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Page 8 of 12 Ugliono et al. Mini-invasive Surg 2021;5:2 I http://dx.doi.org/10.20517/2574-1225.2020.93

Table 1. Outcomes of laparoscopic gastropexy in paraesophageal hernia treatment
Authors Year n GP (n) Associated Recurrences (%) Mortality (%) Follow-up Notes
procedures (n) (months)
Agwunobi et al. [61] 1998 13 HR 13 14.4% symptomatic 7.7 10 15.4% conversions
Hawasli et al. [62] 1998 27 25 MC = 25 0% 0 1-56 22.2% reflux
Van der Peet et al. [63] 2000 19 19 SC = 17 15.8% radiological 0 24 15.8% conversions
MC = 2 75% reflux esophagitis
FP = 15 without FP
Ponsky et al. [64] 2003 28 28 FP = 28 0% radiological 0 12
Diaz et al. [65] 2003 116 48 SC = 110 32% radiological 1.7 30 4.3% major
MC = 6 complications
FP = 114
EL = 6
Horstmann et al. [66] 2004 16 16 MC = 16 0% radiological 0 14 6.25% conversions
FP = 16 31% pleural injury
Poncet et al. [67] 2010 89 77 MC = 89 15.7% radiological 0 57.5 4.4% conversions
FP = 89 7.8% morbidity
Daigle et al. [68] 2015 101 101 SC = 94 16.8% endoscopic/ 0 10.9 22% morbidity
radiological 29.7% reflux
Yates et al. [69] 2015 11 HR 10 TG = 11 0% symptomatic N/A 3 2 readmissions
2 TG dislocations
Higashi et al. [70] 2017 8 HR 100 0% symptomatic 0% 48
HR: high risk patients; GP: gastropexy; MC: mesh cruroplasty; SC: simple cruroplasty; FP: fundoplication; EL: esophageal lengthening;
TG: tube gastrostomy

The rationale for adding a fundoplication is twofold: treating preoperative GER symptoms and preventing
the postoperative onset of GER. GER is a frequent clinical manifestation of PEH because the herniation
through the diaphragmatic hiatus determines a functional incompetence of the lower esophageal
sphincter (LES), favoring the reflux of the gastric contents. GER can also occur “de novo” postoperatively
due to altered functional anatomy of the GEJ caused by extensive mediastinal dissection. Furthermore,
fundoplication is thought to anchor the cardia below the diaphragm, contributing to the reduction in the
rate of recurrences . For these reasons, some authors advocate the routine addition of a fundoplication to
[50]
[71]
restore the functional competence of the LES .

Other authors sustain the selective addition of fundoplication during PEH repair depending on the
presence of preoperative GER or altered esophageal motility at esophageal manometry. They believe that
the intra-abdominal reduction of PEH restores the normal anatomy of the EGJ, therefore no other anti-
[72]
reflux operations, with the consequent risk of dysphagia, are needed .
However, the LES competence can be difficult to assess preoperatively, because esophageal manometry can
[73]
be unreliable in the presence of PEH . Furthermore, the incidence of dysphagia following fundoplication
[74]
is minimal in experienced hands .
Müller-Stich et al. performed a RCT comparing mesh-augmented hiatoplasty with or without the
[75]
addition of a fundoplication. At 12-month follow-up, the fundoplication group had a significantly lower
incidence of GER symptoms than hiatoplasty alone, and the subjective results were confirmed by objective
upper endoscopy findings. Interestingly, the incidence of gas bloat and dysphagia did not differ between the
two groups, leading the authors to favor the systematic addition of an anti-reflux procedure.

[76]
In addition, Furnée et al. performed a comparative study of patients who underwent PEH repair with or
without fundoplication. Of the 20 patients who did not receive fundoplication, new onset of esophagitis
occurred in 28%, and pathological acid exposure was demonstrated in 39%. In the fundoplication group,
8.7% of patients experienced dysphagia. The authors concluded that, since the rate of postoperative side
effects of fundoplication is low, while objective evidence of postoperatively de novo onset of GER occurred
frequently, the addition of a fundoplication should be recommended during PEH repair.