Factors influencing recurrence after minimally invasive treatment of hiatal hernia—a single center experience

Abstract

Background: Despite undoubtable advantages in respect of the open counterpart laparoscopic fundoplication is still burden by high recurrence rate. The aim of this study was to focus on factors that may be linked to a higher risk of recurrence after minimally invasive Nissen fundoplication for hiatal hernia to allow a better preoperative selection of the patients in order to maximize the benefit of minimally invasive surgery. Methods: A retrospective analysis of patients undergoing minimally invasive Nissen fundoplication was done to assess perioperative and postoperative outcomes at Clinica Chirurgica in Ancona, between 2012 and 2018. Inclusion criteria consisted of a positive surgical history for reflux treated with minimally invasive procedures (laparoscopic Nissen fundoplication, LNF, or robotic Nissen fundoplication, RNF) and one year follow up at least. Data regarding baseline population characteristics (age, gender, ASA score, preoperative BMI), hernia characteristics (Type 1, 2, 3, 4) and operative techniques were collected. Time to surgery (TS) was also recorded defined as the time between the first endoscopic diagnosis of hiatal hernia and the time when surgery was performed. Follow-up evaluation was performed at 1, 3, 12, 24, and 36 months after surgery. Results: Among the 50 patients undergone minimally invasive fundoplication between 2012 and 2018, 36 undergone LNF and 14 RNF. The recurrence rate was 18%. Class I Obesity (OR =9, 95% CI, 1.792–45.188; P=0.007), Type 3 hernia (OR =7.35, 95% CI, 1.238–43.694; P=0.028), TS >3 years (OR =18, 95% CI, 3.195–101.385; P<000.1) and surgical procedure (OR =4.33, 95% CI, 0.495–37.929; P=0.125) were found as significant predictors of recurrence on univariate analysis. On multivariate analysis the type of hiatal hernia (P=0.032), obesity (P=0.012) and TS (P=0.003) were risk factors for recurrence, but this did not seem to be influenced by surgical procedure (P=0.300). Conclusions: Although, the type of hiatal hernia and obesity do not constitute absolute contraindications to minimally invasive anti-reflux surgery, proper preoperative patients selection and assessment of the right timing of surgery are crucial to draw the major benefits from this kind of surgery.