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CRACKING THE CODE: KEY FACTORS INFLUENCING RECURRENCE TIMING AFTER HIATAL HERNIA REPAIR
Mikhail Attaar
*, Bradley Kushner, Michael M. Awad
Surgery, Washington University in St Louis School of Medicine, St. Louis, MO
BackgroundSymptomatic recurrence following hiatal hernia repair remains a significant clinical challenge, with recurrence rates ranging from 15% to 50% and causing patients significant morbidity. Research to date has focused primarily on rates of recurrence, however few studies have investigated timing of recurrence and their causative factors. This study aims to investigate patient-specific and technical factors influencing the timing of recurrence after hiatal hernia repair.
MethodsWe conducted a retrospective review of patients who underwent revisional hiatal hernia repair at a high-volume center from 2009-2024. Patients were included if they electively presented with symptomatic recurrence of a previously repaired hiatal hernia, confirmed via imaging. Data included patient factors such as demographics, clinical comorbidities, and preoperative symptomatology, as well as procedural factors from the index repair such as surgical approach, hospital volume, hernia size, elective/urgent, cruroplasty technique and mesh use. The primary outcome was time to recurrence, defined as the interval between initial and the first documented recurrence: very early (<3 months), early (3-12 months), medium (12-36 months), or late (> 36 months) recurrence. Multivariate logistic regression was performed with significance defined as p<0.05.
ResultsWe analyzed 838 patients who underwent revisional hiatal hernia repair at our institution by a single surgeon. Of these 661 had clinical/operative notes with sufficient detail for analysis. Regarding patient factors, history of active smoking (OR 5.11), weight gain >30 lbs after repair (OR 3.26), vomiting (OR 2.91), and urgent repair (OR 2.57) were associated with very early or early recurrence. Regarding procedural factors, low hospital volume (<10 per year) (OR 4.90) and lack of hiatal pexy stitches (OR 3.77) were associated with early recurrence while use of barbed suture (OR 6.74) or Endostitch (OR 5.18) for crural closure were strongly associated with very early recurrences. Interestingly, absolute BMI, number of times of redo, or mesh use did not seem to impact recurrence timing.
ConclusionsOur findings suggest that the timing of hiatal hernia recurrence is influenced by a combination of patient-specific and procedural factors. Potentially modifiable patient factors such as smoking, weight gain, and active vomiting should be addressed prior to subsequent repairs. Recurrences within 3 months were highly associated with the use of barbed suture and Endostitch crural closures and should be used with caution. Interestingly, obese patients did not have earlier recurrences as is often presumed. As appears to be the case with other recent literature, mesh use also did not impact recurrence timing. These findings may provide guidance to surgeons who perform hiatal hernia repairs that may help to optimize patient outcomes.
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