: There is considerable controversy regarding optimal management of patients with paraesophageal hiatus hernia (pHH). This survey aims at identifying recommended strategies for work-up, surgical therapy, and postoperative follow-up using Delphi methodology. METHODS: We conducted a 2-round, 33-question, web-based Delphi survey on perioperative management (preoperative work-up, surgical procedure and follow-up) of non-revisional, elective pHH among European surgeons with expertise in upper-GI. Responses were graded on a 5-point Likert scale and analyzed using descriptive statistics. Items from the questionnaire were defined as "recommended" or "discouraged" if positive or negative concordance among participants was > 75%. Items with lower concordance levels were labelled "acceptable" (neither recommended nor discouraged). RESULTS: Seventy-two surgeons with a median (IQR) experience of 23 (14-30) years from 17 European countries participated (response rate 60%). The annual median (IQR) individual and institutional caseload was 25 (15-36) and 40 (28-60) pHH-surgeries, respectively. After Delphi round 2, "recommended" strategies were defined for preoperative work-up (endoscopy), indication for surgery (typical symptoms and/or chronic anemia), surgical dissection (hernia sac dissection and resection, preservation of the vagal nerves, crural fascia and pleura, resection of retrocardial lipoma) and reconstruction (posterior crurorrhaphy with single stitches, lower esophageal sphincter augmentation (Nissen or Toupet), and postoperative follow-up (contrast radiography). In addition, we identified "discouraged" strategies for preoperative work-up (endosonography), and surgical reconstruction (crurorrhaphy with running sutures, tension-free hiatus repair with mesh only). In contrast, many items from the questionnaire including most details of mesh augmentation (indication, material, shape, placement, and fixation technique) were "acceptable". CONCLUSIONS: This multinational European Delphi survey represents the first expert-led process to identify recommended strategies for the management of pHH. Our work may be useful in clinical practice to guide the diagnostic process, increase procedural consistency and standardization, and to foster collaborative research.