Surg Endosc DOI 10.1007/s00464-013-3292-x
and Other Interventional Techniques
LETTER TO THE EDITOR
Hiatal surface area as a basis for a new classification of hiatal hernia Stavros A. Antoniou • Rudolph Pointner Frank-Alexander Granderath
•
Received: 26 September 2013 / Accepted: 11 October 2013 Springer Science+Business Media New York 2013
To the Editor, We were pleased to read an outstanding study, recently published by Surgical Endoscopy [1]. Grubnik and Malynovskyy introduced a novel outcome-oriented and evidence-based classification for hiatal hernias. The authors divided a cohort of 658 patients into three groups, according to the hiatal surface area (HSA). The cut-off values of 10 and 20 cm2 were used to distinguish small from large and giant hiatal hernias. Their classification was validated by comparison among groups and analysis of variance. The idea of measuring the HSA was introduced in 2007 by Granderath [2] following the clinical observation of large hiatal defects in a subgroup of patients with sliding hernias, and small defects in a subgroup of patients with paraesophageal hernias [3]. Although it was commonly thought that these cases account for a small proportion of patients who undergo anti-reflux surgery, careful observation of the subgroup data of this study provides important insights with significant clinical consequences.
S. A. Antoniou F.-A. Granderath Center for Minimally Invasive Surgery, Neuwerk Hospital, Mo¨nchengladbach, Germany S. A. Antoniou (&) Department of General Surgery, University Hospital of Heraklion, University of Crete, Athinon-Souniou 11, Keratea, 19001 Athens, Greece e-mail: [email protected] R. Pointner Department of General and Visceral Surgery, Hospital Zell am See, Zell am See, Austria
The subgroup of patients with small hiatal defects (HSA \10 cm2) includes 290 patients with type I hernia (92 %). Similarly, the subgroup of patients with large hiatal defects (HSA 10–20 cm2) includes 116 patients with type I hernia (50 %). If the indication for mesh closure were to be based on the type of hernia (i.e. primary repair in sliding hernias and mesh application only in paraesophageal hernias) rather than the HSA, we would statistically expect an additional number of nine patients of the type I group with large hiatal defects to experience hernia recurrence. This would raise the recurrence rate in this group from 3.0 to 5.2 %. Furthermore, 24 patients with paraesophageal hernias and small hiatal defects (7.4 % of patients with HSA \10 cm2) would be subjected to mesh repair, albeit the expected recurrence rate in this subgroup is only 3.5 %. Of course, the expected reduction of the risk for recurrence cannot be calculated, because all cases of small defects and paraesophageal hernia were subjected to primary repair. It would be reasonable for the following comment by Grubnik and Malynovskyy to be considered the essence of the rationale to conduct this study: ‘‘…no strong criterion exists for classifying hiatal hernias, although universal classification is necessary because the recurrence rate is strongly dependent on hernia size and Hill’s type.’’ The authors provide a stable scientific platform for a consensus on the definition of small, large, and giant hiatal hernia; such an evidence basis was missing in the literature. The quality and quantity of the provided data are the apparent strengths of this report and may not be disregarded, whereas the authors were meticulous in providing detailed information on methodology and outcomes. This study instigates the ongoing discussion on the definition of large and giant hiatal hernia and challenges the traditional classification. Since neither the type of the
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Surg Endosc
hernia nor the size of the hiatal defect are the only determinants of the risk for anatomical recurrence, other known or anecdotal risk factors, such as the quality of the crural pillars, obesity, age, and collagen disorders, are expected to be involved in a grading system, which will evaluate the probability of recurrence and allow risk-adjusted application of mesh hiatoplasty. Disclosures Drs. S. A. Antoniou, R. Pointner, and F. A. Granderath have no conflicts of interest or financial ties to disclose.
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References 1. Grubnik VV, Malynovskyy AV (2013) Laparoscopic repair of hiatal hernias: new classification supported by long-term results. Surg Endosc 27(11):4337–4346 2. Granderath FA (2007) Measurement of the esophageal hiatus by calculation of the hiatal surface area (HSA). Why, when and how? Surg Endosc 21:2224–2225 3. Granderath FA, Schweiger UM, Pointner R (2007) Laparoscopic antireflux surgery: tailoring the hiatal closure to the size of hiatal surface area. Surg Endosc 21:542–548
and Other Interventional Techniques
LETTER TO THE EDITOR
Hiatal surface area as a basis for a new classification of hiatal hernia Stavros A. Antoniou • Rudolph Pointner Frank-Alexander Granderath
•
Received: 26 September 2013 / Accepted: 11 October 2013 Springer Science+Business Media New York 2013
To the Editor, We were pleased to read an outstanding study, recently published by Surgical Endoscopy [1]. Grubnik and Malynovskyy introduced a novel outcome-oriented and evidence-based classification for hiatal hernias. The authors divided a cohort of 658 patients into three groups, according to the hiatal surface area (HSA). The cut-off values of 10 and 20 cm2 were used to distinguish small from large and giant hiatal hernias. Their classification was validated by comparison among groups and analysis of variance. The idea of measuring the HSA was introduced in 2007 by Granderath [2] following the clinical observation of large hiatal defects in a subgroup of patients with sliding hernias, and small defects in a subgroup of patients with paraesophageal hernias [3]. Although it was commonly thought that these cases account for a small proportion of patients who undergo anti-reflux surgery, careful observation of the subgroup data of this study provides important insights with significant clinical consequences.
S. A. Antoniou F.-A. Granderath Center for Minimally Invasive Surgery, Neuwerk Hospital, Mo¨nchengladbach, Germany S. A. Antoniou (&) Department of General Surgery, University Hospital of Heraklion, University of Crete, Athinon-Souniou 11, Keratea, 19001 Athens, Greece e-mail: [email protected] R. Pointner Department of General and Visceral Surgery, Hospital Zell am See, Zell am See, Austria
The subgroup of patients with small hiatal defects (HSA \10 cm2) includes 290 patients with type I hernia (92 %). Similarly, the subgroup of patients with large hiatal defects (HSA 10–20 cm2) includes 116 patients with type I hernia (50 %). If the indication for mesh closure were to be based on the type of hernia (i.e. primary repair in sliding hernias and mesh application only in paraesophageal hernias) rather than the HSA, we would statistically expect an additional number of nine patients of the type I group with large hiatal defects to experience hernia recurrence. This would raise the recurrence rate in this group from 3.0 to 5.2 %. Furthermore, 24 patients with paraesophageal hernias and small hiatal defects (7.4 % of patients with HSA \10 cm2) would be subjected to mesh repair, albeit the expected recurrence rate in this subgroup is only 3.5 %. Of course, the expected reduction of the risk for recurrence cannot be calculated, because all cases of small defects and paraesophageal hernia were subjected to primary repair. It would be reasonable for the following comment by Grubnik and Malynovskyy to be considered the essence of the rationale to conduct this study: ‘‘…no strong criterion exists for classifying hiatal hernias, although universal classification is necessary because the recurrence rate is strongly dependent on hernia size and Hill’s type.’’ The authors provide a stable scientific platform for a consensus on the definition of small, large, and giant hiatal hernia; such an evidence basis was missing in the literature. The quality and quantity of the provided data are the apparent strengths of this report and may not be disregarded, whereas the authors were meticulous in providing detailed information on methodology and outcomes. This study instigates the ongoing discussion on the definition of large and giant hiatal hernia and challenges the traditional classification. Since neither the type of the
123
Surg Endosc
hernia nor the size of the hiatal defect are the only determinants of the risk for anatomical recurrence, other known or anecdotal risk factors, such as the quality of the crural pillars, obesity, age, and collagen disorders, are expected to be involved in a grading system, which will evaluate the probability of recurrence and allow risk-adjusted application of mesh hiatoplasty. Disclosures Drs. S. A. Antoniou, R. Pointner, and F. A. Granderath have no conflicts of interest or financial ties to disclose.
123
References 1. Grubnik VV, Malynovskyy AV (2013) Laparoscopic repair of hiatal hernias: new classification supported by long-term results. Surg Endosc 27(11):4337–4346 2. Granderath FA (2007) Measurement of the esophageal hiatus by calculation of the hiatal surface area (HSA). Why, when and how? Surg Endosc 21:2224–2225 3. Granderath FA, Schweiger UM, Pointner R (2007) Laparoscopic antireflux surgery: tailoring the hiatal closure to the size of hiatal surface area. Surg Endosc 21:542–548
