THE CLASSIFICATION OF HIATAL HERNIA SHAPES AND ITS INFLUENCE ON OPERATIVE INTERVENTIONS AND OUTCOMES
John M. Campbell*, Megan L. Ivy, Alexander S. Farivar, Peter T. White, Adam J. Bograd, Brian E. Louie
Thoracic Surgery, Swedish Medical Center, Seattle, WA
Introduction:
Diaphragmatic reconstruction is a key component of hiatal hernia repair. Results are optimized by minimizing axial tension along the esophagus and radial tension across the diaphragmatic opening. Clinically relevant radial tension is difficult to assess intraoperatively. The shape of the hiatal opening appears to influence tension across the hiatus during closure and could be used intraoperatively to inform operative decision making. We categorized hiatal defects into 4 shapes as a surrogate of radial tension to determine their impact on operative interventions and outcomes.
Methods:
We retrospectively reviewed elective primary hiatal hernias (>3 cm in axial length) repaired at a single center from 2010-2020. Patients with intra-operative unrepaired hiatal photos with at least one year of follow up were included. The hiatal openings were classified into shapes: slit, inverted teardrop, "D", and oval, with two-person agreement. Shapes were ordered in this manner to represent progression or increasing complexity based on our center's experience. Recurrence was defined as any anatomical recurrence identified endoscopically or radiographically.
Results:
There were 239 patients studied, of which 111 (46%) recurred. The median follow up was 3.0 years (IQR: 1.8-5.4 years). There were 49 slits, 63 inverted teardrops, 93 "D"s, and 34 ovals. Demographics, comorbidities, and operative characteristics are described in Table 1.
As shape progressed from slit to inverted teardrop to "D" to oval we saw an increase in age (p<0.001), higher percentage of paraesophageal hernias (p<0.001), longer hernia axial length (p<0.001), and increase in hiatal width (p<0.001). Mesh, Collis gastroplasty, and relaxing incisions were more commonly employed in "D" and ovals (p=0.003, p=0.06, p<0.001, respectively).
Radiographic recurrence rates were not statically different amongst the hiatal shapes, but recurrences occurred sooner as shape progressed (p=0.017).
Recurrence free survival analysis with Kaplan Meier curve showed that "D" and oval have a lower recurrence free survival trend compared to slits and inverted teardrops. At 5 years, recurrence free survival trended inversely with increased shape (67% survival, 59%, 51%, and 45%).
Conclusion:
Four different hiatal shapes can be described during hiatal hernia surgery. They provide insight into their chronicity but also a spectrum of complexity with "D" and oval shapes being more complex. While more complex shapes predispose to earlier recurrence; their overall recurrence rates can be equated to less complex shapes with the use of adjunctive measures to reduce hiatal tension. Shape can serve as an intra-operative tool to inform surgeons of the need for adjunctive measures.
Table 1. Patient Characteristics, Hernia Characteristics, Operative Interventions, and Outcomes
Table 2. Recurrence Free Survival by Shape
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