Journal of Minimal Access Surgery

REVIEW ARTICLE
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Year : 2021  |  Volume : 17  |  Issue : 4  |  Page : 435--449

Quality of life after giant hiatus hernia repair: A systematic review

Akshay R Date1, Yan Mei Goh2, Yan Li Goh3, Ilayaraja Rajendran4, Ravindra S Date5,  
1 Department of Orthopaedic Surgery, Basildon and Thurrock University Hospital, Basildon, Essex, UK
2 Department of Surgery, Imperial College London, St Mary's Hospital, London, UK
3 National Bowel Research Centre (NBRC), Blizzard Institute, Queen Mary University of London, London, UK
4 Department of Upper GI Surgery, Lancashire Teaching Hospital NHS Foundation Trust, Chorley, UK
5 Department of Upper GI Surgery, The University of Manchester, Manchester Academic Health Science Centre, Lancashire Teaching Hospital NHS Foundation Trust, Chorley, UK

Correspondence Address:
Dr. Akshay R Date
Basildon and Thurrock University Hospital, Nethermayne, Basildon, Essex SS16 5NL
UK

Abstract

Background: Elective surgery is the treatment of choice for symptomatic giant hiatus hernia (GHH), and quality of life (QoL) has become an important outcome measure following surgery. The aim of this study is to review the literature assessing QoL following repair of GHH. Methodology: A systematic literature search was performed by two reviewers independently to identify original studies evaluating QoL outcomes after GHH surgery. MeSH terms such as paraoesophageal; hiatus hernia; giant hiatus hernia and quality of life were used in the initial search. Original studies in English language using validated questionnaires on humans were included. Review articles, conference abstracts and case reports and studies with duplicate data were excluded. Results: Two hundred and eight articles were identified on initial search, of which 38 studies (4404 patients) were included. Studies showed a significant heterogeneity in QoL assessment tools, surgical techniques and follow-up methods. All studies assessing both pre-operative and post-operative QoL (n = 31) reported improved QoL on follow-up after surgical repair of GHH. Improvement in QoL following GHH repair was not affected by patient age, surgical technique or the use of mesh. Recurrence of GHH after surgery may, however, adversely impact QoL. Conclusion: Surgical repair of GHH improved QoL scores in all the 38 studies. The impact of recurrence on QoL needs further assessment. The authors also recommend uniform reporting of surgical outcomes in future studies.



How to cite this article:
Date AR, Goh YM, Goh YL, Rajendran I, Date RS. Quality of life after giant hiatus hernia repair: A systematic review.J Min Access Surg 2021;17:435-449


How to cite this URL:
Date AR, Goh YM, Goh YL, Rajendran I, Date RS. Quality of life after giant hiatus hernia repair: A systematic review. J Min Access Surg [serial online] 2021 [cited 2021 Nov 29 ];17:435-449
Available from: https://www.journalofmas.com/text.asp?2021/17/4/435/313932


Full Text

 Introduction



Giant hiatus hernia (GHH) is primarily a disease of the elderly with increased reported incidence over the last two decades.[1],[2] This trend is attributed to the ageing population, centralisation of upper gastrointestinal (UGI) services and greater incidental findings of GHH in asymptomatic patients with the increased utilisation of imaging.[1],[3],[4],[5] GHH is associated with a significantly reduced quality of life (QoL) and increased risk of complications such as volvulus of the stomach if left untreated.[6] Surgical repair for all patients with symptomatic GHH has therefore been recommended.[6],[7],[8],[9],[10] Watchful waiting is advocated in asymptomatic patients.[9],[11],[12]

Over the last two decades, careful patient selection and advances in perioperative care have led to significant reduction in post-operative mortality of this condition (0%–5.2%).[3],[13],[14] Improved survival in GHH surgery patients has changed the focus of study outcomes from mortality to that of recurrence and QoL measures, with the reported recurrence rate varying between 9% and 66%.[15],[16],[17] The elderly demographic of GHH patients presents clinicians with challenge in the management of symptomatic GHH, where the improvement in QoL must be weighed against the risks of undergoing surgery.

After the first report by Velanovich et al. in 2001, a number of studies addressing the QoL following the repair of GHH have been published.[18] Some studies have compared QoL outcomes with or without mesh, some have assessed QoL in elderly population and some have compared QoL after two different operations.[19],[20],[21],[22],[23],[24],[25] There remains a lack of clarity on the impact of such variables on QoL outcomes after GHH surgical repair. The aim of this study is to systematically review the literature assessing QoL following elective repair of GHH.

 Methodology



Literature search

A systematic review of the literature was performed using the following databases: Medline (1946–May 2020) via OvidSp, Ovid Embase (1947–20 May 2020) and Cochrane Library. The search aimed to identify original studies evaluating outcomes following repair of GHH with specific emphasis on post-operative improvement in QoL. Three strings using the following search terms were used: Paraoesophageal; hiatus hernia; giant hiatus hernia and quality of life. All variations in spelling including a truncated search term using wild card characters and 'related articles' function were used in combination with the Boolean operators 'AND' and 'OR'. Reference lists of the identified articles were also searched to identify other potentially relevant studies.

Two independent reviewers (YMG and AD) screened the titles and abstracts of all studies identified by a primary electronic search. The full texts of potentially relevant articles were retrieved to assess eligibility for inclusion. Included studies were those reporting surgical and QoL outcomes in patients undergoing GHH or large paraoesophageal hernia (PEH) repair. Different variants of definitions of GHH were accepted, including. (1) paraoesophageal hernia (PEH),[5] (2) GHH >30% or 50% of the stomach in the chest and (3) >2-cm hiatus hernia on radiology or endoscopy. Studies were excluded if they reported on animal or in vitro studies; used non-validated questionnaires; were not published in English language; did not report on QoL outcomes and were review articles, conference abstracts and case reports. A third reviewer (RD) was consulted in the case of a disagreement.

Assessment of quality of studies

The quality of studies was assessed with the 'Quality assessment tool for case series studies', devised by the National Heart, Lung, and Blood Institute.[26] Each study was assessed utilising the 9-point criteria, with 1 point given for each criterion fulfilled. A study's quality rating was subsequently graded as good, fair or poor based on the total score from these points.

Outcome measures

The following data items were extracted from the included publications: year of publication, country of origin, study design, hernia type and size, total number of patients in each study, QoL assessment as the primary study outcome, mean age, use of mesh, type of surgery performed, recurrence, mortality and morbidity, length of follow-up and type of questionnaire used in the study.

 Results



Literature search and study characteristics

A systematic literature search identified a total of 208 studies, of which 45 remained after applying the exclusion criteria and removal of duplicates [Figure 1]. After reviewing full-text articles, a final total of 38 studies comprising a total of 4404 subjects who underwent surgery for GHH were included in the review, with follow-up using questionnaires achieved in over 3000 patients [Table 1]a and [Table 1]b. There were 36 studies that were either retrospective or prospective case series, with an additional two randomised controlled trials. All studies were graded as 'good' (score of ≥8) by both adjudicators except for Kang et al.,[27] which scored 'fair' with 6 points. Based on Quality assessment tool for case series studies, there were no exclusions and all the 38 studies were reviewed in this paper. Of note, Tam et al.[28] and Nason et al.[29] reported on different outcomes from the same patient group; Tam et al. reported multiple outcomes including QoL improvement after surgery, recurrence and significance of mesh, whereas the data from Nason et al. were relevant for Collis gastroplasty.{Figure 1}{Table 1}

The definitions of GHH varied within the included studies due to the lack of consensus in the field. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines classify hiatus hernias in accordance to anatomical classification (Types I–IV).[10] Although most studies have used the SAGES classification,[10] nine authors defined GHH in their study using modified SAGES criteria, as either a Type II or III hernia (four studies),[18],[24],[29],[30] or large PEH (five studies).[31],[32],[33],[34],[35]

Seventeen studies have defined GHH by size; six studies defined GHH as >30% or one-third of the stomach present in the chest[13],[23],[27,[29],[32],[36] and thirteen defined this as >50%.[16],[28],[33],[37],[38],[39],[40],[41],[42],[43],[44] There is another subset of authors that describe size of GHH in accordance with the size measured on radiography, in centimetres.[13],[16],[24],[29],[31],[36],[38],[40] There is an agreed endoscopic definition of PEHs, >2-cm separation of the upward displacement of the gastro-oesophageal junction and diaphragmatic impression.[45] Three authors did not clearly define their definition of GHH included in their study.[46],[47],[48]

Assessment tools and reporting of quality of life

There were a variety of QoL questionnaires used in the studies; these included QoL in Reflux and Dyspepsia (QOLRAD), Gastro-Oesophageal Reflux Disease-Health Related QoL (GERD-HRQL), Gastrointestinal QoL Index (GIQLI), Gastrointestinal Symptom Rating Scale (GSRS), Short-Form health surveys SF-12 and SF-36, Reflux Symptom Index (RSI), Dysphagia Severity Scale (DSS), Gastro-Oesophageal Reflux Symptom Scale (GERSS) and Visick scores [Table 2]. The majority of studies (n = 25, 66%) used QoL questionnaires specific for gastro-oesophageal reflux disease (GERD), such as the QOLRAD and GERD-HRQL questionnaires. GIQLI and GSRS are more general for the entire gastrointestinal tract and were used in eight studies.[49] Seven studies used SF-12 and SF-36, which are generic questionnaires assessing physical and mental scores across eight multi-item dimensions, namely physical functioning (PF), role-physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional (RE) and mental health (MH).[50] SF-12 and SF-36, alongside the RSI, GERSS, DSS and Visick scores, were used mainly post-operatively in conjunction with GERD disease-specific tools.{Table 2}

QOLRAD and GERD-HRQL, though disease specific for reflux, can be applied for many other UGI disorders. GERD-HRQL is validated for measuring the disease severity of GERD and to assess response to medications, endoscopic procedures and surgery. QOLRAD has a high validity and internal reliability in each dimension and composite score. For ease of understanding and interpretation of results of the studies to the readers, the most frequently used tools (QOLRAD, GERD-HRQL, GIQLI, GSRS and SF-36) are described briefly in [Table 2]; their full details can be found elsewhere.[51]

Quality of life improvement after surgery

A total of 31 studies compared the pre-operative and post-operative QoL after GHH surgery [Table 3]. Some studies used multiple questionnaires and reported findings for each questionnaire separately. GERD-HRQL and GIQLI questionnaires have been reported in two different ways; some authors report pre-operative and post-operative scores and any statistical significance between them, whereas others report percentage of patients showing 'excellent' or 'good' improvement in QoL after surgery. Two of the 31 studies[9],[48] did not report statistical analysis in post-operative QoL improvement, but we have included the absolute score values in [Table 3] for reference. Of the remaining 29 studies, 22 (76%) reported either a significant increase in post-operative QoL following GHH surgery, or an 'excellent' or 'good' score post-operatively in at least 83% of patients. The follow-up time of the studies ranged from 6 months to 118 months, with a median follow-up time of 22.5 months.{Table 3}

Eight studies used QOLRAD for assessment of QoL [Table 3]. Seven authors reported a significant improvement in QoL after GHH surgery (P < 0.001).[24],[25],[30],[31],[35],[47],[48] Ng et al. found an improvement in QoL after surgery but did not assess for significance.[48]

GERD-HRQL was used in 17 studies [Table 3]; ten studies[19],[20],[24],[32],[38],[42],[47],[52],[53],[54] using GERD-HRQL reported a significant increase in QoL after surgery, with an additional five studies reporting >83% of patients with 'excellent' or 'good' outcomes.[23],[28],[39],[46],[55] Two studies found that there was no significant increase in post-surgical QoL.[56],[57]

The GIQLI tool was used by seven studies [Table 3]; three studies reported a significant improvement in post-operative QoL,[37],[44],[58] three found no statistical significance[33],[36],[40] and one did not assess for significance.[16] Zhu et al. and Furtado et al. reported a significant improvement in post-operative GIQLI scores (24 to 85.7 and 27 to 89, respectively; P < 0.001).[36],[58] Chen et al. reported 'good' or 'excellent' GIQLI score in 83% (45/54) of patients at follow-up, with a mean post-operative score of 117.[44] Two studies using GIQLI compared post-operative scores with a control population;[37],[40] Zhu et al. reported that a post-operative score of 107.9 was still lower than the scores of healthy individuals (118.2).[36] Targarona et al., on the contrary, felt that successfully operated patients reached a GIQLI value comparable to that of the standard population.[40]

The SF-36 score was used by nine studies, of which three looked at both pre-operative and post-operative QoL.[18],[28],[41] Tam et al. found no significant improvement in QoL in both PCS (P = 0.005) and MCS (P = 0.264) components.[28] Koetje et al. reported a significant improvement across all groups post-operatively (P < 0.001) and at 3 months, 6 months, 12 months and 24 months (range, P < 0.001–P < 0.044).[41] Velanovich et al., using SF-36, compared post-operative improvement in laparoscopic group with that of open group.[18] Post-operatively, the PF score improved in the laparoscopic group (P = 0.02) and RP worsened in the open group (P = 0.0001). However, when comparing the laparoscopic group to the open group, there were significantly better scores in the laparoscopic group in the domains of PF, RP, RE, VT and SF.

One study utilising GSRS found significant improvement in pain, reflux and indigestion (P < 0.001), which supports the findings based on the GERD-HRQL questionnaire used in the same study.[38] Lidor et al. did not use a standardised questionnaire, however reported significant improvement in all symptoms at 12 months and significant overall satisfaction at 36 months.[59]

Age and quality of life

Five studies[5],[24],[25],[30],[57] looked at QoL after repair of GHH with focus on the age demographic of patients [Table 4]. Parker et al. compared three different age groups and demonstrated significant improvement in QOLRAD scores in all the three groups.[25] There was no significant difference in either the pre-operative or post-operative QOLRAD scores between the young and older cohorts, and the overall improvement in QOLRAD scores in the three groups was 2.1, 2.3 and 2.4, respectively (P = 0.9032).[25] Similarly, Jalilvand et al. reported comparable differences in QoL improvement between patients above and below 80 years.[60] However, the authors also reported that older patients are more likely to suffer post-operative complications and significantly greater length of hospital stay (P < 0.005). Merzlikin et al., in carefully selected patients, showed improved QoL that sustained at 5 years and beyond.[57] The data from the study by Louie et al. also support repair of symptomatic GHH in patients aged 70 years or more;[24] the authors conclude that GHH in the elderly can be repaired with minimal surgical mortality and acceptable morbidity in both elective and urgent settings. A significant number of their patients had symptom resolution and improvements in both short- and long-term QoL. Improvement was noted in patients who presented urgently as well as in those with small recurrent herniation.[24]{Table 4}

Recurrence of hernia and quality of life

As with the definition of GHH, the assessment and definition of recurrence varies in the literature; this has been done in three different ways: symptomatic, radiological or endoscopic (or a combination of the two or more methods). From a total of 38 studies reviewed, 9 studies assessed the impact of recurrence on QoL outcomes in GHH surgery. The range of recurrence varied from 9% to 66% [Table 5]. The nine studies together included a total of 1516 patients, of which 225 (14.8%) were shown to have recurrence of hiatus hernia using one or more assessment methods. The median follow-up length ranged from 1 month to 118 months after surgery; due to inconsistency of data, the mean length of follow-up post-operatively could not be assessed in this review. Four studies found a significant difference in the QoL between the recurrence and no-recurrence groups.[40],[41],[44],[52] The remaining five studies failed to demonstrate any significant differences in QoL.[16],[24],[28],[36],[58] Small and large recurrences were compared in one study;[52] from a total 33 (32.7%) recurrences, 14 (13.9%) were small and 19 (18.8%) were large (>2 cm). They found similar post-operative QoL and patient satisfaction scores in both groups, and the authors conclude that clinically, small recurrences may be as important as large ones.{Table 5}

Mesh and quality of life

Six of the 38 included studies compared QoL after reinforcement of crural repair with mesh versus no mesh [Table 6]. Ilyashenko et al. reported a significant difference in QoL between mesh and no-mesh groups (P <0.0001),[19] however the remaining five studies found no statistically significant difference in the two groups.[16],[20],[41],[61],[62] Two studies used mesh in all the patients;[31],[39] At 2 years follow up with barium examination and endoscopy, Hazebroek et al.[31] found no mesh erosion and only one asymptomatic recurrent hernia of <2 cms.[31] The rest of the patients in this study had improvement in post-operative QoL. Zehetner et al. also used Vicryl® mesh and BioGlue® in all patients;[39] two of their 35 patients had recurrences on objective testing. One was symptomatic and dissatisfied, whereas the other patient had a GERD-HRQL score 28 and was satisfied with the surgery.{Table 6}

Gibson et al. did not use mesh in any patient and reported symptomatic recurrence of hiatus hernia in two (2%) patients, both involving a recurrent fundal herniation.[36] Another seven (7%) patients in this study had asymptomatic recurrence of <2 cms on radiological imaging and the most recent QoL score (questionnaire not specified) was significantly higher in those patients without recurrence compared with those with recurrence (110 [±21.8] vs. 94 [±24.6]; P = 0.03).[36]

Zugel et al. reported a serious complication in their case series;[33] one patient had mesh erosion in the aorta, requiring three surgeries at weekly intervals after the first operation. However, the patient was still satisfied at the end of 3-year follow-up and had no gastro-oesophageal symptoms (GIQLI: 127) or radiological recurrence (with CT scan).

Quality of life outcomes compared between two surgical techniques

Most studies used one method of repair, however there were five studies[21],[22],[23],[43],[48] comparing two different surgical methods and their improvement in QoL [Table 7]. There were five studies comparing the impact of surgical techniques on improvement in quality of life. Two studies compared laparoscopic versus open surgery, one study compared Nissen and Belsey Mark,[4] one study compared Nissen and Toupet and one study compared bougie and non bougie. None of the studies showed any difference in post-operative improvement in QoL between the two groups, however QoL still improved after surgery in both groups.{Table 7}

A further four studies[18],[23],[52],[55] used more than two procedures, however did not directly compare their impact on QoL. The procedures used included partial wrap, full wrap, Belsey Mark IV, emergency surgery, gastropexy, laparoscopic procedure, open procedure and Collis gastroplasty. Velanovich et al. reported one death of emergency patient.[18] They had 11.5% symptomatic recurrences in the laparoscopic group and 0% in the open group. Pierre et al. had high rate of complications (n = 57, 28%); there were four recurrent PEHs, of which one died and two required re-operation.[55] There were also six (3%) oesophageal leaks. Karmali et al. performed 270° partial wrap in their majority of patients (31/47) in the open group and 360-fundoplication in 38 out of 46 patients in the laparoscopic group.[23] Collis gastroplasty was performed in 2/46 (4%) and 1/47 (2%) patients in laparoscopic and open groups, respectively. The authors reported low symptomatic recurrence (9%) in each group.[23] The QoL outcomes from these four studies are summarised in [Table 8].{Table 8}

Collis gastroplasty and quality of life

Seven studies[18],[23],[29],[46],[52],[55],[57] used Collis gastroplasty in many of their patients to reduce the chance of recurrence [Table 8]. All studies showed improvement in QoL, with >77% excellent or good outcomes reported in four studies[23],[29],[46],[55] and statistical significance in a further three studies.[18],[52],[57] The recurrence rate varied from 4.7% to 18.8%.

Nason et al.[29] performed Collis gastroplasty if 2 cm of intra-abdominal length of oesophagus was not achieved, whereas other studies[23],[52],[57] used 3 cm as the cut-off point. Pierre et al. used Collis gastroplasty if the gastro-oesophageal junction could not be brought below the hiatus without tension.[55] Tringham et al. diagnosed short oesophagus pre-operatively on barium if the gastro-oesophageal junction was >5 cm above the hiatus or intra-operatively if the length of the oesophagus below the hiatus was <2 cm.[52] Whitson et al. mainly used Collis gastroplasty in combination with various other procedures, including some emergencies.[46] The authors found this technique useful in reducing recurrences and reported only two radiological recurrences. A univariate analysis by Laan et al. revealed that the performance of a wedge gastroplasty was protective of recurrence.[43]

Nason et al. found no correlation with any independent variables and recurrent PEH on radiographic follow-up.[63] However, they suggest a possibility of increased incidence of recurrence in patients with pre-operative pulmonary diseases such as asthma, chronic obstructive pulmonary disease, emphysema, bronchiectasis or interstitial fibrosis (odds ratio [OR]: 2.6; 95% confidence interval [CI]: 1.0, 7.0).[29] A total of 15 patients had radiological recurrence in this study. The authors performed Collis gastroplasty in 86% (160/187) of the patients and did not find oesophageal-lengthening procedure useful in reducing the incidence of recurrence (OR: 0.7; 95% CI: 0.2, 2.2). The QoL scores were excellent or good in 84% in those with radiographic recurrence compared to 85% in those without radiographic recurrence.

 Discussion



To the best of our knowledge, this is the first review exclusively looking at the post-operative QoL in patients undergoing surgical repair of GHH. The most outstanding finding of this review is that all studies demonstrated improvement in absolute QoL score after surgical GHH repair, with statistical significance found in 76% of studies. This was despite variation in key areas of reporting, including definition of GHH, type of surgical procedure (fundoplication 360° or partial, gastropexy and Collis gastroplasty), follow-up methods (radiological vs. endoscopic vs. symptomatic) and questionnaires used for assessing QoL. Patient age did not impact QoL improvement, and surgery was shown to improve QoL in both younger and older patient groups comparably. From the studies that compared the impact of two different surgical techniques on QoL, no significant difference was found. Similarly, only one out of six studies comparing mesh versus no mesh reported significantly improved QoL in patients where mesh was used. The impact of post-operative recurrence of GHH on QoL remains open to debate, with four out of nine studies finding significant differences in QoL between recurrence and non-recurrence groups.

In patients with GHH, dysphagia and shortness of breath are the most common presenting complaints due to intermittent partial volvulus. This contrasts with reflux disease, where heartburn is the predominant symptom. GERD-specific questionnaires such as GERD-HRQL and QOLRAD assessing these symptoms appear to be most useful in this cohort. The QOLRAD tool has been proven to have high validity and internal reliability in each dimension, as well as in composite score.[51] QOLRAD and GERD-HRQL scores also appear to be easy to understand and interpret. Furthermore, GERD-HRQL is claimed to be sensitive to treatment interventions.[51]

There are two different ways in which improvement in QoL is reported in GERD-HRQL and GIQLI questionnaires: (1) absolute scores and (2) percentage of patients having excellent, good, fair or poor results. This variation makes it difficult to assess the cumulative results of different studies or compare them. We believe that reporting absolute scores using these two questionnaires would be easier for readers and for data analyses. Alternatively, reporting both the results may also be acceptable.

SF-36 is a more generic tool, but we did not find it as an appropriate questionnaire for assessment of QoL after repair of GHH. Furthermore, it has often been reported in more than two ways – graphs, charts, component scores and separate PCS and MCS scores – making it difficult for meaningful collation of results. Xiao Li Guan et al. have compared QoL questionnaires in patients with GERD and contrary to our opinion, the authors felt that GERD-HRQL focuses on disease symptoms but ignores the importance of social function and psychological status in QoL, which is covered well by the SF-36.[50],[51] The authors suggest use of GERD-specific scales in conjunction with a generic questionnaire.

The decision to offer major surgery for GHH to prevent gastric volvulus has been debated for long time. In 2002, Stylopoulos et al. reported that a mortality of 1.4% for elective repair should be weighed against a 1.1% annual risk of complication through 'watchful waiting' management.[64] However, with advancing age, the risk of mortality increases and the cumulative annual risk of complications decreases with a reducing life span, thus changing the risk–benefit ratio. All the five studies in this review specifically looking at age and post-operative QoL have shown low mortality and sustained QoL improvement post-operatively in older patient cohorts. Two studies further report no significant differences in QoL improvement between older and younger patient groups, justifying the need to offer surgery to symptomatic elderly patients.[25],[60] Notably, data from one of the studies suggest that although QoL and symptom burden is comparable, older patients may experience higher post-operative morbidity than that of younger patients.[60] Collis gastroplasty and use of mesh have been the two commonly recommended adjuncts to reduce recurrence, used in addition to standard fundoplication or gastropexy. Collis gastroplasty adds the risk of leak from suture line to the conventionally 'clean' operation, and use of a mesh adds the risk of erosion to the viscera. The risks of these serious complications have prevented the general acceptance of these adjuncts in clinical practice. All studies using Collis gastroplasty in this review showed recurrence of 4.7%–18.8% and post-operative improvement in QoL with good or excellent outcomes in 77%–96.2% patients, and significant improvement in a further three studies [Table 8]. These figures are comparable to that of other studies in this review, suggesting that the influence of Collis gastroplasty on recurrence does not seem to affect post-operative QoL adversely.

The value of mesh in preventing recurrence is another contentious issue in the field of GHH surgery. The use of mesh did not appear to affect QoL in this review except in one study by Ilyashenko et al., who found significantly better post-operative QoL in mesh group compared to that of simple hiatal repair.[19] However, the outcome in the non-mesh group in this study was still a 'good' outcome as per the GERD-HRQL tool (16.3 pre-operative to 5.9 post-operative score).

Zugel et al. reported a serious complication in their case series; one patient had mesh erosion in aorta, requiring three surgeries at weekly intervals after the first operation. However, the patient was still satisfied at the end of 3-year follow-up and had no gastro-oesophageal symptoms (GIQLI score: 127) and no radiological recurrence (computed tomography scan). This anecdotal case exemplifies the fact that presence of complications does not necessarily correlate with poorer QoL. Findings from this review furthermore highlight that complications such as recurrence after GHH surgery do not equate to poor QoL scores. Five studies out of nine which directly compared QoL in patients with and without recurrence showed no difference between the two groups, whereas the other four studies showed significant difference in the improvement of QoL. Notably, length of follow-up may influence the rate of recurrence; for example, Dallemagne et al. had the longest follow-up period of 118 months and the highest recurrence of 66%. Furthermore, using more rigorous follow-up methods with multiple modalities of assessing recurrence would increase the chances of identifying recurrence. Therefore, we cannot draw confident conclusions regarding the impact of recurrence of QoL from the data included in this review.

Limitations

This review identified shortfalls in the reporting of studies addressing post-operative QoL after repair of GHH. A large heterogeneity of studies with wide variation between the types of QoL assessment tools used, surgical techniques, follow-up times and periodic QoL assessments made it difficult to 'normalise' and collate data, however within these constraints, we have summarised the outcomes with the best of our ability. There may also be an element of publication bias as all studies reveal positive QoL outcomes after surgery. In addition, only two randomised controlled trials were included in this review article and we identify a need for higher level of evidence in the literature.

 Conclusion



This review of the literature showed that elective repair of GHH offers significant improvement in QoL irrespective of age, surgical technique or use of mesh. The effect of recurrence on QoL is not answered by this review, and further study is required. Elective laparoscopic repair of GHH has low mortality and should be offered to symptomatic patients not just to prevent complications such as volvulus but also to improve QoL. A consensus statement in uniform reporting of surgical outcomes following repair of GHH is recommended.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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