Treatment of paraesophageal hiatal hernia in octogenarians: a systematic review and retrospective cohort study

Treatment of paraesophageal hiatal hernia in octogenarians: a systematic review and retrospective... Summary Over the coming years octogenarians will make up an increasingly large proportion of the population. With the rise in octogenarians more paraesophageal hiatal hernias may be identified. In research for the optimal treatment for paraesophageal hiatal hernias, octogenarians are often omitted and the optimal surgical strategy for this patient group remains unclear. A systematic search in PubMed, Embase, and The Cochrane Library was conducted, including articles compromising ‘surgery,’ ‘paraesophageal hiatal hernia,’ and ‘octogenarians.’ Selection of articles was based on independent review by two authors. Alongside, a retrospective cohort study was conducted including all type II–IV hiatal hernia repairs performed in the VU Medical Center in Amsterdam, The Netherlands, from 2005 to 2015. A total of 486 papers were eligible for selection. After careful selection, a total of eight articles were included. All articles were retrospective cohort studies describing different proportions of octogenarians. The populations and surgical techniques were very heterogeneous. Elective paraesophageal hiatal hernia repair was performed safely in symptomatic octogenarians in all studies. Additional analysis of 84 patients, of which 9.5% octogenarians, was performed at our tertiary referral center. A larger hernia type, more acute interventions and a higher morbidity and mortality rate was observed in octogenarians compared to patients aged <80 years. In conclusion, elective paraesophageal hiatal hernia repair can be performed in octogenarians, especially in patients without comorbidity. Findings suggest improvement in symptoms in short-term follow up, with minimal morbidity and mortality. With regard to surgical techniques, laparoscopy and fundoplication were performed safely. Octogenarians need to be included in future clinical trials to further evaluate the optimal surgical intervention. Preoperative risk assessment by clinical prediction rules should guide operative intervention, in order to evaluate risks and benefits in this challenging population. INTRODUCTION Paraesophageal hiatal hernias (PHH) account for 5% of all hiatal hernias.1 In contrast to sliding hernias, many patients are asymptomatic. When symptoms do occur, heartburn, chest pain, regurgitation, early satiety, chronic anemia, and dysphagia are reported.2–4 The diagnosis of PHH can be an indication for surgery as untreated PHH may lead to potentially lethal complications such as strangulation, incarceration, volvulus, and perforation.5,6 Urgent surgical intervention subjects patients to increased morbidity and mortality.7–9 The mortality rates in emergency repair range from 5% to 50% as opposed to 0.5–3% in an elective setting. Interestingly, octogenarians are underrepresented in these studies.10–17 With regard to operative techniques, consensus has been reached on the necessitated steps; dissection and excision of the hernial sac, dissection and assessment of the intra-abdominal length of the esophagus and closure of the crural defect. Additionally, an antireflux procedure is advised when a mixed type hernia with complaints of gastroesophageal reflux disease is present.18 The approach and technique of crural closure continues to be one of the most controversial topics in surgical literature.13,19 The proportion of octogenarians, within the population aged ≥60 years, increased from 7% in 1950 to 14% in 2013 and is calculated to be as large as 19% in 2050.20 PHH are seen more in patients of older age, and are therefore likely to become more prevalent as the general population ages.21 The proportion of surgical procedures performed in the elderly is increasing in recent years.22 Octogenarians are often omitted in research on PHH and the optimal surgical techniques in this population are therefore unclear. The aim of this study is to assess whether an indication for surgical repair of PHH in octogenarians exists and what surgical technique is most suitable in this population. MATERIALS AND METHODS Literature search A systematic literature search was conducted from inception to October 4th 2016 in Embase, PubMed, and The Cochrane Library. Free search terms and Medical Subject Heading (MeSH) terms were used to identify relevant articles in PubMed and Embase. In The Cochrane Library only free search terms were set up to assess all relevant publications. Search terms comprising ‘paraesophageal hiatal hernia,’ ‘surgery,’ ‘octogenarians,’ and relevant synonyms were used. Selection criteria Articles were independently assessed on relevance by two authors (JS and LG). Inclusion criteria consisted of: (1) PHH, hiatal hernia type II–IV, large hiatal hernias described as hernias >5 cm or contain more than one third of stomach; (2) the study population consisted of octogenarians, or compared octogenarians with younger patient groups; (3) Included articles had to be in English, Dutch, German, or Spanish. The exclusion criteria were: (1) specific patient groups such as obesity surgery, antireflux surgery, recurrent hiatal hernia repair and emergency surgery; (2) animal studies; (3) review articles and case reports. References of the included articles were assessed manually for additional relevant articles. Data extraction and quality assessment This systematic review was conducted in line with the recommendations of the PRISMA Statement for Systematic Reviews and Meta-Analyses.23 Data collection was performed by two authors (JS and LG), which extracted the following data: first author and year of publication, study period, study type, country, sample size, age groups, mean age, sex, hernia type and clinical outcomes. Data extracted was reported in means and standard deviations. The quality assessment of the included studies was classified using the Newcastle-Ottawa Quality Assessment Scale (NOS) for retrospective cohort studies and case-control studies.24 Studies were evaluated independently. A maximum of nine points could be awarded. Selection criteria of the concerned study could receive four points; three points could be awarded for outcome and two points for comparability. A study was classified as high quality when it scored six or more points. A level of evidence was assigned to studies according to the Oxford Centre of Evidence Based Medicine Levels of Evidence.25 Cohort studies with less than six points were assigned a level of evidence of four; a score of six or seven was 2B. Cohort studies that included a comparison between groups were assigned a level of evidence of 3B. Database acquisition Alongside this systematic review an observational cohort study was conducted, including all patients who underwent PHH repair at the VU University Medical Center from January 2005 to June 2015. Patients <18 years of age, traumatic surgery, patients with previous surgery of the esophagus or stomach were excluded. Data were collected regarding patient characteristics, pre- and postoperative symptoms, type of intervention, operative time, conversion, intraoperative complications, postoperative complications, mortality, morbidity, length of hospital stay, and survival. Minor complications were graded as Clavien–Dindo (CD) 1–2 and major complications as CD 3–5. This study was approved by the Medical Ethical Committee from our institution and conforms to requisite ethical and juridical aspects. Statistical analysis Data were analyzed using the SPSS Statistics, version 20 (IBM, Washington, DC). Continuous variables were expressed as means and standard deviations for normal distributions and medians and interquartile ranges for non-normal distributions. Comparison of octogenarians with patients aged <80 years was performed with a Student's T-test or Mann-Whitney-U test as was deemed appropriate. Frequencies were expressed as percentages and analyzed using the Chi-square test. RESULTS Study selection A total of 486 studies were identified, of which 30 duplicates were excluded. Articles were screened for eligibility on title and abstract, based on the predefined inclusion- and exclusion criteria. After independently selecting relevant articles, two authors (JS and LG) compared the two different search results, which led up to the definitive first selection of 24 relevant articles. After full text analysis, another 17 articles were excluded because octogenarians were not analyzed separately, the intervention group did not focus on hiatal hernia repair or included <10 patients. One additional article was identified via cross-referencing.26 Finally, eight articles were included in this systematic review.8,21,22,26–30 A flow-chart of the article selection is depicted in Figure 1. Fig. 1 View largeDownload slide Flow diagram for article selection. Fig. 1 View largeDownload slide Flow diagram for article selection. Study characteristics Eight articles were included for qualitative synthesis, including a total of 218,891 patients; all studies were of observational nature. One study was conducted in Switzerland;21 the other seven studies were conducted in the United States of America.8,22,26–30 Information on the included studies is depicted in Table 1. Two authors (JS and LG) independently appraised all articles using the NOS, alongside the level of evidence was determined. An overview of the assessment is depicted in Table 2. Table 1 Overview of included studies Author Publication year Study period Design Country Sample size Age groups Mean Age Sex M/F Hernia type Outcome Ballian et al.26 2013 1997–2010 RSC USA 980 <50 years, 50–59 years, 60–69 years, 70–79 years, ≥80 years 71 (IQR: 62–78 247/733 >30% of stomach in posterior mediastinum Clinical prediction rules for postoperative mortality and morbidity Larusson et al.21 2009 1995–2006 RSC Switzerland 354 <70 years, 70–79 years, ≥80 years 64 (R: 23–90) 127/227 II(37.0%), III(25.4%), IV(37.6%) Higher mortality in octogenarians and a higher morbidity in hernia repair with gastropexy Luketich et al.8 2010 1997–2003 vs. 2003–2008 RSC USA 662 Subgroup analysis ≥80 years 70 (R: 19–92) 167/495 >30% of stomach herniated into mediastinum Patients who are older, obese or have comorbid diseases are at higher risk for adverse postoperative outcomes Molena et al.22 2014 2005–2011 RSC USA 19,388 <65 years 65–69 years, 70–74 years, 75–79 years, ≥80 years 56.4 7061/12,327 91.4% PHH Age, both alone and in a synergistic fashion with other comorbidities, was an important risk factor for adverse outcomes Parker et al.30 2016 2003–2012 RSC USA 267 <70 years, 70–79 years, ≥80 years 58.5/75.0 /83.0 (R: 32–98) 71/196 100% PHH Despite the advanced age and comorbidities, PHH repair can be performed safely in octogenarians. Paul et al.27 2011 1999–2008 RSC USA 193,554 <50 years, 50–59 years, 60–69 years, 70–79 years, ≥80 years 66.0 (R: 52.0–77.0) 62,568/130, 986 Type I-IV, exclusion: antireflux and small sliding hernia Elective repair was associated with better outcomes than nonelective repair, with a favorable risk-benefit profile Poulose et al.28 2008 2005 RSC USA 1005 ≥80 years 84.7 (SE:0.3) 271/734 Diaphragmatic hernias, exclusion: congenital/traumatic hernia and thoracic approach Nonelective repair was associated with a 6–7 fold increase in mortality and longer hospital stay Spaniolas et al29 2014 2010–2011 RSC USA 2681 <80 years vs. ≥80 years 63 (R:14) 1027/1887 PHH, excluded: bariatric- and emergent surgery Elective repair in octogenarians was not associated with a higher mortality and morbidity than younger patients Author Publication year Study period Design Country Sample size Age groups Mean Age Sex M/F Hernia type Outcome Ballian et al.26 2013 1997–2010 RSC USA 980 <50 years, 50–59 years, 60–69 years, 70–79 years, ≥80 years 71 (IQR: 62–78 247/733 >30% of stomach in posterior mediastinum Clinical prediction rules for postoperative mortality and morbidity Larusson et al.21 2009 1995–2006 RSC Switzerland 354 <70 years, 70–79 years, ≥80 years 64 (R: 23–90) 127/227 II(37.0%), III(25.4%), IV(37.6%) Higher mortality in octogenarians and a higher morbidity in hernia repair with gastropexy Luketich et al.8 2010 1997–2003 vs. 2003–2008 RSC USA 662 Subgroup analysis ≥80 years 70 (R: 19–92) 167/495 >30% of stomach herniated into mediastinum Patients who are older, obese or have comorbid diseases are at higher risk for adverse postoperative outcomes Molena et al.22 2014 2005–2011 RSC USA 19,388 <65 years 65–69 years, 70–74 years, 75–79 years, ≥80 years 56.4 7061/12,327 91.4% PHH Age, both alone and in a synergistic fashion with other comorbidities, was an important risk factor for adverse outcomes Parker et al.30 2016 2003–2012 RSC USA 267 <70 years, 70–79 years, ≥80 years 58.5/75.0 /83.0 (R: 32–98) 71/196 100% PHH Despite the advanced age and comorbidities, PHH repair can be performed safely in octogenarians. Paul et al.27 2011 1999–2008 RSC USA 193,554 <50 years, 50–59 years, 60–69 years, 70–79 years, ≥80 years 66.0 (R: 52.0–77.0) 62,568/130, 986 Type I-IV, exclusion: antireflux and small sliding hernia Elective repair was associated with better outcomes than nonelective repair, with a favorable risk-benefit profile Poulose et al.28 2008 2005 RSC USA 1005 ≥80 years 84.7 (SE:0.3) 271/734 Diaphragmatic hernias, exclusion: congenital/traumatic hernia and thoracic approach Nonelective repair was associated with a 6–7 fold increase in mortality and longer hospital stay Spaniolas et al29 2014 2010–2011 RSC USA 2681 <80 years vs. ≥80 years 63 (R:14) 1027/1887 PHH, excluded: bariatric- and emergent surgery Elective repair in octogenarians was not associated with a higher mortality and morbidity than younger patients BMI, body mass index (kg/m2); IQR, interquartile range, R, range; RSC, retrospective cohort; SE, standard error of the mean; y, years; USA, United States of America. View Large Table 1 Overview of included studies Author Publication year Study period Design Country Sample size Age groups Mean Age Sex M/F Hernia type Outcome Ballian et al.26 2013 1997–2010 RSC USA 980 <50 years, 50–59 years, 60–69 years, 70–79 years, ≥80 years 71 (IQR: 62–78 247/733 >30% of stomach in posterior mediastinum Clinical prediction rules for postoperative mortality and morbidity Larusson et al.21 2009 1995–2006 RSC Switzerland 354 <70 years, 70–79 years, ≥80 years 64 (R: 23–90) 127/227 II(37.0%), III(25.4%), IV(37.6%) Higher mortality in octogenarians and a higher morbidity in hernia repair with gastropexy Luketich et al.8 2010 1997–2003 vs. 2003–2008 RSC USA 662 Subgroup analysis ≥80 years 70 (R: 19–92) 167/495 >30% of stomach herniated into mediastinum Patients who are older, obese or have comorbid diseases are at higher risk for adverse postoperative outcomes Molena et al.22 2014 2005–2011 RSC USA 19,388 <65 years 65–69 years, 70–74 years, 75–79 years, ≥80 years 56.4 7061/12,327 91.4% PHH Age, both alone and in a synergistic fashion with other comorbidities, was an important risk factor for adverse outcomes Parker et al.30 2016 2003–2012 RSC USA 267 <70 years, 70–79 years, ≥80 years 58.5/75.0 /83.0 (R: 32–98) 71/196 100% PHH Despite the advanced age and comorbidities, PHH repair can be performed safely in octogenarians. Paul et al.27 2011 1999–2008 RSC USA 193,554 <50 years, 50–59 years, 60–69 years, 70–79 years, ≥80 years 66.0 (R: 52.0–77.0) 62,568/130, 986 Type I-IV, exclusion: antireflux and small sliding hernia Elective repair was associated with better outcomes than nonelective repair, with a favorable risk-benefit profile Poulose et al.28 2008 2005 RSC USA 1005 ≥80 years 84.7 (SE:0.3) 271/734 Diaphragmatic hernias, exclusion: congenital/traumatic hernia and thoracic approach Nonelective repair was associated with a 6–7 fold increase in mortality and longer hospital stay Spaniolas et al29 2014 2010–2011 RSC USA 2681 <80 years vs. ≥80 years 63 (R:14) 1027/1887 PHH, excluded: bariatric- and emergent surgery Elective repair in octogenarians was not associated with a higher mortality and morbidity than younger patients Author Publication year Study period Design Country Sample size Age groups Mean Age Sex M/F Hernia type Outcome Ballian et al.26 2013 1997–2010 RSC USA 980 <50 years, 50–59 years, 60–69 years, 70–79 years, ≥80 years 71 (IQR: 62–78 247/733 >30% of stomach in posterior mediastinum Clinical prediction rules for postoperative mortality and morbidity Larusson et al.21 2009 1995–2006 RSC Switzerland 354 <70 years, 70–79 years, ≥80 years 64 (R: 23–90) 127/227 II(37.0%), III(25.4%), IV(37.6%) Higher mortality in octogenarians and a higher morbidity in hernia repair with gastropexy Luketich et al.8 2010 1997–2003 vs. 2003–2008 RSC USA 662 Subgroup analysis ≥80 years 70 (R: 19–92) 167/495 >30% of stomach herniated into mediastinum Patients who are older, obese or have comorbid diseases are at higher risk for adverse postoperative outcomes Molena et al.22 2014 2005–2011 RSC USA 19,388 <65 years 65–69 years, 70–74 years, 75–79 years, ≥80 years 56.4 7061/12,327 91.4% PHH Age, both alone and in a synergistic fashion with other comorbidities, was an important risk factor for adverse outcomes Parker et al.30 2016 2003–2012 RSC USA 267 <70 years, 70–79 years, ≥80 years 58.5/75.0 /83.0 (R: 32–98) 71/196 100% PHH Despite the advanced age and comorbidities, PHH repair can be performed safely in octogenarians. Paul et al.27 2011 1999–2008 RSC USA 193,554 <50 years, 50–59 years, 60–69 years, 70–79 years, ≥80 years 66.0 (R: 52.0–77.0) 62,568/130, 986 Type I-IV, exclusion: antireflux and small sliding hernia Elective repair was associated with better outcomes than nonelective repair, with a favorable risk-benefit profile Poulose et al.28 2008 2005 RSC USA 1005 ≥80 years 84.7 (SE:0.3) 271/734 Diaphragmatic hernias, exclusion: congenital/traumatic hernia and thoracic approach Nonelective repair was associated with a 6–7 fold increase in mortality and longer hospital stay Spaniolas et al29 2014 2010–2011 RSC USA 2681 <80 years vs. ≥80 years 63 (R:14) 1027/1887 PHH, excluded: bariatric- and emergent surgery Elective repair in octogenarians was not associated with a higher mortality and morbidity than younger patients BMI, body mass index (kg/m2); IQR, interquartile range, R, range; RSC, retrospective cohort; SE, standard error of the mean; y, years; USA, United States of America. View Large Table 2 Newcastle-Ottawa quality assessment scale and level of evidence of the included articles Authors Publication year Represent-ativeness exposed cohort Selection nonexposed cohort Ascertain-ment of exposure Demonstration outcome of interest not present at start of study Compara-bility cohorts (max. 2 points) Assessment of outcome Follow-up long enough for outcome interest Adequacy of follow-up Total Level of evidence Ballian et al.26 2013 1 1 1 1 2 1 1 1 9 3B Larusson et al.21 2009 0 0 1 1 1 1 0 0 4 4 Luketich et al.8 2010 0 1 1 1 0 1 1 1 6 2B Molena et al.22 2014 1 1 1 1 2 1 1 1 9 3B Parker et al.30 2016 1 1 1 1 2 1 1 1 9 3B Poulose et al.28 2008 1 0 1 1 0 1 0 0 4 4 Spaniolas et al.29 2014 1 1 1 1 2 1 1 1 9 3B Authors Publication year Represent-ativeness exposed cohort Selection nonexposed cohort Ascertain-ment of exposure Demonstration outcome of interest not present at start of study Compara-bility cohorts (max. 2 points) Assessment of outcome Follow-up long enough for outcome interest Adequacy of follow-up Total Level of evidence Ballian et al.26 2013 1 1 1 1 2 1 1 1 9 3B Larusson et al.21 2009 0 0 1 1 1 1 0 0 4 4 Luketich et al.8 2010 0 1 1 1 0 1 1 1 6 2B Molena et al.22 2014 1 1 1 1 2 1 1 1 9 3B Parker et al.30 2016 1 1 1 1 2 1 1 1 9 3B Poulose et al.28 2008 1 0 1 1 0 1 0 0 4 4 Spaniolas et al.29 2014 1 1 1 1 2 1 1 1 9 3B View Large Table 2 Newcastle-Ottawa quality assessment scale and level of evidence of the included articles Authors Publication year Represent-ativeness exposed cohort Selection nonexposed cohort Ascertain-ment of exposure Demonstration outcome of interest not present at start of study Compara-bility cohorts (max. 2 points) Assessment of outcome Follow-up long enough for outcome interest Adequacy of follow-up Total Level of evidence Ballian et al.26 2013 1 1 1 1 2 1 1 1 9 3B Larusson et al.21 2009 0 0 1 1 1 1 0 0 4 4 Luketich et al.8 2010 0 1 1 1 0 1 1 1 6 2B Molena et al.22 2014 1 1 1 1 2 1 1 1 9 3B Parker et al.30 2016 1 1 1 1 2 1 1 1 9 3B Poulose et al.28 2008 1 0 1 1 0 1 0 0 4 4 Spaniolas et al.29 2014 1 1 1 1 2 1 1 1 9 3B Authors Publication year Represent-ativeness exposed cohort Selection nonexposed cohort Ascertain-ment of exposure Demonstration outcome of interest not present at start of study Compara-bility cohorts (max. 2 points) Assessment of outcome Follow-up long enough for outcome interest Adequacy of follow-up Total Level of evidence Ballian et al.26 2013 1 1 1 1 2 1 1 1 9 3B Larusson et al.21 2009 0 0 1 1 1 1 0 0 4 4 Luketich et al.8 2010 0 1 1 1 0 1 1 1 6 2B Molena et al.22 2014 1 1 1 1 2 1 1 1 9 3B Parker et al.30 2016 1 1 1 1 2 1 1 1 9 3B Poulose et al.28 2008 1 0 1 1 0 1 0 0 4 4 Spaniolas et al.29 2014 1 1 1 1 2 1 1 1 9 3B View Large The percentage of octogenarians in the included studies ranged from 6.3–19.6%21,22,26,27,29,30 and one study included only octogenarians.28 In one study no specific number of octogenarians was mentioned, in this study 51% of the study population was aged ≥70 years and a subanalysis in octogenarians was conducted.8 Octogenarians had an higher Charlson comorbidity score than younger patient groups and presented with a higher percentage of intrathoracic stomach.30 Timing of the surgical repair Nonelective repairs are defined as being urgent or acute. Urgent repairs presented with symptoms and were operated in the same admission, but later than 12 hours after presentation. A symptomatic PHH that was operated within 12 hours was characterized as an acute repair. Overall an elective PHH repair was conducted in 24–98%, the remaining repairs were of nonelective nature.22,26–28,30 In four studies, with the study population divided into different age groups, octogenarians received an elective PHH repair in 34–92% and a nonelective PHH repair in 8–66%.22,26,27,30 One study described a case series of octogenarians in which an elective PHH repair was performed in 57% and a nonelective PHH repair in 43%.28 Two studies did not specify the amount of elective or nonelective PHH repairs.8,21 Another two studies excluded acute PHH repairs.8,29 Only one article mentioned the indication for performing an nonelective repair, which was an acute presentation with an incarcerated PHH.30 Nonelective PHH repair was performed significantly more in octogenarians compared to younger patient groups.22,26,27,30 Length of hospital stay was significantly increased for nonelective patients compared to elective patients.28,29 Morbidity was higher in nonelective PHH repair and highest in patients presenting with gangrene.27 Overall mortality was significantly higher for nonelective PHH repair than for elective PHH repair, 5.0–16% versus 0.5–6%, respectively.8,22,26–29 The nonelective laparoscopic approach had a 4.2–7.1 greater odds and the open nonelective approach a 6.3 greater odds of 30-day mortality, compared with the elective laparoscopic PHH repair.22,28 The risk for perioperative mortality tripled and the risk for major morbidity doubled when a nonelective repair was required.26 In octogenarians, mortality in elective repair was 3.9%, compared with 0.6% in patients aged <80 years.27 Nonelective PHH repair was determined to be a predictor of mortality in octogenarians.28 Regression analysis depicted octogenarians, hernia size of 75% or greater, BMI <18.5 kg/m2 and comorbid disease to be independent predictors for nonelective repair.26 Operative techniques Minimally invasive versus open A laparoscopic approach was planned in 84–100% of PHH repairs, with a conversion rate of 1.5–5.6%.8,21,22,26,29 In one study, conversions were excluded based on a preset diagnosis and coding system and another study described no conversions.29,30 Three studies included open and laparoscopic repairs, but did not stratify for approach in their results.26–28 The open approach was performed more frequently in octogenarians compared to patients of younger age. Open surgery was associated with a higher 30-day mortality rate, being 4.3% in open surgery versus 1.4% in laparoscopic surgery. Morbidity was lower in laparoscopic surgery in octogenarians, being 13.1% versus 26.9% in open surgery.22 Cruroplasty; mesh versus no mesh Mesh cruroplasty was performed in 12–77% of PHH patients.8,26,29,30 Two studies assessed the outcomes of mesh cruroplasty.8,30 When comparing octogenarians to a younger patient group, mesh cruroplasty was performed in 47.6–77.8% of octogenarians and in 42.9–76.6% of patients aged <80 years.29,30 Mesh use did not differ between age groups.30 In one study, mesh cruroplasty was associated with significantly increased odds of reoperation for hernia recurrence.8 Fundoplication and gastropexy Fundoplication was performed in 67–98% of PHH patients,8,21,26,30 of which 23–31.1% received a partial fundoplication (Dor or Toupet) and 63.3–77% a Nissen fundoplication.26,30 The type of fundoplication was determined intraoperatively at the discretion of the surgeon.8,26,30 A Nissen fundoplication was significantly performed more often in younger patient groups than in octogenarians, 69.4% versus 31.1%, respectively.30 Performing fundoplication in patients of advancing age did not result in increased morbidity compared to patients <80 years of age.21 Gastropexy was applied more often in octogenarians.8 Postoperative outcomes were separately assessed between gastropexy and fundoplication in one study, showing similar postoperative results in morbidity for fundoplication and gastropexy.21 Collis gastroplasty: esophageal lengthening Esophageal lengthening (Collis gastroplasty) was performed to restore adequate length of the intra-abdominal esophagus and thereby releasing axial tension in 2–63%.8,26,29,30 In 52% of patients who also received a fundoplication, a Collis gastroplasty was added.26 Of the 2.5% postoperative leaks, 88% occurred when esophageal lengthening was performed.8 Esophageal lengthening was performed in 1.8–30.2% of patients <80 years of age and in 2.9–31.1% of octogenarians, which did not differ significantly.29 Interestingly the incidence of esophageal lengthening decreased over the years, in recent years mesh cruroplasty was applied more often.8 Postoperative results Radiographic recurrence was not associated with recurrent symptoms and satisfaction with surgery. Symptoms were significantly reduced at follow-up (median of 30 months follow-up) in comparison to preoperative level.8 Postoperative Quality of Life in Reflux and Dyspepsia (QOLRAD) scores were significantly improved compared to preoperative scores in all age groups. No difference in QOLRAD scores between age groups was observed in both the pre-operative or postoperative QOLRAD scores.30 Of all operated patients, 89% reported satisfaction with the surgical result.8 Overall morbidity in PHH repair was 5.6–13.2% in patients aged <80 years and 11.2–32.4% in octogenarians, which significantly differed.21,29 In one study, overall morbidity of octogenarians (22.2%) did not differ significantly compared to patients aged <80 years (17.1%).30 Reoperation was carried out in 3.4–4.9%, with no difference between age groups.8,30 Length of hospital stay Hospital stay was associated with age, ASA score, morbidity, conversion and when gastropexy was performed.21,22 Postoperative complications or conversion doubled hospital stay.21 Length of hospital stay did not significantly differ between the eras 1997–2003 and 2003–2008, even though the incidence of comorbid diseases increased in this time period.8 Patients ≥70 years stayed two days longer than younger patients.21 Octogenarians experienced a significantly longer hospital stay irrespective of open or laparoscopic approach.22,30 Mortality An adverse outcome was seen less in PHH patients presenting with heartburn.8 The mortality rate in octogenarians was 0–10% compared to an overall mortality of 0.7–2.6%,8,21,26,28,30 this was significantly different and independent of the type of operation.21,22 In two studies, no significantly difference was found in mortality between the older and younger patient groups.29,30 Serious morbidity was not different between age groups in one study, however another study showed more serious morbidity in octogenarians (17.8%), compared to patients <80 years of age (6.3%).29,30 Obstructive symptoms were not associated with a greater rate of mortality or morbidity.27 Mortality in octogenarians versus patients aged <80 years with obstruction was 9.7% versus 2.2%, in PHH with gangrene a mortality of 36.8% in octogenarians and 19.9% in patients aged <80 years was found.27 Factors associated with mortality included older age, BMI <18.5 kg/m2, history of congestive heart failure, cerebrovascular accident, dementia, pulmonary disease and malignancy within the past five years.26 Type IV hernia was associated with the highest morbidity and mortality, which is the predominant hernia type in the elderly.21 Observational cohort study Using the surgical registry, 84 PHH patients were operated between 2005 and 2015 at the VU university medical center, Amsterdam, The Netherlands. Out of 84 included PHH patients, 9.5% were octogenarians. No differences were observed for baseline characteristics, besides age. Baseline characteristics are depicted in Table 3. When comparing octogenarians with patients <80 years of age, hernia type, acute indication and type of fundoplication significantly differed between the two groups. Octogenarians frequently had a larger hernia type and PHH repair was performed more often in the acute setting. Fundoplication was performed less in octogenarians. A fundoplication was added in PHH repair when gastroesophageal reflux symptoms were present. Intraoperative complications consisted of supraventricular tachycardia and hypotension (n = 1), perforation of the esophagus (n = 1), laceration of the fundus of the stomach (n = 1) of which both were managed with a laparoscopic suture and a pneumothorax (n = 1) treated with a drain. An overview of operative details is depicted in Table 4. Table 3 Baseline characteristics stratified by age <80 years ≥80 years P-value Patients (n) 76 (90.5%) 8 (9.5%) Gender (female, %) 58 (76.3%) 6 (75.0%) 0.934 Age (years) 63,9 ± 9.5 85,38 ± 3.5 0.000 BMI (kg/m2) 28.6 ± 5.0 25.2 ± 2.9 0.061 ASA classification  I 3 (4.1%) 1 (12.5%) 0.618  II 50 (67.6%) 4 (50.0%)  III 20 (27.0%) 3 (37.5%)  IV 1 (1.4%) 0 (0%) MET-score  1–4 12 (27.9%) 3 (60%) 0.312  5–9 27 (62.8%) 2 (40.0%)  10 or higher 4 (9.3%) 0 (0%) Comorbidity 53 (69,7%) 6 (75.0%) 0.757  Cardiac comorbidities 50 (65.8%) 6 (75%) 0.342  Diabetes  NIDDM 5 (6.6%) 2 (25.0%) 0.186  IDDM 2 (2.6%) 0 (0%)  COPD 13 (17.1%) 1 (12.5%) 0.740 Smoking 13 (17.8%) 1 (12.5%) 0.706 Alcohol 27 (37.5%) 2 (25.0%) 0.485 <80 years ≥80 years P-value Patients (n) 76 (90.5%) 8 (9.5%) Gender (female, %) 58 (76.3%) 6 (75.0%) 0.934 Age (years) 63,9 ± 9.5 85,38 ± 3.5 0.000 BMI (kg/m2) 28.6 ± 5.0 25.2 ± 2.9 0.061 ASA classification  I 3 (4.1%) 1 (12.5%) 0.618  II 50 (67.6%) 4 (50.0%)  III 20 (27.0%) 3 (37.5%)  IV 1 (1.4%) 0 (0%) MET-score  1–4 12 (27.9%) 3 (60%) 0.312  5–9 27 (62.8%) 2 (40.0%)  10 or higher 4 (9.3%) 0 (0%) Comorbidity 53 (69,7%) 6 (75.0%) 0.757  Cardiac comorbidities 50 (65.8%) 6 (75%) 0.342  Diabetes  NIDDM 5 (6.6%) 2 (25.0%) 0.186  IDDM 2 (2.6%) 0 (0%)  COPD 13 (17.1%) 1 (12.5%) 0.740 Smoking 13 (17.8%) 1 (12.5%) 0.706 Alcohol 27 (37.5%) 2 (25.0%) 0.485 View Large Table 3 Baseline characteristics stratified by age <80 years ≥80 years P-value Patients (n) 76 (90.5%) 8 (9.5%) Gender (female, %) 58 (76.3%) 6 (75.0%) 0.934 Age (years) 63,9 ± 9.5 85,38 ± 3.5 0.000 BMI (kg/m2) 28.6 ± 5.0 25.2 ± 2.9 0.061 ASA classification  I 3 (4.1%) 1 (12.5%) 0.618  II 50 (67.6%) 4 (50.0%)  III 20 (27.0%) 3 (37.5%)  IV 1 (1.4%) 0 (0%) MET-score  1–4 12 (27.9%) 3 (60%) 0.312  5–9 27 (62.8%) 2 (40.0%)  10 or higher 4 (9.3%) 0 (0%) Comorbidity 53 (69,7%) 6 (75.0%) 0.757  Cardiac comorbidities 50 (65.8%) 6 (75%) 0.342  Diabetes  NIDDM 5 (6.6%) 2 (25.0%) 0.186  IDDM 2 (2.6%) 0 (0%)  COPD 13 (17.1%) 1 (12.5%) 0.740 Smoking 13 (17.8%) 1 (12.5%) 0.706 Alcohol 27 (37.5%) 2 (25.0%) 0.485 <80 years ≥80 years P-value Patients (n) 76 (90.5%) 8 (9.5%) Gender (female, %) 58 (76.3%) 6 (75.0%) 0.934 Age (years) 63,9 ± 9.5 85,38 ± 3.5 0.000 BMI (kg/m2) 28.6 ± 5.0 25.2 ± 2.9 0.061 ASA classification  I 3 (4.1%) 1 (12.5%) 0.618  II 50 (67.6%) 4 (50.0%)  III 20 (27.0%) 3 (37.5%)  IV 1 (1.4%) 0 (0%) MET-score  1–4 12 (27.9%) 3 (60%) 0.312  5–9 27 (62.8%) 2 (40.0%)  10 or higher 4 (9.3%) 0 (0%) Comorbidity 53 (69,7%) 6 (75.0%) 0.757  Cardiac comorbidities 50 (65.8%) 6 (75%) 0.342  Diabetes  NIDDM 5 (6.6%) 2 (25.0%) 0.186  IDDM 2 (2.6%) 0 (0%)  COPD 13 (17.1%) 1 (12.5%) 0.740 Smoking 13 (17.8%) 1 (12.5%) 0.706 Alcohol 27 (37.5%) 2 (25.0%) 0.485 View Large Table 4 Operative details <80 years ≥80 years P-value Previous abdominal surgery 43 (56.6%) 5 (71.4%) 0.446 Previous hernia surgery 6 (7.9%) 1 (12.5%) 0.654 Hernia type  type 2 57 (75.0%) 4 (50.0%) 0.037  type 3 8 (10.5%) 0 (0%)  type 4 11 (14.5%) 4 (50.0%) Indication, acute (%) 9 (11.8%) 3 (37.5%) 0.049 Access  Open 4 (5.3%) 1 (12.5%) 0.411  Minimally invasive 72 (94.7%) 7 (87.5%)  Conversion 4 (5.3%) 1 (12.5%) 0.411 Crus  Sutures 57 (77.0%) 7 (87.5%) 0.497  Mesh (PTFE) 17 (17.2%) 1 (12.5%) Fundoplication  None 18 (24.0%) 4 (50.0%) 0.002  Nissen 54 (72.0%) 2 (25.0%)  Dor 0 (0%) 1 (12.5%)  Toupet 3 (4.0%) 1 (12.5%) Gastropexy 55 (73.3%) 5 (62.5%) 0.515 Duration (min) 141 ± 42 150.0 ± 56 0.591 Intraoperative complications 24 (23.8%) 4 (50.0%) 0.102 <80 years ≥80 years P-value Previous abdominal surgery 43 (56.6%) 5 (71.4%) 0.446 Previous hernia surgery 6 (7.9%) 1 (12.5%) 0.654 Hernia type  type 2 57 (75.0%) 4 (50.0%) 0.037  type 3 8 (10.5%) 0 (0%)  type 4 11 (14.5%) 4 (50.0%) Indication, acute (%) 9 (11.8%) 3 (37.5%) 0.049 Access  Open 4 (5.3%) 1 (12.5%) 0.411  Minimally invasive 72 (94.7%) 7 (87.5%)  Conversion 4 (5.3%) 1 (12.5%) 0.411 Crus  Sutures 57 (77.0%) 7 (87.5%) 0.497  Mesh (PTFE) 17 (17.2%) 1 (12.5%) Fundoplication  None 18 (24.0%) 4 (50.0%) 0.002  Nissen 54 (72.0%) 2 (25.0%)  Dor 0 (0%) 1 (12.5%)  Toupet 3 (4.0%) 1 (12.5%) Gastropexy 55 (73.3%) 5 (62.5%) 0.515 Duration (min) 141 ± 42 150.0 ± 56 0.591 Intraoperative complications 24 (23.8%) 4 (50.0%) 0.102 View Large Table 4 Operative details <80 years ≥80 years P-value Previous abdominal surgery 43 (56.6%) 5 (71.4%) 0.446 Previous hernia surgery 6 (7.9%) 1 (12.5%) 0.654 Hernia type  type 2 57 (75.0%) 4 (50.0%) 0.037  type 3 8 (10.5%) 0 (0%)  type 4 11 (14.5%) 4 (50.0%) Indication, acute (%) 9 (11.8%) 3 (37.5%) 0.049 Access  Open 4 (5.3%) 1 (12.5%) 0.411  Minimally invasive 72 (94.7%) 7 (87.5%)  Conversion 4 (5.3%) 1 (12.5%) 0.411 Crus  Sutures 57 (77.0%) 7 (87.5%) 0.497  Mesh (PTFE) 17 (17.2%) 1 (12.5%) Fundoplication  None 18 (24.0%) 4 (50.0%) 0.002  Nissen 54 (72.0%) 2 (25.0%)  Dor 0 (0%) 1 (12.5%)  Toupet 3 (4.0%) 1 (12.5%) Gastropexy 55 (73.3%) 5 (62.5%) 0.515 Duration (min) 141 ± 42 150.0 ± 56 0.591 Intraoperative complications 24 (23.8%) 4 (50.0%) 0.102 <80 years ≥80 years P-value Previous abdominal surgery 43 (56.6%) 5 (71.4%) 0.446 Previous hernia surgery 6 (7.9%) 1 (12.5%) 0.654 Hernia type  type 2 57 (75.0%) 4 (50.0%) 0.037  type 3 8 (10.5%) 0 (0%)  type 4 11 (14.5%) 4 (50.0%) Indication, acute (%) 9 (11.8%) 3 (37.5%) 0.049 Access  Open 4 (5.3%) 1 (12.5%) 0.411  Minimally invasive 72 (94.7%) 7 (87.5%)  Conversion 4 (5.3%) 1 (12.5%) 0.411 Crus  Sutures 57 (77.0%) 7 (87.5%) 0.497  Mesh (PTFE) 17 (17.2%) 1 (12.5%) Fundoplication  None 18 (24.0%) 4 (50.0%) 0.002  Nissen 54 (72.0%) 2 (25.0%)  Dor 0 (0%) 1 (12.5%)  Toupet 3 (4.0%) 1 (12.5%) Gastropexy 55 (73.3%) 5 (62.5%) 0.515 Duration (min) 141 ± 42 150.0 ± 56 0.591 Intraoperative complications 24 (23.8%) 4 (50.0%) 0.102 View Large In an uncomplicated course, the median length of hospital stay was 5 days (IQR: 4–6) in patients <80 of age and 9 days (IQR: 5–13) in octogenarians (P = 0.049). Overall complications occurred more often in octogenarians, 62.5% in octogenarians versus 28.7% in <80 years (P = 0.047). Complications in octogenarians consisted of pneumonia (n = 1), urine retention and obstipation (n = 1), mediastinal hematoma, and de novo atrial flutter (n = 1). Two octogenarians died following minimally invasive PHH repair. One octogenarian died after an acute PHH repair complicated by esophagus perforation and postoperative suspicion of mediastinitis for which reoperation was performed where no leakage or septic matter was seen. Placement of a mediastinal drain revealed postoperative intrathoracic leakage of percutaneous endoscopic gastrostomy tube feeding due to dislocation of the tube in the stomach instead of the duodenum. In consultation with family it was decided for conservative treatment, after which the patient developed sepsis followed by multi-organ failure. The other patient died of multi-organ failure after elective PHH repair with gastropexy, by pleural effusion and wall inflammation of the excised hernia sac. Gastropexy was performed because fundoplication was not technically feasible. Preoperative a mechanical obstruction with dyspnea was present because of the PHH, leading to the inability to eat resulting in a weight loss of 17 kg. Significant comorbid diseases were present in this patient, with extensive metastatic prostate cancer, end-stage congestive heart failure, atrium fibrillation, COPD, and esophagitis. An overview of all complications is depicted in Table 5. Table 5 Complications <80 years >80 years P-value Uncomplicated 72 (71.3%) 3 (37.5%) 0.047 Minor complication 15 (57.7%) 2 (40.0%) 0.467 Major complication 11 (42.3%) 3 (60.0%) In-hospital mortality 0 (0%) 2 (25.0%) 0.000 Duration of hospital stay (median (IQR))  Uncomplicated 5 (4–6) 9 (5– 13) 0.049  Complicated 10 (6–15) 13 (8– 15) 0.620 <80 years >80 years P-value Uncomplicated 72 (71.3%) 3 (37.5%) 0.047 Minor complication 15 (57.7%) 2 (40.0%) 0.467 Major complication 11 (42.3%) 3 (60.0%) In-hospital mortality 0 (0%) 2 (25.0%) 0.000 Duration of hospital stay (median (IQR))  Uncomplicated 5 (4–6) 9 (5– 13) 0.049  Complicated 10 (6–15) 13 (8– 15) 0.620 View Large Table 5 Complications <80 years >80 years P-value Uncomplicated 72 (71.3%) 3 (37.5%) 0.047 Minor complication 15 (57.7%) 2 (40.0%) 0.467 Major complication 11 (42.3%) 3 (60.0%) In-hospital mortality 0 (0%) 2 (25.0%) 0.000 Duration of hospital stay (median (IQR))  Uncomplicated 5 (4–6) 9 (5– 13) 0.049  Complicated 10 (6–15) 13 (8– 15) 0.620 <80 years >80 years P-value Uncomplicated 72 (71.3%) 3 (37.5%) 0.047 Minor complication 15 (57.7%) 2 (40.0%) 0.467 Major complication 11 (42.3%) 3 (60.0%) In-hospital mortality 0 (0%) 2 (25.0%) 0.000 Duration of hospital stay (median (IQR))  Uncomplicated 5 (4–6) 9 (5– 13) 0.049  Complicated 10 (6–15) 13 (8– 15) 0.620 View Large DISCUSSION PHH repair can be performed safely in symptomatic octogenarians. Although it should be noted octogenarians are underrepresented in current literature. Based on the literature, several factors should be taken into account when assessing octogenarians for PHH repair. The significant impact of PHH on quality of life (QoL) could indicate surgery.8,31,32 PHH repair results in a significant improvement in QoL of octogenarians.30,32,33 Preoperative work-up should aim to optimize comorbid diseases, nutritional and functional health status. The indication for PHH repair should take into account symptoms and assessment of the risk of postoperative morbidity and mortality, for instance with a clinical prediction rule.26 One study showed no difference in mortality between age groups.30 In the other studies, overall mortality was higher in octogenarians compared to younger patients, especially if emergency repair was necessary.8,22,26–29 The risk of progression to symptoms requiring emergency repair was 0.69–3.86% per year.27 The higher frequency of nonelective repairs in octogenarians could reflect the restraints that live among surgeons to plan an elective PHH repair in octogenarians. Elective repair in symptomatic patients should be the preferred choice in octogenarians, improved surgical techniques may improve outcomes even in nonelective surgery.27 If PHH repair is indicated, several surgical techniques are available. Minimally invasive techniques are associated with less morbidity and mortality.22 Results should be interpreted carefully, as conversions were excluded from analysis in one study.29 Gastropexy was associated with increased overall- and general morbidity in octogenarians, whereas no evidence exists for increased morbidity in fundoplication in octogenarians.21,30 With regard to indication for gastropexy, it was deemed less invasive and better handled in octogenarians, indicating a possible bias in these results with fundoplication being performed mainly in octogenarians with less comorbid diseases. A complete fundoplication was performed significantly less in octogenarians, instead a partial fundoplication was performed in octogenarians.30 Fundoplication could have potential benefits, due to continued improvements in clinical symptoms in the majority of patients with recurrent PHH and an intact fundoplication.14,34–36 A recent retrospective cohort did not found a difference in QoL between PHH repair with or without fundoplication after long-term follow-up. It should be noted that in this study 47% of the group with fundoplication and 51% of the group without fundoplication were lost to follow-up and no pre-operative QoL assessment was performed. Fundoplication resulted in a significant improvement of all the pre-operative symptoms; in the group without fundoplication only chest pain was significantly improved.37 Fundoplication allows for a good fixation of the fundus and gastroesophageal junction to the crura, preventing recurrence of a hiatal hernia in two studies.36,38 A randomized controlled trial should be performed to assess the benefit of fundoplication in PHH repair and compare pre- and postoperative QoL data, until then a fundoplication may be performed safely at the discretion of the surgeon. Mesh cruroplasty showed worse outcomes in octogenarians in one study; however another study showed no difference between age groups.8,30 These results may partially be explained due to the use of mesh in the case of a large hiatal defect.8 In the last decennium, several studies assessed the advantage of adding mesh in PHH repair. Of special interest is biomesh cruroplasty, which revealed short-term benefits with no durable long-term efficacy.39–43 A relatively new technique is the use of autologous prosthetics in which teres ligament, triangular ligament, and falciform ligament are added in cruroplasty.44–46 Due to different classifications of PHH, heterogeneous types and configurations of mesh, different methods of securing mesh, different classification and detection of a recurrent hernia and the lack of long-term postoperative data, no conclusions toward the benefit of mesh cruroplasty in PHH could be drawn.39,47–50 In order to obtain more durable results in mesh repair, both improvements in technique as well as material are needed to show durable superior results. Relaxing incisions are used to reduce radial tension and can facilitate tension-free closure of the hiatus. Recurrent hernia was similar in low-tension PHH with or without biomesh cruroplasty compared to high-tension PHH with the addition of relaxing incisions covered by biomesh.51 Relaxing incisions added to mesh cruroplasty could show promising results in a tailored approach to PHH repair and could improve recurrence rates.52,53 Esophageal lengthening is heavily debated in the literature.54,55 Collis gastroplasty shows more postoperative leaks and higher postoperative mortality.8 Due to this and increased experience in mediastinal mobilization, Collis gastroplasty was performed less in recent year.8 None of the patients in recent randomized trials and at our own institution underwent an esophageal lengthening procedure and based on the risk of complications this procedure is not recommended. This review has several strengths and limitations. Only eight studies described outcomes in octogenarians. The studies were very different in design, in- and exclusion criteria, definitions and reporting of outcomes. All studies had a short follow-up period, except for one,8 limiting functional outcome and hernia recurrence conclusions. Outcomes of the cohort study are limited by the observational nature of the study, with only a small proportion of octogenarians. The VU University Medical Center is a tertiary referral center for hiatal hernia repair, indicating a selection bias and this could explain the higher mortality rate compared to other series in the current literature. CONCLUSION PHH repair may be performed safely in symptomatic octogenarians. Preoperative assessment should aim to assess octogenarians at risk of complications and aim to optimize health status. No strong recommendation can be made for surgical techniques; laparoscopic repair was associated with less morbidity and mortality. Fundoplication may be performed instead of performing routine gastropexy, with similar outcomes. The indication and outcomes for mesh cruroplasty remain unclear. Importantly, octogenarians were underrepresented and should be included in future studies assessing optimal surgical strategies in PHH repair, to evaluate both operative and symptomatic outcomes. Acknowledgments All authors declare no conflicts of interest. No funding was received for this project. Notes Specific author contributions: Donald L. van der Peet, Miguel A. Cuesta, Freek Daams, and Jennifer Straatman designed the project. Lennaert C.B. Groen, Elise P. Jansma, and Jennifer Straatman designed the search strategy. Lennaert C.B. Groen and Nicole van der Wielen collected data. Lennaert C.B. Groen and Jennifer Straatman critically reviewed all articles. Lennaert C.B. Groen, Jennifer Straatman, and Nicole van der Wielen drafted the manuscript. Donald L. van der Peet, Freek Daams, and Miguel A. Cuesta critically revised the manuscript. All authors approved the final version of the manuscript. APPENDIX Search strategy for PubMed database Search PubMed Query 04-10-2016 Items found #23 Search #20 AND #21 AND #22 387 #22 Search ‘Aged, 80 and over’[Mesh] OR ‘Oldest Old’[tiab] OR Nonagenarian*[tiab] OR Octogenarian*[tiab] OR Octogenarian[tiab] OR Centenarian*[tiab] OR ‘very elderly’[tiab] OR ‘very old’[tiab] OR ‘advancing age’[tiab] 720,064 #21 Search ‘Surgical Procedures, Minimally Invasive’[Mesh:NoExp] OR ‘Elective Surgical Procedures’[Mesh] OR ‘Ambulatory Surgical Procedures’[Mesh] OR ‘Minor Surgical Procedures’[Mesh] OR ‘Video-Assisted Surgery’[Mesh] OR ‘Laparoscopy’[Mesh] OR ‘Laparotomy’[Mesh] OR Laparoscop*[tiab] OR videolaparoscop*[tiab] OR Laparotom*[tiab] OR ‘Video-Assisted’[tiab] OR ‘Minimal Surgical’[tiab] OR ‘Minimally Invasive’[tiab] OR ‘Minimal Invasive’[tiab] OR ‘Minimal Access Surgical Procedures’[tiab] OR surger*[tiab] OR operation*[tiab] 1,412,436 #20 Search ‘Hernia, Hiatal’[Mesh] OR ‘Hiatal Hernias’[tiab] OR ‘Hiatal Hernia’[tiab] OR ‘Hiatus Hernia’[tiab] OR ‘Hiatus Hernias’[tiab] OR ‘Hernia Hiatica’[tiab] OR ‘Hernia Hiati Oesophagi’[tiab] OR ‘Esofagushernia’[tiab] OR ‘Esofagushernias’[tiab] OR ‘Esophagushernia’[tiab] OR ‘Esophagushernias’[tiab] OR ‘Oesophagushernia’[tiab] OR ‘Oesophagushernias’[tiab] OR ‘Oesofagushernia’[tiab] OR ‘Oesofagushernias’[tiab] OR ‘Esofagealhernia’[tiab] OR ‘Esofagealhernias’[tiab] OR ‘Esophagealhernia’[tiab] OR ‘Esophagealhernias’[tiab] OR ‘Oesophagealhernia’[tiab] OR ‘Oesophagealhernias’[tiab] OR ‘Oesofagealhernia’[tiab] OR ‘Oesofagealhernias’[tiab] OR ‘oesophageal Hernia’[tiab] OR ‘oesophageal Hernias’[tiab] OR ‘oesofageal Hernia’[tiab] OR ‘oesofageal Hernias’[tiab] OR ‘Esophageal hernia’[tiab] OR ‘Esophageal Hernias’[tiab] OR ‘Esofageal Hernia’[tiab] OR ‘Esofageal hernias’[tiab] OR ‘esophagus hiatus’[tiab] OR ‘oesophagus Hernia’[tiab] OR ‘oesophagus Hernias’[tiab] OR ‘oesofagus Hernia’[tiab] OR ‘oesofagus Hernias’[tiab] OR ‘Esophagus hernia’[tiab] OR ‘Esophagus Hernias’[tiab] OR ‘Esofagus Hernia’[tiab] OR ‘Esofagus hernias’[tiab] OR ‘Rolling hernia’[tiab] OR ‘Rolling hernias’[tiab] OR ‘Paraesophageal Hernia’[tiab] OR ‘Paraesophageal Hernias’[tiab] OR ‘Paraoesophageal Hernia’[tiab] OR ‘Paraoesophageal Hernias’[tiab] OR ‘Paraesofageal Hernia’[tiab] OR ‘Paraesofageal Hernias’[tiab] OR ‘Paraoesofageal Hernia’[tiab] OR ‘Paraoesofageal Hernias’[tiab] OR ‘Para-esophageal hernia’[tiab] OR ‘Para-esophageal hernias’[tiab] OR ‘Para-esofageal hernia’[tiab] OR ‘Para-esofageal hernias’[tiab] OR ‘Para-oesophageal hernia’[tiab] OR ‘Para-oesophageal hernias’[tiab] OR ‘Para-oesofageal hernia’[tiab] OR ‘Para-oesofageal hernia’[tiab] OR ‘diaphragmatic hernia’[tiab] OR ‘Diaphragmatic hernias’[tiab] OR ‘Hernia Diaphragmatica’[tiab] OR ‘Hernias Diaphragmatica’[tiab] OR ‘hiatus esophagi hernia’[tiab] OR ‘hiatus esophagi hernias’[tiab] OR ‘stomach hernia’[tiab] OR ‘Stomach hernias’[tiab] OR ‘intrathoracic stomach’[tiab] 15,777 Search PubMed Query 04-10-2016 Items found #23 Search #20 AND #21 AND #22 387 #22 Search ‘Aged, 80 and over’[Mesh] OR ‘Oldest Old’[tiab] OR Nonagenarian*[tiab] OR Octogenarian*[tiab] OR Octogenarian[tiab] OR Centenarian*[tiab] OR ‘very elderly’[tiab] OR ‘very old’[tiab] OR ‘advancing age’[tiab] 720,064 #21 Search ‘Surgical Procedures, Minimally Invasive’[Mesh:NoExp] OR ‘Elective Surgical Procedures’[Mesh] OR ‘Ambulatory Surgical Procedures’[Mesh] OR ‘Minor Surgical Procedures’[Mesh] OR ‘Video-Assisted Surgery’[Mesh] OR ‘Laparoscopy’[Mesh] OR ‘Laparotomy’[Mesh] OR Laparoscop*[tiab] OR videolaparoscop*[tiab] OR Laparotom*[tiab] OR ‘Video-Assisted’[tiab] OR ‘Minimal Surgical’[tiab] OR ‘Minimally Invasive’[tiab] OR ‘Minimal Invasive’[tiab] OR ‘Minimal Access Surgical Procedures’[tiab] OR surger*[tiab] OR operation*[tiab] 1,412,436 #20 Search ‘Hernia, Hiatal’[Mesh] OR ‘Hiatal Hernias’[tiab] OR ‘Hiatal Hernia’[tiab] OR ‘Hiatus Hernia’[tiab] OR ‘Hiatus Hernias’[tiab] OR ‘Hernia Hiatica’[tiab] OR ‘Hernia Hiati Oesophagi’[tiab] OR ‘Esofagushernia’[tiab] OR ‘Esofagushernias’[tiab] OR ‘Esophagushernia’[tiab] OR ‘Esophagushernias’[tiab] OR ‘Oesophagushernia’[tiab] OR ‘Oesophagushernias’[tiab] OR ‘Oesofagushernia’[tiab] OR ‘Oesofagushernias’[tiab] OR ‘Esofagealhernia’[tiab] OR ‘Esofagealhernias’[tiab] OR ‘Esophagealhernia’[tiab] OR ‘Esophagealhernias’[tiab] OR ‘Oesophagealhernia’[tiab] OR ‘Oesophagealhernias’[tiab] OR ‘Oesofagealhernia’[tiab] OR ‘Oesofagealhernias’[tiab] OR ‘oesophageal Hernia’[tiab] OR ‘oesophageal Hernias’[tiab] OR ‘oesofageal Hernia’[tiab] OR ‘oesofageal Hernias’[tiab] OR ‘Esophageal hernia’[tiab] OR ‘Esophageal Hernias’[tiab] OR ‘Esofageal Hernia’[tiab] OR ‘Esofageal hernias’[tiab] OR ‘esophagus hiatus’[tiab] OR ‘oesophagus Hernia’[tiab] OR ‘oesophagus Hernias’[tiab] OR ‘oesofagus Hernia’[tiab] OR ‘oesofagus Hernias’[tiab] OR ‘Esophagus hernia’[tiab] OR ‘Esophagus Hernias’[tiab] OR ‘Esofagus Hernia’[tiab] OR ‘Esofagus hernias’[tiab] OR ‘Rolling hernia’[tiab] OR ‘Rolling hernias’[tiab] OR ‘Paraesophageal Hernia’[tiab] OR ‘Paraesophageal Hernias’[tiab] OR ‘Paraoesophageal Hernia’[tiab] OR ‘Paraoesophageal Hernias’[tiab] OR ‘Paraesofageal Hernia’[tiab] OR ‘Paraesofageal Hernias’[tiab] OR ‘Paraoesofageal Hernia’[tiab] OR ‘Paraoesofageal Hernias’[tiab] OR ‘Para-esophageal hernia’[tiab] OR ‘Para-esophageal hernias’[tiab] OR ‘Para-esofageal hernia’[tiab] OR ‘Para-esofageal hernias’[tiab] OR ‘Para-oesophageal hernia’[tiab] OR ‘Para-oesophageal hernias’[tiab] OR ‘Para-oesofageal hernia’[tiab] OR ‘Para-oesofageal hernia’[tiab] OR ‘diaphragmatic hernia’[tiab] OR ‘Diaphragmatic hernias’[tiab] OR ‘Hernia Diaphragmatica’[tiab] OR ‘Hernias Diaphragmatica’[tiab] OR ‘hiatus esophagi hernia’[tiab] OR ‘hiatus esophagi hernias’[tiab] OR ‘stomach hernia’[tiab] OR ‘Stomach hernias’[tiab] OR ‘intrathoracic stomach’[tiab] 15,777 View Large Search PubMed Query 04-10-2016 Items found #23 Search #20 AND #21 AND #22 387 #22 Search ‘Aged, 80 and over’[Mesh] OR ‘Oldest Old’[tiab] OR Nonagenarian*[tiab] OR Octogenarian*[tiab] OR Octogenarian[tiab] OR Centenarian*[tiab] OR ‘very elderly’[tiab] OR ‘very old’[tiab] OR ‘advancing age’[tiab] 720,064 #21 Search ‘Surgical Procedures, Minimally Invasive’[Mesh:NoExp] OR ‘Elective Surgical Procedures’[Mesh] OR ‘Ambulatory Surgical Procedures’[Mesh] OR ‘Minor Surgical Procedures’[Mesh] OR ‘Video-Assisted Surgery’[Mesh] OR ‘Laparoscopy’[Mesh] OR ‘Laparotomy’[Mesh] OR Laparoscop*[tiab] OR videolaparoscop*[tiab] OR Laparotom*[tiab] OR ‘Video-Assisted’[tiab] OR ‘Minimal Surgical’[tiab] OR ‘Minimally Invasive’[tiab] OR ‘Minimal Invasive’[tiab] OR ‘Minimal Access Surgical Procedures’[tiab] OR surger*[tiab] OR operation*[tiab] 1,412,436 #20 Search ‘Hernia, Hiatal’[Mesh] OR ‘Hiatal Hernias’[tiab] OR ‘Hiatal Hernia’[tiab] OR ‘Hiatus Hernia’[tiab] OR ‘Hiatus Hernias’[tiab] OR ‘Hernia Hiatica’[tiab] OR ‘Hernia Hiati Oesophagi’[tiab] OR ‘Esofagushernia’[tiab] OR ‘Esofagushernias’[tiab] OR ‘Esophagushernia’[tiab] OR ‘Esophagushernias’[tiab] OR ‘Oesophagushernia’[tiab] OR ‘Oesophagushernias’[tiab] OR ‘Oesofagushernia’[tiab] OR ‘Oesofagushernias’[tiab] OR ‘Esofagealhernia’[tiab] OR ‘Esofagealhernias’[tiab] OR ‘Esophagealhernia’[tiab] OR ‘Esophagealhernias’[tiab] OR ‘Oesophagealhernia’[tiab] OR ‘Oesophagealhernias’[tiab] OR ‘Oesofagealhernia’[tiab] OR ‘Oesofagealhernias’[tiab] OR ‘oesophageal Hernia’[tiab] OR ‘oesophageal Hernias’[tiab] OR ‘oesofageal Hernia’[tiab] OR ‘oesofageal Hernias’[tiab] OR ‘Esophageal hernia’[tiab] OR ‘Esophageal Hernias’[tiab] OR ‘Esofageal Hernia’[tiab] OR ‘Esofageal hernias’[tiab] OR ‘esophagus hiatus’[tiab] OR ‘oesophagus Hernia’[tiab] OR ‘oesophagus Hernias’[tiab] OR ‘oesofagus Hernia’[tiab] OR ‘oesofagus Hernias’[tiab] OR ‘Esophagus hernia’[tiab] OR ‘Esophagus Hernias’[tiab] OR ‘Esofagus Hernia’[tiab] OR ‘Esofagus hernias’[tiab] OR ‘Rolling hernia’[tiab] OR ‘Rolling hernias’[tiab] OR ‘Paraesophageal Hernia’[tiab] OR ‘Paraesophageal Hernias’[tiab] OR ‘Paraoesophageal Hernia’[tiab] OR ‘Paraoesophageal Hernias’[tiab] OR ‘Paraesofageal Hernia’[tiab] OR ‘Paraesofageal Hernias’[tiab] OR ‘Paraoesofageal Hernia’[tiab] OR ‘Paraoesofageal Hernias’[tiab] OR ‘Para-esophageal hernia’[tiab] OR ‘Para-esophageal hernias’[tiab] OR ‘Para-esofageal hernia’[tiab] OR ‘Para-esofageal hernias’[tiab] OR ‘Para-oesophageal hernia’[tiab] OR ‘Para-oesophageal hernias’[tiab] OR ‘Para-oesofageal hernia’[tiab] OR ‘Para-oesofageal hernia’[tiab] OR ‘diaphragmatic hernia’[tiab] OR ‘Diaphragmatic hernias’[tiab] OR ‘Hernia Diaphragmatica’[tiab] OR ‘Hernias Diaphragmatica’[tiab] OR ‘hiatus esophagi hernia’[tiab] OR ‘hiatus esophagi hernias’[tiab] OR ‘stomach hernia’[tiab] OR ‘Stomach hernias’[tiab] OR ‘intrathoracic stomach’[tiab] 15,777 Search PubMed Query 04-10-2016 Items found #23 Search #20 AND #21 AND #22 387 #22 Search ‘Aged, 80 and over’[Mesh] OR ‘Oldest Old’[tiab] OR Nonagenarian*[tiab] OR Octogenarian*[tiab] OR Octogenarian[tiab] OR Centenarian*[tiab] OR ‘very elderly’[tiab] OR ‘very old’[tiab] OR ‘advancing age’[tiab] 720,064 #21 Search ‘Surgical Procedures, Minimally Invasive’[Mesh:NoExp] OR ‘Elective Surgical Procedures’[Mesh] OR ‘Ambulatory Surgical Procedures’[Mesh] OR ‘Minor Surgical Procedures’[Mesh] OR ‘Video-Assisted Surgery’[Mesh] OR ‘Laparoscopy’[Mesh] OR ‘Laparotomy’[Mesh] OR Laparoscop*[tiab] OR videolaparoscop*[tiab] OR Laparotom*[tiab] OR ‘Video-Assisted’[tiab] OR ‘Minimal Surgical’[tiab] OR ‘Minimally Invasive’[tiab] OR ‘Minimal Invasive’[tiab] OR ‘Minimal Access Surgical Procedures’[tiab] OR surger*[tiab] OR operation*[tiab] 1,412,436 #20 Search ‘Hernia, Hiatal’[Mesh] OR ‘Hiatal Hernias’[tiab] OR ‘Hiatal Hernia’[tiab] OR ‘Hiatus Hernia’[tiab] OR ‘Hiatus Hernias’[tiab] OR ‘Hernia Hiatica’[tiab] OR ‘Hernia Hiati Oesophagi’[tiab] OR ‘Esofagushernia’[tiab] OR ‘Esofagushernias’[tiab] OR ‘Esophagushernia’[tiab] OR ‘Esophagushernias’[tiab] OR ‘Oesophagushernia’[tiab] OR ‘Oesophagushernias’[tiab] OR ‘Oesofagushernia’[tiab] OR ‘Oesofagushernias’[tiab] OR ‘Esofagealhernia’[tiab] OR ‘Esofagealhernias’[tiab] OR ‘Esophagealhernia’[tiab] OR ‘Esophagealhernias’[tiab] OR ‘Oesophagealhernia’[tiab] OR ‘Oesophagealhernias’[tiab] OR ‘Oesofagealhernia’[tiab] OR ‘Oesofagealhernias’[tiab] OR ‘oesophageal Hernia’[tiab] OR ‘oesophageal Hernias’[tiab] OR ‘oesofageal Hernia’[tiab] OR ‘oesofageal Hernias’[tiab] OR ‘Esophageal hernia’[tiab] OR ‘Esophageal Hernias’[tiab] OR ‘Esofageal Hernia’[tiab] OR ‘Esofageal hernias’[tiab] OR ‘esophagus hiatus’[tiab] OR ‘oesophagus Hernia’[tiab] OR ‘oesophagus Hernias’[tiab] OR ‘oesofagus Hernia’[tiab] OR ‘oesofagus Hernias’[tiab] OR ‘Esophagus hernia’[tiab] OR ‘Esophagus Hernias’[tiab] OR ‘Esofagus Hernia’[tiab] OR ‘Esofagus hernias’[tiab] OR ‘Rolling hernia’[tiab] OR ‘Rolling hernias’[tiab] OR ‘Paraesophageal Hernia’[tiab] OR ‘Paraesophageal Hernias’[tiab] OR ‘Paraoesophageal Hernia’[tiab] OR ‘Paraoesophageal Hernias’[tiab] OR ‘Paraesofageal Hernia’[tiab] OR ‘Paraesofageal Hernias’[tiab] OR ‘Paraoesofageal Hernia’[tiab] OR ‘Paraoesofageal Hernias’[tiab] OR ‘Para-esophageal hernia’[tiab] OR ‘Para-esophageal hernias’[tiab] OR ‘Para-esofageal hernia’[tiab] OR ‘Para-esofageal hernias’[tiab] OR ‘Para-oesophageal hernia’[tiab] OR ‘Para-oesophageal hernias’[tiab] OR ‘Para-oesofageal hernia’[tiab] OR ‘Para-oesofageal hernia’[tiab] OR ‘diaphragmatic hernia’[tiab] OR ‘Diaphragmatic hernias’[tiab] OR ‘Hernia Diaphragmatica’[tiab] OR ‘Hernias Diaphragmatica’[tiab] OR ‘hiatus esophagi hernia’[tiab] OR ‘hiatus esophagi hernias’[tiab] OR ‘stomach hernia’[tiab] OR ‘Stomach hernias’[tiab] OR ‘intrathoracic stomach’[tiab] 15,777 View Large References 1 Dahlberg P S , Deschamps C , Miller D L , Allen M S , Nichols F C , Pairolero P C . Laparoscopic repair of large paraesophageal hiatal hernia . Ann Thorac Surg 2001 ; 72 : 1125 – 9 . Google Scholar CrossRef Search ADS PubMed 2 Oelschlager B K , Petersen R P , Brunt L M et al. Laparoscopic paraesophageal hernia repair: defining long-term clinical and anatomic outcomes . J Gastrointest Surg 2012 ; 16 : 453 – 9 . Google Scholar CrossRef Search ADS PubMed 3 Carrott P W , Hong J , Kuppusamy M , Koehler R P , Low D E . Clinical ramifications of giant paraesophageal hernias are underappreciated: making the case for routine surgical repair . Ann Thorac Surg 2012 ; 94 : 421 – 8 ; discussion 426–8 . Google Scholar CrossRef Search ADS PubMed 4 Furnee E J , Draaisma W A , Simmermacher R K , Stapper G , Broeders I A . Long-term symptomatic outcome and radiologic assessment of laparoscopic hiatal hernia repair . Am J Surg 2010 ; 199 : 695 – 701 . Google Scholar CrossRef Search ADS PubMed 5 Skinner D B , Belsey R H . Surgical management of esophageal reflux and hiatus hernia. Long-term results with 1,030 patients . J Thorac Cardiovasc Surg 1967 ; 53 : 33 – 54 . Google Scholar PubMed 6 Hill L D . Incarcerated paraesophageal hernia . Am J Surg 1973 ; 126 : 286 – 91 . Google Scholar CrossRef Search ADS PubMed 7 Polomsky M , Jones C E , Sepesi B et al. Should elective repair of intrathoracic stomach be encouraged? J Gastrointest Surg 2010 ; 14 : 203 – 10 . Google Scholar CrossRef Search ADS PubMed 8 Luketich J D , Nason K S , Christie N A , et al . Outcomes after a decade of laparoscopic giant paraesophageal hernia repair . J Thorac Cardiovasc Surg 2010 ; 139 : 395 – 404.e1 , 404 e1 . Google Scholar CrossRef Search ADS PubMed 9 Fullum T M , Oyetunji T A , Ortega G et al. Open versus laparoscopic hiatal hernia repair . JSLS 2013 ; 17 ( 1 ): 23 – 29 . Google Scholar CrossRef Search ADS PubMed 10 Weiss C A 3rd , Stevens R M , Schwartz R W . Paraesophageal hernia: current diagnosis and treatment . Curr Surg 2002 ; 59 : 180 – 2 . Google Scholar CrossRef Search ADS PubMed 11 Stylopoulos N , Gazelle G S , Rattner D W . Paraesophageal hernias: operation or observation? Ann Surg 2002 ; 236 : 492 – 501 ; discussion 500–1 . Google Scholar CrossRef Search ADS PubMed 12 Gantert W A , Patti M G , Arcerito M et al. Laparoscopic repair of paraesophageal hiatal hernias . J Am Coll Surg 1998 ; 186 : 428 – 33 ; discussion 432–3 . Google Scholar CrossRef Search ADS PubMed 13 Pierre A F , Luketich J D , Fernando H C , et al . Results of laparoscopic repair of giant paraesophageal hernias: 200 consecutive patients . Ann Thorac Surg 2002 ; 74 : 1909 – 16 ; discussion 1915–6 . Google Scholar CrossRef Search ADS PubMed 14 Mattar S G , Bowers S P , Galloway K D , Hunter J G , Smith C D . Long-term outcome of laparoscopic repair of paraesophageal hernia . Surg Endosc 2002 ; 16 : 745 – 9 . Google Scholar CrossRef Search ADS PubMed 15 Trus T L , Bax T , Richardson W S , Branum G D , Mauren S J , Swanstrom L L , Hunter J G . Complications of laparoscopic paraesophageal hernia repair . J Gastrointest Surg 1997 ; 1 : 221 – 8 ; discussion 228 . Google Scholar CrossRef Search ADS PubMed 16 Diaz S , Brunt L M , Klingensmith M E , Frisella P M , Soper N J . Laparoscopic paraesophageal hernia repair, a challenging operation: medium-term outcome of 116 patients . J Gastrointest Surg 2003 ; 7 : 59 – 67 ; discussion 66–7 . Google Scholar CrossRef Search ADS PubMed 17 Collet D , Luc G , Chiche L . Management of large para-esophageal hiatal hernias . J Visceral Surg 2013 ; 150 : 395 – 402 . Google Scholar CrossRef Search ADS 18 van der Peet D L , Klinkenberg-Knol E C , Alonso Poza A , Sietses C , Eijsbouts Q A , Cuesta M A . Laparoscopic treatment of large paraesophageal hernias both excision of the sac and gastropexy are imperative for adequate surgical treatment . Surg Endosc 2000 ; 14 : 1015 – 8 . Google Scholar CrossRef Search ADS PubMed 19 Davis S S Jr. Current controversies in paraesophageal hernia repair . Surg Clin North Am 2008 ; 88 : 959 – 78 , vi . Google Scholar CrossRef Search ADS PubMed 20 United Nations . World Population Ageing. Department of Economic and Social Affairs, Population Division 2013 [cited 2 Jul 2015.] Available from: http://www.un.org/en/development/desa/population/publications/pdf/ageing/WorldPopulationAgeing2013.pdf . 21 Larusson H J , Zingg U , Hahnloser D , Delport K , Seifert B , Oertli D . Predictive factors for morbidity and mortality in patients undergoing laparoscopic paraesophageal hernia repair: age, ASA score, and operation type influence morbidity . World J Surg , 2009 ; 33 : 980 – 5 . Google Scholar CrossRef Search ADS PubMed 22 Molena D , Mungo B , Stem M , Feinberg R L , Lidor A O . Outcomes of operations for benign foregut disease in elderly patients: a National Surgical Quality Improvement Program database analysis . Surgery 2014 ; 156 : 352 – 60 . Google Scholar CrossRef Search ADS PubMed 23 Liberati A , Altman D G , Tetzlaff J et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration . BMJ 2009 ; 339 : b2700 . Google Scholar CrossRef Search ADS PubMed 24 Deeks J J , Dinnes J , D’Amico R et al. Evaluating non-randomised intervention studies . Health Technol Assess 2003 ; 7 : iii–x , 1 – 173 . Google Scholar CrossRef Search ADS 25 Centre for Evidence-Based Medicine . Levels of Evidence . 2009 [cited 2015 10 Aug] Available from: http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/ . 26 Ballian N , Luketich J D , Levy R M et al. A clinical prediction rule for perioperative mortality and major morbidity after laparoscopic giant paraesophageal hernia repair . J Thorac Cardiovasc Surg 2013 ; 145 : 721 – 9 . Google Scholar CrossRef Search ADS PubMed 27 Paul S , Mirza F M , Nasar A et al. Prevalence, outcomes, and a risk-benefit analysis of diaphragmatic hernia admissions: An examination of the National Inpatient Sample database . J Thorac Cardiovasc Surg 2011 ; 142 : 747 – 54 . Google Scholar CrossRef Search ADS PubMed 28 Poulose B K , Gosen C , Marks J M et al. Inpatient mortality analysis of paraesophageal hernia repair in octogenarians . J Gastrointest Surg 2008 ; 12 : 1888 – 92 . Google Scholar CrossRef Search ADS PubMed 29 Spaniolas K , Laycock W S , Adrales G L , Trus T L . Laparoscopic paraesophageal hernia repair: advanced age is associated with minor but not major morbidity or mortality . J Am Coll Surg 2014 ; 218 : 1187 – 92 . Google Scholar CrossRef Search ADS PubMed 30 Parker D M , Rambhajan A A , Horsley R D , Johanson K , Gabrielsen J D , Petrick A T . Laparoscopic paraesophageal hernia repair is safe in elderly patients . Surg Endosc 2017 ; 31 : 1186 – 91 . Google Scholar CrossRef Search ADS PubMed 31 Gangopadhyay N , Perrone J M , Soper N J et al. Outcomes of laparoscopic paraesophageal hernia repair in elderly and high-risk patients . Surgery 2006 ; 140 : 491 – 9 ; discussion 498–9 . Google Scholar CrossRef Search ADS PubMed 32 Louie B E , Blitz M , Farivar A S , Orlina J , Aye R W . Repair of symptomatic giant paraesophageal hernias in elderly (>70 years) patients results in improved quality of life . J Gastrointest Surg 2011 ; 15 : 389 – 96 . Google Scholar CrossRef Search ADS PubMed 33 Hazebroek E J , Gananadha S , Koak Y , Berry H , Leibman S , Smith G S . Laparoscopic paraesophageal hernia repair: quality of life outcomes in the elderly . Dis Esophagus 2008 ; 21 : 737 – 41 . Google Scholar CrossRef Search ADS PubMed 34 Hashemi M , Peters J H , DeMeester T R et al. Laparoscopic repair of large type III hiatal hernia: objective followup reveals high recurrence rate11No competing interests declared . J Am Coll Surg 2000 ; 190 : 553 – 60 ; discussion 560–1 . Google Scholar CrossRef Search ADS PubMed 35 Muller-Stich B P , Achtstätter V , Diener M K et al. Repair of paraesophageal hiatal hernias-is a fundoplication needed? A randomized controlled pilot trial . J Am Coll Surg 2015 ; 221 : 602 – 10 . Google Scholar CrossRef Search ADS PubMed 36 Casabella F , Sinanan M , Horgan S , Pellegrini C A . Systematic use of gastric fundoplication in laparoscopic repair of paraesophageal hernias . Am J Surg 1996 ; 171 : 485 – 9 . Google Scholar CrossRef Search ADS PubMed 37 Svetanoff W J , Pallati P , Nandipati K , Lee T , Mittal S K . Does the addition of fundoplication to repair the intra-thoracic stomach improve quality of life? Surg Endosc 2016 ; 30 : 4590 – 7 . Google Scholar CrossRef Search ADS PubMed 38 Edye M B , Canin-Endres J , Gattorno F , Salky B A . Durability of laparoscopic repair of paraesophageal hernia . Ann Surg 1998 ; 228 : 528 – 35 . Google Scholar CrossRef Search ADS PubMed 39 Antoniou S A , Müller-Stich B P , Antoniou G A et al. Laparoscopic augmentation of the diaphragmatic hiatus with biologic mesh versus suture repair: a systematic review and meta-analysis . Langenbecks Arch Surg 2015 ; 400 : 577 – 83 . Google Scholar CrossRef Search ADS PubMed 40 Oelschlager B K , Pellegrini C A , Hunter J et al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial . Ann Surg 2006 ; 244 : 481 – 90 . Google Scholar PubMed 41 Oelschlager B K , Pellegrini C A , Hunter J et al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair: long-term follow-up from a multicenter, prospective, randomized trial . J Am Coll Surg 2011 ; 213 : 461 – 8 . Google Scholar CrossRef Search ADS PubMed 42 Watson D I , Thompson S K , Devitt P G et al. Laparoscopic repair of very large hiatus hernia with sutures versus absorbable mesh versus nonabsorbable mesh . Ann Surg 2015 ; 261 : 282 – 9 . Google Scholar CrossRef Search ADS PubMed 43 Koetje J H , Irvine T , Thompson S K et al. Quality of life following repair of large hiatal hernia is improved but not influenced by use of mesh: results from a randomized controlled trial . World J Surg 2015 ; 39 : 1465 – 73 . Google Scholar CrossRef Search ADS PubMed 44 Varga G , Cseke L , Kalmar K , Horvath O P . Laparoscopic repair of large hiatal hernia with teres ligament: midterm follow-up . Surg Endosc 2008 ; 22 : 881 – 4 . Google Scholar CrossRef Search ADS PubMed 45 Ghanem O , Doyle C , Sebastian R , Park A . New surgical approach for giant paraesophageal hernia repair: closure of the esophageal hiatus anteriorly using the left triangular ligament . Dig Surg 2015 ; 32 : 124 – 8 . Google Scholar CrossRef Search ADS PubMed 46 Park A E , Hoogerboord C M , Sutton E . Use of the falciform ligament flap for closure of the esophageal hiatus in giant paraesophageal hernia . J Gastrointest Surg 2012 ; 16 : 1417 – 21 . Google Scholar CrossRef Search ADS PubMed 47 Furnee E , Hazebroek E . Mesh in laparoscopic large hiatal hernia repair: a systematic review of the literature . Surg Endosc 2013 ; 27 : 3998 – 4008 . Google Scholar CrossRef Search ADS PubMed 48 Memon M A , Memon B , Yunus R M , Khan S . Suture cruroplasty versus prosthetic hiatal herniorrhaphy for large hiatal hernia . Ann Surg 2016 ; 263 : 258 – 66 . Google Scholar CrossRef Search ADS PubMed 49 Muller-Stich B P , Kenngott H G , Gondan M et al. Use of mesh in laparoscopic paraesophageal hernia repair: a meta-analysis and risk-benefit analysis . PLoS One 2015 ; 10 : e0139547 . Google Scholar CrossRef Search ADS PubMed 50 Tam V , Winger D G , Nason K S . A systematic review and meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair . Am J Surg 2016 ; 211 : 226 – 38 . Google Scholar CrossRef Search ADS PubMed 51 Crespin O M , Yates R B , Martin A V , Pellegrini C A , Oelschlager B K . The use of crural relaxing incisions with biologic mesh reinforcement during laparoscopic repair of complex hiatal hernias . Surg Endosc 2016 ; 30 : 2179 – 85 . Google Scholar CrossRef Search ADS PubMed 52 Alicuben E T , Worrell S G , DeMeester S R . Impact of crural relaxing incisions, Collis gastroplasty, and non-cross-linked human dermal mesh crural reinforcement on early hiatal hernia recurrence rates . J Am Coll Surg 2014 ; 219 : 988 – 92 . Google Scholar CrossRef Search ADS PubMed 53 Greene C L , DeMeester S R , Zehetner J , Worrell S G , Oh D S , Hagen J A . Diaphragmatic relaxing incisions during laparoscopic paraesophageal hernia repair . Surg Endosc , 2013 ; 27 : 4532 – 8 . Google Scholar CrossRef Search ADS PubMed 54 Puri V , Jacobsen K , Bell J M et al. Hiatal hernia repair with or without esophageal lengthening: is there a difference? Innovations (Phila) 2013 ; 8 : 341 – 7 . Google Scholar CrossRef Search ADS PubMed 55 Oelschlager B K , Pellegrini C A , Hunter J et al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair: long-term follow-up from a multicenter, prospective, randomized trial . J Am Coll Surg 2011 ; 213 : 461 – 8 . Google Scholar CrossRef Search ADS PubMed © The Authors 2018. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Diseases of the Esophagus Oxford University Press

Treatment of paraesophageal hiatal hernia in octogenarians: a systematic review and retrospective cohort study

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Publisher
The International Society for Diseases of the Esophagus
Copyright
© The Authors 2018. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus.
ISSN
1120-8694
eISSN
1442-2050
D.O.I.
10.1093/dote/doy010
Publisher site
See Article on Publisher Site

Abstract

Summary Over the coming years octogenarians will make up an increasingly large proportion of the population. With the rise in octogenarians more paraesophageal hiatal hernias may be identified. In research for the optimal treatment for paraesophageal hiatal hernias, octogenarians are often omitted and the optimal surgical strategy for this patient group remains unclear. A systematic search in PubMed, Embase, and The Cochrane Library was conducted, including articles compromising ‘surgery,’ ‘paraesophageal hiatal hernia,’ and ‘octogenarians.’ Selection of articles was based on independent review by two authors. Alongside, a retrospective cohort study was conducted including all type II–IV hiatal hernia repairs performed in the VU Medical Center in Amsterdam, The Netherlands, from 2005 to 2015. A total of 486 papers were eligible for selection. After careful selection, a total of eight articles were included. All articles were retrospective cohort studies describing different proportions of octogenarians. The populations and surgical techniques were very heterogeneous. Elective paraesophageal hiatal hernia repair was performed safely in symptomatic octogenarians in all studies. Additional analysis of 84 patients, of which 9.5% octogenarians, was performed at our tertiary referral center. A larger hernia type, more acute interventions and a higher morbidity and mortality rate was observed in octogenarians compared to patients aged <80 years. In conclusion, elective paraesophageal hiatal hernia repair can be performed in octogenarians, especially in patients without comorbidity. Findings suggest improvement in symptoms in short-term follow up, with minimal morbidity and mortality. With regard to surgical techniques, laparoscopy and fundoplication were performed safely. Octogenarians need to be included in future clinical trials to further evaluate the optimal surgical intervention. Preoperative risk assessment by clinical prediction rules should guide operative intervention, in order to evaluate risks and benefits in this challenging population. INTRODUCTION Paraesophageal hiatal hernias (PHH) account for 5% of all hiatal hernias.1 In contrast to sliding hernias, many patients are asymptomatic. When symptoms do occur, heartburn, chest pain, regurgitation, early satiety, chronic anemia, and dysphagia are reported.2–4 The diagnosis of PHH can be an indication for surgery as untreated PHH may lead to potentially lethal complications such as strangulation, incarceration, volvulus, and perforation.5,6 Urgent surgical intervention subjects patients to increased morbidity and mortality.7–9 The mortality rates in emergency repair range from 5% to 50% as opposed to 0.5–3% in an elective setting. Interestingly, octogenarians are underrepresented in these studies.10–17 With regard to operative techniques, consensus has been reached on the necessitated steps; dissection and excision of the hernial sac, dissection and assessment of the intra-abdominal length of the esophagus and closure of the crural defect. Additionally, an antireflux procedure is advised when a mixed type hernia with complaints of gastroesophageal reflux disease is present.18 The approach and technique of crural closure continues to be one of the most controversial topics in surgical literature.13,19 The proportion of octogenarians, within the population aged ≥60 years, increased from 7% in 1950 to 14% in 2013 and is calculated to be as large as 19% in 2050.20 PHH are seen more in patients of older age, and are therefore likely to become more prevalent as the general population ages.21 The proportion of surgical procedures performed in the elderly is increasing in recent years.22 Octogenarians are often omitted in research on PHH and the optimal surgical techniques in this population are therefore unclear. The aim of this study is to assess whether an indication for surgical repair of PHH in octogenarians exists and what surgical technique is most suitable in this population. MATERIALS AND METHODS Literature search A systematic literature search was conducted from inception to October 4th 2016 in Embase, PubMed, and The Cochrane Library. Free search terms and Medical Subject Heading (MeSH) terms were used to identify relevant articles in PubMed and Embase. In The Cochrane Library only free search terms were set up to assess all relevant publications. Search terms comprising ‘paraesophageal hiatal hernia,’ ‘surgery,’ ‘octogenarians,’ and relevant synonyms were used. Selection criteria Articles were independently assessed on relevance by two authors (JS and LG). Inclusion criteria consisted of: (1) PHH, hiatal hernia type II–IV, large hiatal hernias described as hernias >5 cm or contain more than one third of stomach; (2) the study population consisted of octogenarians, or compared octogenarians with younger patient groups; (3) Included articles had to be in English, Dutch, German, or Spanish. The exclusion criteria were: (1) specific patient groups such as obesity surgery, antireflux surgery, recurrent hiatal hernia repair and emergency surgery; (2) animal studies; (3) review articles and case reports. References of the included articles were assessed manually for additional relevant articles. Data extraction and quality assessment This systematic review was conducted in line with the recommendations of the PRISMA Statement for Systematic Reviews and Meta-Analyses.23 Data collection was performed by two authors (JS and LG), which extracted the following data: first author and year of publication, study period, study type, country, sample size, age groups, mean age, sex, hernia type and clinical outcomes. Data extracted was reported in means and standard deviations. The quality assessment of the included studies was classified using the Newcastle-Ottawa Quality Assessment Scale (NOS) for retrospective cohort studies and case-control studies.24 Studies were evaluated independently. A maximum of nine points could be awarded. Selection criteria of the concerned study could receive four points; three points could be awarded for outcome and two points for comparability. A study was classified as high quality when it scored six or more points. A level of evidence was assigned to studies according to the Oxford Centre of Evidence Based Medicine Levels of Evidence.25 Cohort studies with less than six points were assigned a level of evidence of four; a score of six or seven was 2B. Cohort studies that included a comparison between groups were assigned a level of evidence of 3B. Database acquisition Alongside this systematic review an observational cohort study was conducted, including all patients who underwent PHH repair at the VU University Medical Center from January 2005 to June 2015. Patients <18 years of age, traumatic surgery, patients with previous surgery of the esophagus or stomach were excluded. Data were collected regarding patient characteristics, pre- and postoperative symptoms, type of intervention, operative time, conversion, intraoperative complications, postoperative complications, mortality, morbidity, length of hospital stay, and survival. Minor complications were graded as Clavien–Dindo (CD) 1–2 and major complications as CD 3–5. This study was approved by the Medical Ethical Committee from our institution and conforms to requisite ethical and juridical aspects. Statistical analysis Data were analyzed using the SPSS Statistics, version 20 (IBM, Washington, DC). Continuous variables were expressed as means and standard deviations for normal distributions and medians and interquartile ranges for non-normal distributions. Comparison of octogenarians with patients aged <80 years was performed with a Student's T-test or Mann-Whitney-U test as was deemed appropriate. Frequencies were expressed as percentages and analyzed using the Chi-square test. RESULTS Study selection A total of 486 studies were identified, of which 30 duplicates were excluded. Articles were screened for eligibility on title and abstract, based on the predefined inclusion- and exclusion criteria. After independently selecting relevant articles, two authors (JS and LG) compared the two different search results, which led up to the definitive first selection of 24 relevant articles. After full text analysis, another 17 articles were excluded because octogenarians were not analyzed separately, the intervention group did not focus on hiatal hernia repair or included <10 patients. One additional article was identified via cross-referencing.26 Finally, eight articles were included in this systematic review.8,21,22,26–30 A flow-chart of the article selection is depicted in Figure 1. Fig. 1 View largeDownload slide Flow diagram for article selection. Fig. 1 View largeDownload slide Flow diagram for article selection. Study characteristics Eight articles were included for qualitative synthesis, including a total of 218,891 patients; all studies were of observational nature. One study was conducted in Switzerland;21 the other seven studies were conducted in the United States of America.8,22,26–30 Information on the included studies is depicted in Table 1. Two authors (JS and LG) independently appraised all articles using the NOS, alongside the level of evidence was determined. An overview of the assessment is depicted in Table 2. Table 1 Overview of included studies Author Publication year Study period Design Country Sample size Age groups Mean Age Sex M/F Hernia type Outcome Ballian et al.26 2013 1997–2010 RSC USA 980 <50 years, 50–59 years, 60–69 years, 70–79 years, ≥80 years 71 (IQR: 62–78 247/733 >30% of stomach in posterior mediastinum Clinical prediction rules for postoperative mortality and morbidity Larusson et al.21 2009 1995–2006 RSC Switzerland 354 <70 years, 70–79 years, ≥80 years 64 (R: 23–90) 127/227 II(37.0%), III(25.4%), IV(37.6%) Higher mortality in octogenarians and a higher morbidity in hernia repair with gastropexy Luketich et al.8 2010 1997–2003 vs. 2003–2008 RSC USA 662 Subgroup analysis ≥80 years 70 (R: 19–92) 167/495 >30% of stomach herniated into mediastinum Patients who are older, obese or have comorbid diseases are at higher risk for adverse postoperative outcomes Molena et al.22 2014 2005–2011 RSC USA 19,388 <65 years 65–69 years, 70–74 years, 75–79 years, ≥80 years 56.4 7061/12,327 91.4% PHH Age, both alone and in a synergistic fashion with other comorbidities, was an important risk factor for adverse outcomes Parker et al.30 2016 2003–2012 RSC USA 267 <70 years, 70–79 years, ≥80 years 58.5/75.0 /83.0 (R: 32–98) 71/196 100% PHH Despite the advanced age and comorbidities, PHH repair can be performed safely in octogenarians. Paul et al.27 2011 1999–2008 RSC USA 193,554 <50 years, 50–59 years, 60–69 years, 70–79 years, ≥80 years 66.0 (R: 52.0–77.0) 62,568/130, 986 Type I-IV, exclusion: antireflux and small sliding hernia Elective repair was associated with better outcomes than nonelective repair, with a favorable risk-benefit profile Poulose et al.28 2008 2005 RSC USA 1005 ≥80 years 84.7 (SE:0.3) 271/734 Diaphragmatic hernias, exclusion: congenital/traumatic hernia and thoracic approach Nonelective repair was associated with a 6–7 fold increase in mortality and longer hospital stay Spaniolas et al29 2014 2010–2011 RSC USA 2681 <80 years vs. ≥80 years 63 (R:14) 1027/1887 PHH, excluded: bariatric- and emergent surgery Elective repair in octogenarians was not associated with a higher mortality and morbidity than younger patients Author Publication year Study period Design Country Sample size Age groups Mean Age Sex M/F Hernia type Outcome Ballian et al.26 2013 1997–2010 RSC USA 980 <50 years, 50–59 years, 60–69 years, 70–79 years, ≥80 years 71 (IQR: 62–78 247/733 >30% of stomach in posterior mediastinum Clinical prediction rules for postoperative mortality and morbidity Larusson et al.21 2009 1995–2006 RSC Switzerland 354 <70 years, 70–79 years, ≥80 years 64 (R: 23–90) 127/227 II(37.0%), III(25.4%), IV(37.6%) Higher mortality in octogenarians and a higher morbidity in hernia repair with gastropexy Luketich et al.8 2010 1997–2003 vs. 2003–2008 RSC USA 662 Subgroup analysis ≥80 years 70 (R: 19–92) 167/495 >30% of stomach herniated into mediastinum Patients who are older, obese or have comorbid diseases are at higher risk for adverse postoperative outcomes Molena et al.22 2014 2005–2011 RSC USA 19,388 <65 years 65–69 years, 70–74 years, 75–79 years, ≥80 years 56.4 7061/12,327 91.4% PHH Age, both alone and in a synergistic fashion with other comorbidities, was an important risk factor for adverse outcomes Parker et al.30 2016 2003–2012 RSC USA 267 <70 years, 70–79 years, ≥80 years 58.5/75.0 /83.0 (R: 32–98) 71/196 100% PHH Despite the advanced age and comorbidities, PHH repair can be performed safely in octogenarians. Paul et al.27 2011 1999–2008 RSC USA 193,554 <50 years, 50–59 years, 60–69 years, 70–79 years, ≥80 years 66.0 (R: 52.0–77.0) 62,568/130, 986 Type I-IV, exclusion: antireflux and small sliding hernia Elective repair was associated with better outcomes than nonelective repair, with a favorable risk-benefit profile Poulose et al.28 2008 2005 RSC USA 1005 ≥80 years 84.7 (SE:0.3) 271/734 Diaphragmatic hernias, exclusion: congenital/traumatic hernia and thoracic approach Nonelective repair was associated with a 6–7 fold increase in mortality and longer hospital stay Spaniolas et al29 2014 2010–2011 RSC USA 2681 <80 years vs. ≥80 years 63 (R:14) 1027/1887 PHH, excluded: bariatric- and emergent surgery Elective repair in octogenarians was not associated with a higher mortality and morbidity than younger patients BMI, body mass index (kg/m2); IQR, interquartile range, R, range; RSC, retrospective cohort; SE, standard error of the mean; y, years; USA, United States of America. View Large Table 1 Overview of included studies Author Publication year Study period Design Country Sample size Age groups Mean Age Sex M/F Hernia type Outcome Ballian et al.26 2013 1997–2010 RSC USA 980 <50 years, 50–59 years, 60–69 years, 70–79 years, ≥80 years 71 (IQR: 62–78 247/733 >30% of stomach in posterior mediastinum Clinical prediction rules for postoperative mortality and morbidity Larusson et al.21 2009 1995–2006 RSC Switzerland 354 <70 years, 70–79 years, ≥80 years 64 (R: 23–90) 127/227 II(37.0%), III(25.4%), IV(37.6%) Higher mortality in octogenarians and a higher morbidity in hernia repair with gastropexy Luketich et al.8 2010 1997–2003 vs. 2003–2008 RSC USA 662 Subgroup analysis ≥80 years 70 (R: 19–92) 167/495 >30% of stomach herniated into mediastinum Patients who are older, obese or have comorbid diseases are at higher risk for adverse postoperative outcomes Molena et al.22 2014 2005–2011 RSC USA 19,388 <65 years 65–69 years, 70–74 years, 75–79 years, ≥80 years 56.4 7061/12,327 91.4% PHH Age, both alone and in a synergistic fashion with other comorbidities, was an important risk factor for adverse outcomes Parker et al.30 2016 2003–2012 RSC USA 267 <70 years, 70–79 years, ≥80 years 58.5/75.0 /83.0 (R: 32–98) 71/196 100% PHH Despite the advanced age and comorbidities, PHH repair can be performed safely in octogenarians. Paul et al.27 2011 1999–2008 RSC USA 193,554 <50 years, 50–59 years, 60–69 years, 70–79 years, ≥80 years 66.0 (R: 52.0–77.0) 62,568/130, 986 Type I-IV, exclusion: antireflux and small sliding hernia Elective repair was associated with better outcomes than nonelective repair, with a favorable risk-benefit profile Poulose et al.28 2008 2005 RSC USA 1005 ≥80 years 84.7 (SE:0.3) 271/734 Diaphragmatic hernias, exclusion: congenital/traumatic hernia and thoracic approach Nonelective repair was associated with a 6–7 fold increase in mortality and longer hospital stay Spaniolas et al29 2014 2010–2011 RSC USA 2681 <80 years vs. ≥80 years 63 (R:14) 1027/1887 PHH, excluded: bariatric- and emergent surgery Elective repair in octogenarians was not associated with a higher mortality and morbidity than younger patients Author Publication year Study period Design Country Sample size Age groups Mean Age Sex M/F Hernia type Outcome Ballian et al.26 2013 1997–2010 RSC USA 980 <50 years, 50–59 years, 60–69 years, 70–79 years, ≥80 years 71 (IQR: 62–78 247/733 >30% of stomach in posterior mediastinum Clinical prediction rules for postoperative mortality and morbidity Larusson et al.21 2009 1995–2006 RSC Switzerland 354 <70 years, 70–79 years, ≥80 years 64 (R: 23–90) 127/227 II(37.0%), III(25.4%), IV(37.6%) Higher mortality in octogenarians and a higher morbidity in hernia repair with gastropexy Luketich et al.8 2010 1997–2003 vs. 2003–2008 RSC USA 662 Subgroup analysis ≥80 years 70 (R: 19–92) 167/495 >30% of stomach herniated into mediastinum Patients who are older, obese or have comorbid diseases are at higher risk for adverse postoperative outcomes Molena et al.22 2014 2005–2011 RSC USA 19,388 <65 years 65–69 years, 70–74 years, 75–79 years, ≥80 years 56.4 7061/12,327 91.4% PHH Age, both alone and in a synergistic fashion with other comorbidities, was an important risk factor for adverse outcomes Parker et al.30 2016 2003–2012 RSC USA 267 <70 years, 70–79 years, ≥80 years 58.5/75.0 /83.0 (R: 32–98) 71/196 100% PHH Despite the advanced age and comorbidities, PHH repair can be performed safely in octogenarians. Paul et al.27 2011 1999–2008 RSC USA 193,554 <50 years, 50–59 years, 60–69 years, 70–79 years, ≥80 years 66.0 (R: 52.0–77.0) 62,568/130, 986 Type I-IV, exclusion: antireflux and small sliding hernia Elective repair was associated with better outcomes than nonelective repair, with a favorable risk-benefit profile Poulose et al.28 2008 2005 RSC USA 1005 ≥80 years 84.7 (SE:0.3) 271/734 Diaphragmatic hernias, exclusion: congenital/traumatic hernia and thoracic approach Nonelective repair was associated with a 6–7 fold increase in mortality and longer hospital stay Spaniolas et al29 2014 2010–2011 RSC USA 2681 <80 years vs. ≥80 years 63 (R:14) 1027/1887 PHH, excluded: bariatric- and emergent surgery Elective repair in octogenarians was not associated with a higher mortality and morbidity than younger patients BMI, body mass index (kg/m2); IQR, interquartile range, R, range; RSC, retrospective cohort; SE, standard error of the mean; y, years; USA, United States of America. View Large Table 2 Newcastle-Ottawa quality assessment scale and level of evidence of the included articles Authors Publication year Represent-ativeness exposed cohort Selection nonexposed cohort Ascertain-ment of exposure Demonstration outcome of interest not present at start of study Compara-bility cohorts (max. 2 points) Assessment of outcome Follow-up long enough for outcome interest Adequacy of follow-up Total Level of evidence Ballian et al.26 2013 1 1 1 1 2 1 1 1 9 3B Larusson et al.21 2009 0 0 1 1 1 1 0 0 4 4 Luketich et al.8 2010 0 1 1 1 0 1 1 1 6 2B Molena et al.22 2014 1 1 1 1 2 1 1 1 9 3B Parker et al.30 2016 1 1 1 1 2 1 1 1 9 3B Poulose et al.28 2008 1 0 1 1 0 1 0 0 4 4 Spaniolas et al.29 2014 1 1 1 1 2 1 1 1 9 3B Authors Publication year Represent-ativeness exposed cohort Selection nonexposed cohort Ascertain-ment of exposure Demonstration outcome of interest not present at start of study Compara-bility cohorts (max. 2 points) Assessment of outcome Follow-up long enough for outcome interest Adequacy of follow-up Total Level of evidence Ballian et al.26 2013 1 1 1 1 2 1 1 1 9 3B Larusson et al.21 2009 0 0 1 1 1 1 0 0 4 4 Luketich et al.8 2010 0 1 1 1 0 1 1 1 6 2B Molena et al.22 2014 1 1 1 1 2 1 1 1 9 3B Parker et al.30 2016 1 1 1 1 2 1 1 1 9 3B Poulose et al.28 2008 1 0 1 1 0 1 0 0 4 4 Spaniolas et al.29 2014 1 1 1 1 2 1 1 1 9 3B View Large Table 2 Newcastle-Ottawa quality assessment scale and level of evidence of the included articles Authors Publication year Represent-ativeness exposed cohort Selection nonexposed cohort Ascertain-ment of exposure Demonstration outcome of interest not present at start of study Compara-bility cohorts (max. 2 points) Assessment of outcome Follow-up long enough for outcome interest Adequacy of follow-up Total Level of evidence Ballian et al.26 2013 1 1 1 1 2 1 1 1 9 3B Larusson et al.21 2009 0 0 1 1 1 1 0 0 4 4 Luketich et al.8 2010 0 1 1 1 0 1 1 1 6 2B Molena et al.22 2014 1 1 1 1 2 1 1 1 9 3B Parker et al.30 2016 1 1 1 1 2 1 1 1 9 3B Poulose et al.28 2008 1 0 1 1 0 1 0 0 4 4 Spaniolas et al.29 2014 1 1 1 1 2 1 1 1 9 3B Authors Publication year Represent-ativeness exposed cohort Selection nonexposed cohort Ascertain-ment of exposure Demonstration outcome of interest not present at start of study Compara-bility cohorts (max. 2 points) Assessment of outcome Follow-up long enough for outcome interest Adequacy of follow-up Total Level of evidence Ballian et al.26 2013 1 1 1 1 2 1 1 1 9 3B Larusson et al.21 2009 0 0 1 1 1 1 0 0 4 4 Luketich et al.8 2010 0 1 1 1 0 1 1 1 6 2B Molena et al.22 2014 1 1 1 1 2 1 1 1 9 3B Parker et al.30 2016 1 1 1 1 2 1 1 1 9 3B Poulose et al.28 2008 1 0 1 1 0 1 0 0 4 4 Spaniolas et al.29 2014 1 1 1 1 2 1 1 1 9 3B View Large The percentage of octogenarians in the included studies ranged from 6.3–19.6%21,22,26,27,29,30 and one study included only octogenarians.28 In one study no specific number of octogenarians was mentioned, in this study 51% of the study population was aged ≥70 years and a subanalysis in octogenarians was conducted.8 Octogenarians had an higher Charlson comorbidity score than younger patient groups and presented with a higher percentage of intrathoracic stomach.30 Timing of the surgical repair Nonelective repairs are defined as being urgent or acute. Urgent repairs presented with symptoms and were operated in the same admission, but later than 12 hours after presentation. A symptomatic PHH that was operated within 12 hours was characterized as an acute repair. Overall an elective PHH repair was conducted in 24–98%, the remaining repairs were of nonelective nature.22,26–28,30 In four studies, with the study population divided into different age groups, octogenarians received an elective PHH repair in 34–92% and a nonelective PHH repair in 8–66%.22,26,27,30 One study described a case series of octogenarians in which an elective PHH repair was performed in 57% and a nonelective PHH repair in 43%.28 Two studies did not specify the amount of elective or nonelective PHH repairs.8,21 Another two studies excluded acute PHH repairs.8,29 Only one article mentioned the indication for performing an nonelective repair, which was an acute presentation with an incarcerated PHH.30 Nonelective PHH repair was performed significantly more in octogenarians compared to younger patient groups.22,26,27,30 Length of hospital stay was significantly increased for nonelective patients compared to elective patients.28,29 Morbidity was higher in nonelective PHH repair and highest in patients presenting with gangrene.27 Overall mortality was significantly higher for nonelective PHH repair than for elective PHH repair, 5.0–16% versus 0.5–6%, respectively.8,22,26–29 The nonelective laparoscopic approach had a 4.2–7.1 greater odds and the open nonelective approach a 6.3 greater odds of 30-day mortality, compared with the elective laparoscopic PHH repair.22,28 The risk for perioperative mortality tripled and the risk for major morbidity doubled when a nonelective repair was required.26 In octogenarians, mortality in elective repair was 3.9%, compared with 0.6% in patients aged <80 years.27 Nonelective PHH repair was determined to be a predictor of mortality in octogenarians.28 Regression analysis depicted octogenarians, hernia size of 75% or greater, BMI <18.5 kg/m2 and comorbid disease to be independent predictors for nonelective repair.26 Operative techniques Minimally invasive versus open A laparoscopic approach was planned in 84–100% of PHH repairs, with a conversion rate of 1.5–5.6%.8,21,22,26,29 In one study, conversions were excluded based on a preset diagnosis and coding system and another study described no conversions.29,30 Three studies included open and laparoscopic repairs, but did not stratify for approach in their results.26–28 The open approach was performed more frequently in octogenarians compared to patients of younger age. Open surgery was associated with a higher 30-day mortality rate, being 4.3% in open surgery versus 1.4% in laparoscopic surgery. Morbidity was lower in laparoscopic surgery in octogenarians, being 13.1% versus 26.9% in open surgery.22 Cruroplasty; mesh versus no mesh Mesh cruroplasty was performed in 12–77% of PHH patients.8,26,29,30 Two studies assessed the outcomes of mesh cruroplasty.8,30 When comparing octogenarians to a younger patient group, mesh cruroplasty was performed in 47.6–77.8% of octogenarians and in 42.9–76.6% of patients aged <80 years.29,30 Mesh use did not differ between age groups.30 In one study, mesh cruroplasty was associated with significantly increased odds of reoperation for hernia recurrence.8 Fundoplication and gastropexy Fundoplication was performed in 67–98% of PHH patients,8,21,26,30 of which 23–31.1% received a partial fundoplication (Dor or Toupet) and 63.3–77% a Nissen fundoplication.26,30 The type of fundoplication was determined intraoperatively at the discretion of the surgeon.8,26,30 A Nissen fundoplication was significantly performed more often in younger patient groups than in octogenarians, 69.4% versus 31.1%, respectively.30 Performing fundoplication in patients of advancing age did not result in increased morbidity compared to patients <80 years of age.21 Gastropexy was applied more often in octogenarians.8 Postoperative outcomes were separately assessed between gastropexy and fundoplication in one study, showing similar postoperative results in morbidity for fundoplication and gastropexy.21 Collis gastroplasty: esophageal lengthening Esophageal lengthening (Collis gastroplasty) was performed to restore adequate length of the intra-abdominal esophagus and thereby releasing axial tension in 2–63%.8,26,29,30 In 52% of patients who also received a fundoplication, a Collis gastroplasty was added.26 Of the 2.5% postoperative leaks, 88% occurred when esophageal lengthening was performed.8 Esophageal lengthening was performed in 1.8–30.2% of patients <80 years of age and in 2.9–31.1% of octogenarians, which did not differ significantly.29 Interestingly the incidence of esophageal lengthening decreased over the years, in recent years mesh cruroplasty was applied more often.8 Postoperative results Radiographic recurrence was not associated with recurrent symptoms and satisfaction with surgery. Symptoms were significantly reduced at follow-up (median of 30 months follow-up) in comparison to preoperative level.8 Postoperative Quality of Life in Reflux and Dyspepsia (QOLRAD) scores were significantly improved compared to preoperative scores in all age groups. No difference in QOLRAD scores between age groups was observed in both the pre-operative or postoperative QOLRAD scores.30 Of all operated patients, 89% reported satisfaction with the surgical result.8 Overall morbidity in PHH repair was 5.6–13.2% in patients aged <80 years and 11.2–32.4% in octogenarians, which significantly differed.21,29 In one study, overall morbidity of octogenarians (22.2%) did not differ significantly compared to patients aged <80 years (17.1%).30 Reoperation was carried out in 3.4–4.9%, with no difference between age groups.8,30 Length of hospital stay Hospital stay was associated with age, ASA score, morbidity, conversion and when gastropexy was performed.21,22 Postoperative complications or conversion doubled hospital stay.21 Length of hospital stay did not significantly differ between the eras 1997–2003 and 2003–2008, even though the incidence of comorbid diseases increased in this time period.8 Patients ≥70 years stayed two days longer than younger patients.21 Octogenarians experienced a significantly longer hospital stay irrespective of open or laparoscopic approach.22,30 Mortality An adverse outcome was seen less in PHH patients presenting with heartburn.8 The mortality rate in octogenarians was 0–10% compared to an overall mortality of 0.7–2.6%,8,21,26,28,30 this was significantly different and independent of the type of operation.21,22 In two studies, no significantly difference was found in mortality between the older and younger patient groups.29,30 Serious morbidity was not different between age groups in one study, however another study showed more serious morbidity in octogenarians (17.8%), compared to patients <80 years of age (6.3%).29,30 Obstructive symptoms were not associated with a greater rate of mortality or morbidity.27 Mortality in octogenarians versus patients aged <80 years with obstruction was 9.7% versus 2.2%, in PHH with gangrene a mortality of 36.8% in octogenarians and 19.9% in patients aged <80 years was found.27 Factors associated with mortality included older age, BMI <18.5 kg/m2, history of congestive heart failure, cerebrovascular accident, dementia, pulmonary disease and malignancy within the past five years.26 Type IV hernia was associated with the highest morbidity and mortality, which is the predominant hernia type in the elderly.21 Observational cohort study Using the surgical registry, 84 PHH patients were operated between 2005 and 2015 at the VU university medical center, Amsterdam, The Netherlands. Out of 84 included PHH patients, 9.5% were octogenarians. No differences were observed for baseline characteristics, besides age. Baseline characteristics are depicted in Table 3. When comparing octogenarians with patients <80 years of age, hernia type, acute indication and type of fundoplication significantly differed between the two groups. Octogenarians frequently had a larger hernia type and PHH repair was performed more often in the acute setting. Fundoplication was performed less in octogenarians. A fundoplication was added in PHH repair when gastroesophageal reflux symptoms were present. Intraoperative complications consisted of supraventricular tachycardia and hypotension (n = 1), perforation of the esophagus (n = 1), laceration of the fundus of the stomach (n = 1) of which both were managed with a laparoscopic suture and a pneumothorax (n = 1) treated with a drain. An overview of operative details is depicted in Table 4. Table 3 Baseline characteristics stratified by age <80 years ≥80 years P-value Patients (n) 76 (90.5%) 8 (9.5%) Gender (female, %) 58 (76.3%) 6 (75.0%) 0.934 Age (years) 63,9 ± 9.5 85,38 ± 3.5 0.000 BMI (kg/m2) 28.6 ± 5.0 25.2 ± 2.9 0.061 ASA classification  I 3 (4.1%) 1 (12.5%) 0.618  II 50 (67.6%) 4 (50.0%)  III 20 (27.0%) 3 (37.5%)  IV 1 (1.4%) 0 (0%) MET-score  1–4 12 (27.9%) 3 (60%) 0.312  5–9 27 (62.8%) 2 (40.0%)  10 or higher 4 (9.3%) 0 (0%) Comorbidity 53 (69,7%) 6 (75.0%) 0.757  Cardiac comorbidities 50 (65.8%) 6 (75%) 0.342  Diabetes  NIDDM 5 (6.6%) 2 (25.0%) 0.186  IDDM 2 (2.6%) 0 (0%)  COPD 13 (17.1%) 1 (12.5%) 0.740 Smoking 13 (17.8%) 1 (12.5%) 0.706 Alcohol 27 (37.5%) 2 (25.0%) 0.485 <80 years ≥80 years P-value Patients (n) 76 (90.5%) 8 (9.5%) Gender (female, %) 58 (76.3%) 6 (75.0%) 0.934 Age (years) 63,9 ± 9.5 85,38 ± 3.5 0.000 BMI (kg/m2) 28.6 ± 5.0 25.2 ± 2.9 0.061 ASA classification  I 3 (4.1%) 1 (12.5%) 0.618  II 50 (67.6%) 4 (50.0%)  III 20 (27.0%) 3 (37.5%)  IV 1 (1.4%) 0 (0%) MET-score  1–4 12 (27.9%) 3 (60%) 0.312  5–9 27 (62.8%) 2 (40.0%)  10 or higher 4 (9.3%) 0 (0%) Comorbidity 53 (69,7%) 6 (75.0%) 0.757  Cardiac comorbidities 50 (65.8%) 6 (75%) 0.342  Diabetes  NIDDM 5 (6.6%) 2 (25.0%) 0.186  IDDM 2 (2.6%) 0 (0%)  COPD 13 (17.1%) 1 (12.5%) 0.740 Smoking 13 (17.8%) 1 (12.5%) 0.706 Alcohol 27 (37.5%) 2 (25.0%) 0.485 View Large Table 3 Baseline characteristics stratified by age <80 years ≥80 years P-value Patients (n) 76 (90.5%) 8 (9.5%) Gender (female, %) 58 (76.3%) 6 (75.0%) 0.934 Age (years) 63,9 ± 9.5 85,38 ± 3.5 0.000 BMI (kg/m2) 28.6 ± 5.0 25.2 ± 2.9 0.061 ASA classification  I 3 (4.1%) 1 (12.5%) 0.618  II 50 (67.6%) 4 (50.0%)  III 20 (27.0%) 3 (37.5%)  IV 1 (1.4%) 0 (0%) MET-score  1–4 12 (27.9%) 3 (60%) 0.312  5–9 27 (62.8%) 2 (40.0%)  10 or higher 4 (9.3%) 0 (0%) Comorbidity 53 (69,7%) 6 (75.0%) 0.757  Cardiac comorbidities 50 (65.8%) 6 (75%) 0.342  Diabetes  NIDDM 5 (6.6%) 2 (25.0%) 0.186  IDDM 2 (2.6%) 0 (0%)  COPD 13 (17.1%) 1 (12.5%) 0.740 Smoking 13 (17.8%) 1 (12.5%) 0.706 Alcohol 27 (37.5%) 2 (25.0%) 0.485 <80 years ≥80 years P-value Patients (n) 76 (90.5%) 8 (9.5%) Gender (female, %) 58 (76.3%) 6 (75.0%) 0.934 Age (years) 63,9 ± 9.5 85,38 ± 3.5 0.000 BMI (kg/m2) 28.6 ± 5.0 25.2 ± 2.9 0.061 ASA classification  I 3 (4.1%) 1 (12.5%) 0.618  II 50 (67.6%) 4 (50.0%)  III 20 (27.0%) 3 (37.5%)  IV 1 (1.4%) 0 (0%) MET-score  1–4 12 (27.9%) 3 (60%) 0.312  5–9 27 (62.8%) 2 (40.0%)  10 or higher 4 (9.3%) 0 (0%) Comorbidity 53 (69,7%) 6 (75.0%) 0.757  Cardiac comorbidities 50 (65.8%) 6 (75%) 0.342  Diabetes  NIDDM 5 (6.6%) 2 (25.0%) 0.186  IDDM 2 (2.6%) 0 (0%)  COPD 13 (17.1%) 1 (12.5%) 0.740 Smoking 13 (17.8%) 1 (12.5%) 0.706 Alcohol 27 (37.5%) 2 (25.0%) 0.485 View Large Table 4 Operative details <80 years ≥80 years P-value Previous abdominal surgery 43 (56.6%) 5 (71.4%) 0.446 Previous hernia surgery 6 (7.9%) 1 (12.5%) 0.654 Hernia type  type 2 57 (75.0%) 4 (50.0%) 0.037  type 3 8 (10.5%) 0 (0%)  type 4 11 (14.5%) 4 (50.0%) Indication, acute (%) 9 (11.8%) 3 (37.5%) 0.049 Access  Open 4 (5.3%) 1 (12.5%) 0.411  Minimally invasive 72 (94.7%) 7 (87.5%)  Conversion 4 (5.3%) 1 (12.5%) 0.411 Crus  Sutures 57 (77.0%) 7 (87.5%) 0.497  Mesh (PTFE) 17 (17.2%) 1 (12.5%) Fundoplication  None 18 (24.0%) 4 (50.0%) 0.002  Nissen 54 (72.0%) 2 (25.0%)  Dor 0 (0%) 1 (12.5%)  Toupet 3 (4.0%) 1 (12.5%) Gastropexy 55 (73.3%) 5 (62.5%) 0.515 Duration (min) 141 ± 42 150.0 ± 56 0.591 Intraoperative complications 24 (23.8%) 4 (50.0%) 0.102 <80 years ≥80 years P-value Previous abdominal surgery 43 (56.6%) 5 (71.4%) 0.446 Previous hernia surgery 6 (7.9%) 1 (12.5%) 0.654 Hernia type  type 2 57 (75.0%) 4 (50.0%) 0.037  type 3 8 (10.5%) 0 (0%)  type 4 11 (14.5%) 4 (50.0%) Indication, acute (%) 9 (11.8%) 3 (37.5%) 0.049 Access  Open 4 (5.3%) 1 (12.5%) 0.411  Minimally invasive 72 (94.7%) 7 (87.5%)  Conversion 4 (5.3%) 1 (12.5%) 0.411 Crus  Sutures 57 (77.0%) 7 (87.5%) 0.497  Mesh (PTFE) 17 (17.2%) 1 (12.5%) Fundoplication  None 18 (24.0%) 4 (50.0%) 0.002  Nissen 54 (72.0%) 2 (25.0%)  Dor 0 (0%) 1 (12.5%)  Toupet 3 (4.0%) 1 (12.5%) Gastropexy 55 (73.3%) 5 (62.5%) 0.515 Duration (min) 141 ± 42 150.0 ± 56 0.591 Intraoperative complications 24 (23.8%) 4 (50.0%) 0.102 View Large Table 4 Operative details <80 years ≥80 years P-value Previous abdominal surgery 43 (56.6%) 5 (71.4%) 0.446 Previous hernia surgery 6 (7.9%) 1 (12.5%) 0.654 Hernia type  type 2 57 (75.0%) 4 (50.0%) 0.037  type 3 8 (10.5%) 0 (0%)  type 4 11 (14.5%) 4 (50.0%) Indication, acute (%) 9 (11.8%) 3 (37.5%) 0.049 Access  Open 4 (5.3%) 1 (12.5%) 0.411  Minimally invasive 72 (94.7%) 7 (87.5%)  Conversion 4 (5.3%) 1 (12.5%) 0.411 Crus  Sutures 57 (77.0%) 7 (87.5%) 0.497  Mesh (PTFE) 17 (17.2%) 1 (12.5%) Fundoplication  None 18 (24.0%) 4 (50.0%) 0.002  Nissen 54 (72.0%) 2 (25.0%)  Dor 0 (0%) 1 (12.5%)  Toupet 3 (4.0%) 1 (12.5%) Gastropexy 55 (73.3%) 5 (62.5%) 0.515 Duration (min) 141 ± 42 150.0 ± 56 0.591 Intraoperative complications 24 (23.8%) 4 (50.0%) 0.102 <80 years ≥80 years P-value Previous abdominal surgery 43 (56.6%) 5 (71.4%) 0.446 Previous hernia surgery 6 (7.9%) 1 (12.5%) 0.654 Hernia type  type 2 57 (75.0%) 4 (50.0%) 0.037  type 3 8 (10.5%) 0 (0%)  type 4 11 (14.5%) 4 (50.0%) Indication, acute (%) 9 (11.8%) 3 (37.5%) 0.049 Access  Open 4 (5.3%) 1 (12.5%) 0.411  Minimally invasive 72 (94.7%) 7 (87.5%)  Conversion 4 (5.3%) 1 (12.5%) 0.411 Crus  Sutures 57 (77.0%) 7 (87.5%) 0.497  Mesh (PTFE) 17 (17.2%) 1 (12.5%) Fundoplication  None 18 (24.0%) 4 (50.0%) 0.002  Nissen 54 (72.0%) 2 (25.0%)  Dor 0 (0%) 1 (12.5%)  Toupet 3 (4.0%) 1 (12.5%) Gastropexy 55 (73.3%) 5 (62.5%) 0.515 Duration (min) 141 ± 42 150.0 ± 56 0.591 Intraoperative complications 24 (23.8%) 4 (50.0%) 0.102 View Large In an uncomplicated course, the median length of hospital stay was 5 days (IQR: 4–6) in patients <80 of age and 9 days (IQR: 5–13) in octogenarians (P = 0.049). Overall complications occurred more often in octogenarians, 62.5% in octogenarians versus 28.7% in <80 years (P = 0.047). Complications in octogenarians consisted of pneumonia (n = 1), urine retention and obstipation (n = 1), mediastinal hematoma, and de novo atrial flutter (n = 1). Two octogenarians died following minimally invasive PHH repair. One octogenarian died after an acute PHH repair complicated by esophagus perforation and postoperative suspicion of mediastinitis for which reoperation was performed where no leakage or septic matter was seen. Placement of a mediastinal drain revealed postoperative intrathoracic leakage of percutaneous endoscopic gastrostomy tube feeding due to dislocation of the tube in the stomach instead of the duodenum. In consultation with family it was decided for conservative treatment, after which the patient developed sepsis followed by multi-organ failure. The other patient died of multi-organ failure after elective PHH repair with gastropexy, by pleural effusion and wall inflammation of the excised hernia sac. Gastropexy was performed because fundoplication was not technically feasible. Preoperative a mechanical obstruction with dyspnea was present because of the PHH, leading to the inability to eat resulting in a weight loss of 17 kg. Significant comorbid diseases were present in this patient, with extensive metastatic prostate cancer, end-stage congestive heart failure, atrium fibrillation, COPD, and esophagitis. An overview of all complications is depicted in Table 5. Table 5 Complications <80 years >80 years P-value Uncomplicated 72 (71.3%) 3 (37.5%) 0.047 Minor complication 15 (57.7%) 2 (40.0%) 0.467 Major complication 11 (42.3%) 3 (60.0%) In-hospital mortality 0 (0%) 2 (25.0%) 0.000 Duration of hospital stay (median (IQR))  Uncomplicated 5 (4–6) 9 (5– 13) 0.049  Complicated 10 (6–15) 13 (8– 15) 0.620 <80 years >80 years P-value Uncomplicated 72 (71.3%) 3 (37.5%) 0.047 Minor complication 15 (57.7%) 2 (40.0%) 0.467 Major complication 11 (42.3%) 3 (60.0%) In-hospital mortality 0 (0%) 2 (25.0%) 0.000 Duration of hospital stay (median (IQR))  Uncomplicated 5 (4–6) 9 (5– 13) 0.049  Complicated 10 (6–15) 13 (8– 15) 0.620 View Large Table 5 Complications <80 years >80 years P-value Uncomplicated 72 (71.3%) 3 (37.5%) 0.047 Minor complication 15 (57.7%) 2 (40.0%) 0.467 Major complication 11 (42.3%) 3 (60.0%) In-hospital mortality 0 (0%) 2 (25.0%) 0.000 Duration of hospital stay (median (IQR))  Uncomplicated 5 (4–6) 9 (5– 13) 0.049  Complicated 10 (6–15) 13 (8– 15) 0.620 <80 years >80 years P-value Uncomplicated 72 (71.3%) 3 (37.5%) 0.047 Minor complication 15 (57.7%) 2 (40.0%) 0.467 Major complication 11 (42.3%) 3 (60.0%) In-hospital mortality 0 (0%) 2 (25.0%) 0.000 Duration of hospital stay (median (IQR))  Uncomplicated 5 (4–6) 9 (5– 13) 0.049  Complicated 10 (6–15) 13 (8– 15) 0.620 View Large DISCUSSION PHH repair can be performed safely in symptomatic octogenarians. Although it should be noted octogenarians are underrepresented in current literature. Based on the literature, several factors should be taken into account when assessing octogenarians for PHH repair. The significant impact of PHH on quality of life (QoL) could indicate surgery.8,31,32 PHH repair results in a significant improvement in QoL of octogenarians.30,32,33 Preoperative work-up should aim to optimize comorbid diseases, nutritional and functional health status. The indication for PHH repair should take into account symptoms and assessment of the risk of postoperative morbidity and mortality, for instance with a clinical prediction rule.26 One study showed no difference in mortality between age groups.30 In the other studies, overall mortality was higher in octogenarians compared to younger patients, especially if emergency repair was necessary.8,22,26–29 The risk of progression to symptoms requiring emergency repair was 0.69–3.86% per year.27 The higher frequency of nonelective repairs in octogenarians could reflect the restraints that live among surgeons to plan an elective PHH repair in octogenarians. Elective repair in symptomatic patients should be the preferred choice in octogenarians, improved surgical techniques may improve outcomes even in nonelective surgery.27 If PHH repair is indicated, several surgical techniques are available. Minimally invasive techniques are associated with less morbidity and mortality.22 Results should be interpreted carefully, as conversions were excluded from analysis in one study.29 Gastropexy was associated with increased overall- and general morbidity in octogenarians, whereas no evidence exists for increased morbidity in fundoplication in octogenarians.21,30 With regard to indication for gastropexy, it was deemed less invasive and better handled in octogenarians, indicating a possible bias in these results with fundoplication being performed mainly in octogenarians with less comorbid diseases. A complete fundoplication was performed significantly less in octogenarians, instead a partial fundoplication was performed in octogenarians.30 Fundoplication could have potential benefits, due to continued improvements in clinical symptoms in the majority of patients with recurrent PHH and an intact fundoplication.14,34–36 A recent retrospective cohort did not found a difference in QoL between PHH repair with or without fundoplication after long-term follow-up. It should be noted that in this study 47% of the group with fundoplication and 51% of the group without fundoplication were lost to follow-up and no pre-operative QoL assessment was performed. Fundoplication resulted in a significant improvement of all the pre-operative symptoms; in the group without fundoplication only chest pain was significantly improved.37 Fundoplication allows for a good fixation of the fundus and gastroesophageal junction to the crura, preventing recurrence of a hiatal hernia in two studies.36,38 A randomized controlled trial should be performed to assess the benefit of fundoplication in PHH repair and compare pre- and postoperative QoL data, until then a fundoplication may be performed safely at the discretion of the surgeon. Mesh cruroplasty showed worse outcomes in octogenarians in one study; however another study showed no difference between age groups.8,30 These results may partially be explained due to the use of mesh in the case of a large hiatal defect.8 In the last decennium, several studies assessed the advantage of adding mesh in PHH repair. Of special interest is biomesh cruroplasty, which revealed short-term benefits with no durable long-term efficacy.39–43 A relatively new technique is the use of autologous prosthetics in which teres ligament, triangular ligament, and falciform ligament are added in cruroplasty.44–46 Due to different classifications of PHH, heterogeneous types and configurations of mesh, different methods of securing mesh, different classification and detection of a recurrent hernia and the lack of long-term postoperative data, no conclusions toward the benefit of mesh cruroplasty in PHH could be drawn.39,47–50 In order to obtain more durable results in mesh repair, both improvements in technique as well as material are needed to show durable superior results. Relaxing incisions are used to reduce radial tension and can facilitate tension-free closure of the hiatus. Recurrent hernia was similar in low-tension PHH with or without biomesh cruroplasty compared to high-tension PHH with the addition of relaxing incisions covered by biomesh.51 Relaxing incisions added to mesh cruroplasty could show promising results in a tailored approach to PHH repair and could improve recurrence rates.52,53 Esophageal lengthening is heavily debated in the literature.54,55 Collis gastroplasty shows more postoperative leaks and higher postoperative mortality.8 Due to this and increased experience in mediastinal mobilization, Collis gastroplasty was performed less in recent year.8 None of the patients in recent randomized trials and at our own institution underwent an esophageal lengthening procedure and based on the risk of complications this procedure is not recommended. This review has several strengths and limitations. Only eight studies described outcomes in octogenarians. The studies were very different in design, in- and exclusion criteria, definitions and reporting of outcomes. All studies had a short follow-up period, except for one,8 limiting functional outcome and hernia recurrence conclusions. Outcomes of the cohort study are limited by the observational nature of the study, with only a small proportion of octogenarians. The VU University Medical Center is a tertiary referral center for hiatal hernia repair, indicating a selection bias and this could explain the higher mortality rate compared to other series in the current literature. CONCLUSION PHH repair may be performed safely in symptomatic octogenarians. Preoperative assessment should aim to assess octogenarians at risk of complications and aim to optimize health status. No strong recommendation can be made for surgical techniques; laparoscopic repair was associated with less morbidity and mortality. Fundoplication may be performed instead of performing routine gastropexy, with similar outcomes. The indication and outcomes for mesh cruroplasty remain unclear. Importantly, octogenarians were underrepresented and should be included in future studies assessing optimal surgical strategies in PHH repair, to evaluate both operative and symptomatic outcomes. Acknowledgments All authors declare no conflicts of interest. No funding was received for this project. Notes Specific author contributions: Donald L. van der Peet, Miguel A. Cuesta, Freek Daams, and Jennifer Straatman designed the project. Lennaert C.B. Groen, Elise P. Jansma, and Jennifer Straatman designed the search strategy. Lennaert C.B. Groen and Nicole van der Wielen collected data. Lennaert C.B. Groen and Jennifer Straatman critically reviewed all articles. Lennaert C.B. Groen, Jennifer Straatman, and Nicole van der Wielen drafted the manuscript. Donald L. van der Peet, Freek Daams, and Miguel A. Cuesta critically revised the manuscript. All authors approved the final version of the manuscript. APPENDIX Search strategy for PubMed database Search PubMed Query 04-10-2016 Items found #23 Search #20 AND #21 AND #22 387 #22 Search ‘Aged, 80 and over’[Mesh] OR ‘Oldest Old’[tiab] OR Nonagenarian*[tiab] OR Octogenarian*[tiab] OR Octogenarian[tiab] OR Centenarian*[tiab] OR ‘very elderly’[tiab] OR ‘very old’[tiab] OR ‘advancing age’[tiab] 720,064 #21 Search ‘Surgical Procedures, Minimally Invasive’[Mesh:NoExp] OR ‘Elective Surgical Procedures’[Mesh] OR ‘Ambulatory Surgical Procedures’[Mesh] OR ‘Minor Surgical Procedures’[Mesh] OR ‘Video-Assisted Surgery’[Mesh] OR ‘Laparoscopy’[Mesh] OR ‘Laparotomy’[Mesh] OR Laparoscop*[tiab] OR videolaparoscop*[tiab] OR Laparotom*[tiab] OR ‘Video-Assisted’[tiab] OR ‘Minimal Surgical’[tiab] OR ‘Minimally Invasive’[tiab] OR ‘Minimal Invasive’[tiab] OR ‘Minimal Access Surgical Procedures’[tiab] OR surger*[tiab] OR operation*[tiab] 1,412,436 #20 Search ‘Hernia, Hiatal’[Mesh] OR ‘Hiatal Hernias’[tiab] OR ‘Hiatal Hernia’[tiab] OR ‘Hiatus Hernia’[tiab] OR ‘Hiatus Hernias’[tiab] OR ‘Hernia Hiatica’[tiab] OR ‘Hernia Hiati Oesophagi’[tiab] OR ‘Esofagushernia’[tiab] OR ‘Esofagushernias’[tiab] OR ‘Esophagushernia’[tiab] OR ‘Esophagushernias’[tiab] OR ‘Oesophagushernia’[tiab] OR ‘Oesophagushernias’[tiab] OR ‘Oesofagushernia’[tiab] OR ‘Oesofagushernias’[tiab] OR ‘Esofagealhernia’[tiab] OR ‘Esofagealhernias’[tiab] OR ‘Esophagealhernia’[tiab] OR ‘Esophagealhernias’[tiab] OR ‘Oesophagealhernia’[tiab] OR ‘Oesophagealhernias’[tiab] OR ‘Oesofagealhernia’[tiab] OR ‘Oesofagealhernias’[tiab] OR ‘oesophageal Hernia’[tiab] OR ‘oesophageal Hernias’[tiab] OR ‘oesofageal Hernia’[tiab] OR ‘oesofageal Hernias’[tiab] OR ‘Esophageal hernia’[tiab] OR ‘Esophageal Hernias’[tiab] OR ‘Esofageal Hernia’[tiab] OR ‘Esofageal hernias’[tiab] OR ‘esophagus hiatus’[tiab] OR ‘oesophagus Hernia’[tiab] OR ‘oesophagus Hernias’[tiab] OR ‘oesofagus Hernia’[tiab] OR ‘oesofagus Hernias’[tiab] OR ‘Esophagus hernia’[tiab] OR ‘Esophagus Hernias’[tiab] OR ‘Esofagus Hernia’[tiab] OR ‘Esofagus hernias’[tiab] OR ‘Rolling hernia’[tiab] OR ‘Rolling hernias’[tiab] OR ‘Paraesophageal Hernia’[tiab] OR ‘Paraesophageal Hernias’[tiab] OR ‘Paraoesophageal Hernia’[tiab] OR ‘Paraoesophageal Hernias’[tiab] OR ‘Paraesofageal Hernia’[tiab] OR ‘Paraesofageal Hernias’[tiab] OR ‘Paraoesofageal Hernia’[tiab] OR ‘Paraoesofageal Hernias’[tiab] OR ‘Para-esophageal hernia’[tiab] OR ‘Para-esophageal hernias’[tiab] OR ‘Para-esofageal hernia’[tiab] OR ‘Para-esofageal hernias’[tiab] OR ‘Para-oesophageal hernia’[tiab] OR ‘Para-oesophageal hernias’[tiab] OR ‘Para-oesofageal hernia’[tiab] OR ‘Para-oesofageal hernia’[tiab] OR ‘diaphragmatic hernia’[tiab] OR ‘Diaphragmatic hernias’[tiab] OR ‘Hernia Diaphragmatica’[tiab] OR ‘Hernias Diaphragmatica’[tiab] OR ‘hiatus esophagi hernia’[tiab] OR ‘hiatus esophagi hernias’[tiab] OR ‘stomach hernia’[tiab] OR ‘Stomach hernias’[tiab] OR ‘intrathoracic stomach’[tiab] 15,777 Search PubMed Query 04-10-2016 Items found #23 Search #20 AND #21 AND #22 387 #22 Search ‘Aged, 80 and over’[Mesh] OR ‘Oldest Old’[tiab] OR Nonagenarian*[tiab] OR Octogenarian*[tiab] OR Octogenarian[tiab] OR Centenarian*[tiab] OR ‘very elderly’[tiab] OR ‘very old’[tiab] OR ‘advancing age’[tiab] 720,064 #21 Search ‘Surgical Procedures, Minimally Invasive’[Mesh:NoExp] OR ‘Elective Surgical Procedures’[Mesh] OR ‘Ambulatory Surgical Procedures’[Mesh] OR ‘Minor Surgical Procedures’[Mesh] OR ‘Video-Assisted Surgery’[Mesh] OR ‘Laparoscopy’[Mesh] OR ‘Laparotomy’[Mesh] OR Laparoscop*[tiab] OR videolaparoscop*[tiab] OR Laparotom*[tiab] OR ‘Video-Assisted’[tiab] OR ‘Minimal Surgical’[tiab] OR ‘Minimally Invasive’[tiab] OR ‘Minimal Invasive’[tiab] OR ‘Minimal Access Surgical Procedures’[tiab] OR surger*[tiab] OR operation*[tiab] 1,412,436 #20 Search ‘Hernia, Hiatal’[Mesh] OR ‘Hiatal Hernias’[tiab] OR ‘Hiatal Hernia’[tiab] OR ‘Hiatus Hernia’[tiab] OR ‘Hiatus Hernias’[tiab] OR ‘Hernia Hiatica’[tiab] OR ‘Hernia Hiati Oesophagi’[tiab] OR ‘Esofagushernia’[tiab] OR ‘Esofagushernias’[tiab] OR ‘Esophagushernia’[tiab] OR ‘Esophagushernias’[tiab] OR ‘Oesophagushernia’[tiab] OR ‘Oesophagushernias’[tiab] OR ‘Oesofagushernia’[tiab] OR ‘Oesofagushernias’[tiab] OR ‘Esofagealhernia’[tiab] OR ‘Esofagealhernias’[tiab] OR ‘Esophagealhernia’[tiab] OR ‘Esophagealhernias’[tiab] OR ‘Oesophagealhernia’[tiab] OR ‘Oesophagealhernias’[tiab] OR ‘Oesofagealhernia’[tiab] OR ‘Oesofagealhernias’[tiab] OR ‘oesophageal Hernia’[tiab] OR ‘oesophageal Hernias’[tiab] OR ‘oesofageal Hernia’[tiab] OR ‘oesofageal Hernias’[tiab] OR ‘Esophageal hernia’[tiab] OR ‘Esophageal Hernias’[tiab] OR ‘Esofageal Hernia’[tiab] OR ‘Esofageal hernias’[tiab] OR ‘esophagus hiatus’[tiab] OR ‘oesophagus Hernia’[tiab] OR ‘oesophagus Hernias’[tiab] OR ‘oesofagus Hernia’[tiab] OR ‘oesofagus Hernias’[tiab] OR ‘Esophagus hernia’[tiab] OR ‘Esophagus Hernias’[tiab] OR ‘Esofagus Hernia’[tiab] OR ‘Esofagus hernias’[tiab] OR ‘Rolling hernia’[tiab] OR ‘Rolling hernias’[tiab] OR ‘Paraesophageal Hernia’[tiab] OR ‘Paraesophageal Hernias’[tiab] OR ‘Paraoesophageal Hernia’[tiab] OR ‘Paraoesophageal Hernias’[tiab] OR ‘Paraesofageal Hernia’[tiab] OR ‘Paraesofageal Hernias’[tiab] OR ‘Paraoesofageal Hernia’[tiab] OR ‘Paraoesofageal Hernias’[tiab] OR ‘Para-esophageal hernia’[tiab] OR ‘Para-esophageal hernias’[tiab] OR ‘Para-esofageal hernia’[tiab] OR ‘Para-esofageal hernias’[tiab] OR ‘Para-oesophageal hernia’[tiab] OR ‘Para-oesophageal hernias’[tiab] OR ‘Para-oesofageal hernia’[tiab] OR ‘Para-oesofageal hernia’[tiab] OR ‘diaphragmatic hernia’[tiab] OR ‘Diaphragmatic hernias’[tiab] OR ‘Hernia Diaphragmatica’[tiab] OR ‘Hernias Diaphragmatica’[tiab] OR ‘hiatus esophagi hernia’[tiab] OR ‘hiatus esophagi hernias’[tiab] OR ‘stomach hernia’[tiab] OR ‘Stomach hernias’[tiab] OR ‘intrathoracic stomach’[tiab] 15,777 View Large Search PubMed Query 04-10-2016 Items found #23 Search #20 AND #21 AND #22 387 #22 Search ‘Aged, 80 and over’[Mesh] OR ‘Oldest Old’[tiab] OR Nonagenarian*[tiab] OR Octogenarian*[tiab] OR Octogenarian[tiab] OR Centenarian*[tiab] OR ‘very elderly’[tiab] OR ‘very old’[tiab] OR ‘advancing age’[tiab] 720,064 #21 Search ‘Surgical Procedures, Minimally Invasive’[Mesh:NoExp] OR ‘Elective Surgical Procedures’[Mesh] OR ‘Ambulatory Surgical Procedures’[Mesh] OR ‘Minor Surgical Procedures’[Mesh] OR ‘Video-Assisted Surgery’[Mesh] OR ‘Laparoscopy’[Mesh] OR ‘Laparotomy’[Mesh] OR Laparoscop*[tiab] OR videolaparoscop*[tiab] OR Laparotom*[tiab] OR ‘Video-Assisted’[tiab] OR ‘Minimal Surgical’[tiab] OR ‘Minimally Invasive’[tiab] OR ‘Minimal Invasive’[tiab] OR ‘Minimal Access Surgical Procedures’[tiab] OR surger*[tiab] OR operation*[tiab] 1,412,436 #20 Search ‘Hernia, Hiatal’[Mesh] OR ‘Hiatal Hernias’[tiab] OR ‘Hiatal Hernia’[tiab] OR ‘Hiatus Hernia’[tiab] OR ‘Hiatus Hernias’[tiab] OR ‘Hernia Hiatica’[tiab] OR ‘Hernia Hiati Oesophagi’[tiab] OR ‘Esofagushernia’[tiab] OR ‘Esofagushernias’[tiab] OR ‘Esophagushernia’[tiab] OR ‘Esophagushernias’[tiab] OR ‘Oesophagushernia’[tiab] OR ‘Oesophagushernias’[tiab] OR ‘Oesofagushernia’[tiab] OR ‘Oesofagushernias’[tiab] OR ‘Esofagealhernia’[tiab] OR ‘Esofagealhernias’[tiab] OR ‘Esophagealhernia’[tiab] OR ‘Esophagealhernias’[tiab] OR ‘Oesophagealhernia’[tiab] OR ‘Oesophagealhernias’[tiab] OR ‘Oesofagealhernia’[tiab] OR ‘Oesofagealhernias’[tiab] OR ‘oesophageal Hernia’[tiab] OR ‘oesophageal Hernias’[tiab] OR ‘oesofageal Hernia’[tiab] OR ‘oesofageal Hernias’[tiab] OR ‘Esophageal hernia’[tiab] OR ‘Esophageal Hernias’[tiab] OR ‘Esofageal Hernia’[tiab] OR ‘Esofageal hernias’[tiab] OR ‘esophagus hiatus’[tiab] OR ‘oesophagus Hernia’[tiab] OR ‘oesophagus Hernias’[tiab] OR ‘oesofagus Hernia’[tiab] OR ‘oesofagus Hernias’[tiab] OR ‘Esophagus hernia’[tiab] OR ‘Esophagus Hernias’[tiab] OR ‘Esofagus Hernia’[tiab] OR ‘Esofagus hernias’[tiab] OR ‘Rolling hernia’[tiab] OR ‘Rolling hernias’[tiab] OR ‘Paraesophageal Hernia’[tiab] OR ‘Paraesophageal Hernias’[tiab] OR ‘Paraoesophageal Hernia’[tiab] OR ‘Paraoesophageal Hernias’[tiab] OR ‘Paraesofageal Hernia’[tiab] OR ‘Paraesofageal Hernias’[tiab] OR ‘Paraoesofageal Hernia’[tiab] OR ‘Paraoesofageal Hernias’[tiab] OR ‘Para-esophageal hernia’[tiab] OR ‘Para-esophageal hernias’[tiab] OR ‘Para-esofageal hernia’[tiab] OR ‘Para-esofageal hernias’[tiab] OR ‘Para-oesophageal hernia’[tiab] OR ‘Para-oesophageal hernias’[tiab] OR ‘Para-oesofageal hernia’[tiab] OR ‘Para-oesofageal hernia’[tiab] OR ‘diaphragmatic hernia’[tiab] OR ‘Diaphragmatic hernias’[tiab] OR ‘Hernia Diaphragmatica’[tiab] OR ‘Hernias Diaphragmatica’[tiab] OR ‘hiatus esophagi hernia’[tiab] OR ‘hiatus esophagi hernias’[tiab] OR ‘stomach hernia’[tiab] OR ‘Stomach hernias’[tiab] OR ‘intrathoracic stomach’[tiab] 15,777 Search PubMed Query 04-10-2016 Items found #23 Search #20 AND #21 AND #22 387 #22 Search ‘Aged, 80 and over’[Mesh] OR ‘Oldest Old’[tiab] OR Nonagenarian*[tiab] OR Octogenarian*[tiab] OR Octogenarian[tiab] OR Centenarian*[tiab] OR ‘very elderly’[tiab] OR ‘very old’[tiab] OR ‘advancing age’[tiab] 720,064 #21 Search ‘Surgical Procedures, Minimally Invasive’[Mesh:NoExp] OR ‘Elective Surgical Procedures’[Mesh] OR ‘Ambulatory Surgical Procedures’[Mesh] OR ‘Minor Surgical Procedures’[Mesh] OR ‘Video-Assisted Surgery’[Mesh] OR ‘Laparoscopy’[Mesh] OR ‘Laparotomy’[Mesh] OR Laparoscop*[tiab] OR videolaparoscop*[tiab] OR Laparotom*[tiab] OR ‘Video-Assisted’[tiab] OR ‘Minimal Surgical’[tiab] OR ‘Minimally Invasive’[tiab] OR ‘Minimal Invasive’[tiab] OR ‘Minimal Access Surgical Procedures’[tiab] OR surger*[tiab] OR operation*[tiab] 1,412,436 #20 Search ‘Hernia, Hiatal’[Mesh] OR ‘Hiatal Hernias’[tiab] OR ‘Hiatal Hernia’[tiab] OR ‘Hiatus Hernia’[tiab] OR ‘Hiatus Hernias’[tiab] OR ‘Hernia Hiatica’[tiab] OR ‘Hernia Hiati Oesophagi’[tiab] OR ‘Esofagushernia’[tiab] OR ‘Esofagushernias’[tiab] OR ‘Esophagushernia’[tiab] OR ‘Esophagushernias’[tiab] OR ‘Oesophagushernia’[tiab] OR ‘Oesophagushernias’[tiab] OR ‘Oesofagushernia’[tiab] OR ‘Oesofagushernias’[tiab] OR ‘Esofagealhernia’[tiab] OR ‘Esofagealhernias’[tiab] OR ‘Esophagealhernia’[tiab] OR ‘Esophagealhernias’[tiab] OR ‘Oesophagealhernia’[tiab] OR ‘Oesophagealhernias’[tiab] OR ‘Oesofagealhernia’[tiab] OR ‘Oesofagealhernias’[tiab] OR ‘oesophageal Hernia’[tiab] OR ‘oesophageal Hernias’[tiab] OR ‘oesofageal Hernia’[tiab] OR ‘oesofageal Hernias’[tiab] OR ‘Esophageal hernia’[tiab] OR ‘Esophageal Hernias’[tiab] OR ‘Esofageal Hernia’[tiab] OR ‘Esofageal hernias’[tiab] OR ‘esophagus hiatus’[tiab] OR ‘oesophagus Hernia’[tiab] OR ‘oesophagus Hernias’[tiab] OR ‘oesofagus Hernia’[tiab] OR ‘oesofagus Hernias’[tiab] OR ‘Esophagus hernia’[tiab] OR ‘Esophagus Hernias’[tiab] OR ‘Esofagus Hernia’[tiab] OR ‘Esofagus hernias’[tiab] OR ‘Rolling hernia’[tiab] OR ‘Rolling hernias’[tiab] OR ‘Paraesophageal Hernia’[tiab] OR ‘Paraesophageal Hernias’[tiab] OR ‘Paraoesophageal Hernia’[tiab] OR ‘Paraoesophageal Hernias’[tiab] OR ‘Paraesofageal Hernia’[tiab] OR ‘Paraesofageal Hernias’[tiab] OR ‘Paraoesofageal Hernia’[tiab] OR ‘Paraoesofageal Hernias’[tiab] OR ‘Para-esophageal hernia’[tiab] OR ‘Para-esophageal hernias’[tiab] OR ‘Para-esofageal hernia’[tiab] OR ‘Para-esofageal hernias’[tiab] OR ‘Para-oesophageal hernia’[tiab] OR ‘Para-oesophageal hernias’[tiab] OR ‘Para-oesofageal hernia’[tiab] OR ‘Para-oesofageal hernia’[tiab] OR ‘diaphragmatic hernia’[tiab] OR ‘Diaphragmatic hernias’[tiab] OR ‘Hernia Diaphragmatica’[tiab] OR ‘Hernias Diaphragmatica’[tiab] OR ‘hiatus esophagi hernia’[tiab] OR ‘hiatus esophagi hernias’[tiab] OR ‘stomach hernia’[tiab] OR ‘Stomach hernias’[tiab] OR ‘intrathoracic stomach’[tiab] 15,777 View Large References 1 Dahlberg P S , Deschamps C , Miller D L , Allen M S , Nichols F C , Pairolero P C . Laparoscopic repair of large paraesophageal hiatal hernia . Ann Thorac Surg 2001 ; 72 : 1125 – 9 . Google Scholar CrossRef Search ADS PubMed 2 Oelschlager B K , Petersen R P , Brunt L M et al. Laparoscopic paraesophageal hernia repair: defining long-term clinical and anatomic outcomes . J Gastrointest Surg 2012 ; 16 : 453 – 9 . Google Scholar CrossRef Search ADS PubMed 3 Carrott P W , Hong J , Kuppusamy M , Koehler R P , Low D E . Clinical ramifications of giant paraesophageal hernias are underappreciated: making the case for routine surgical repair . Ann Thorac Surg 2012 ; 94 : 421 – 8 ; discussion 426–8 . Google Scholar CrossRef Search ADS PubMed 4 Furnee E J , Draaisma W A , Simmermacher R K , Stapper G , Broeders I A . Long-term symptomatic outcome and radiologic assessment of laparoscopic hiatal hernia repair . Am J Surg 2010 ; 199 : 695 – 701 . Google Scholar CrossRef Search ADS PubMed 5 Skinner D B , Belsey R H . Surgical management of esophageal reflux and hiatus hernia. Long-term results with 1,030 patients . J Thorac Cardiovasc Surg 1967 ; 53 : 33 – 54 . Google Scholar PubMed 6 Hill L D . Incarcerated paraesophageal hernia . Am J Surg 1973 ; 126 : 286 – 91 . Google Scholar CrossRef Search ADS PubMed 7 Polomsky M , Jones C E , Sepesi B et al. Should elective repair of intrathoracic stomach be encouraged? J Gastrointest Surg 2010 ; 14 : 203 – 10 . Google Scholar CrossRef Search ADS PubMed 8 Luketich J D , Nason K S , Christie N A , et al . Outcomes after a decade of laparoscopic giant paraesophageal hernia repair . J Thorac Cardiovasc Surg 2010 ; 139 : 395 – 404.e1 , 404 e1 . Google Scholar CrossRef Search ADS PubMed 9 Fullum T M , Oyetunji T A , Ortega G et al. Open versus laparoscopic hiatal hernia repair . JSLS 2013 ; 17 ( 1 ): 23 – 29 . Google Scholar CrossRef Search ADS PubMed 10 Weiss C A 3rd , Stevens R M , Schwartz R W . Paraesophageal hernia: current diagnosis and treatment . Curr Surg 2002 ; 59 : 180 – 2 . Google Scholar CrossRef Search ADS PubMed 11 Stylopoulos N , Gazelle G S , Rattner D W . Paraesophageal hernias: operation or observation? Ann Surg 2002 ; 236 : 492 – 501 ; discussion 500–1 . Google Scholar CrossRef Search ADS PubMed 12 Gantert W A , Patti M G , Arcerito M et al. Laparoscopic repair of paraesophageal hiatal hernias . J Am Coll Surg 1998 ; 186 : 428 – 33 ; discussion 432–3 . Google Scholar CrossRef Search ADS PubMed 13 Pierre A F , Luketich J D , Fernando H C , et al . Results of laparoscopic repair of giant paraesophageal hernias: 200 consecutive patients . Ann Thorac Surg 2002 ; 74 : 1909 – 16 ; discussion 1915–6 . Google Scholar CrossRef Search ADS PubMed 14 Mattar S G , Bowers S P , Galloway K D , Hunter J G , Smith C D . Long-term outcome of laparoscopic repair of paraesophageal hernia . Surg Endosc 2002 ; 16 : 745 – 9 . Google Scholar CrossRef Search ADS PubMed 15 Trus T L , Bax T , Richardson W S , Branum G D , Mauren S J , Swanstrom L L , Hunter J G . Complications of laparoscopic paraesophageal hernia repair . J Gastrointest Surg 1997 ; 1 : 221 – 8 ; discussion 228 . Google Scholar CrossRef Search ADS PubMed 16 Diaz S , Brunt L M , Klingensmith M E , Frisella P M , Soper N J . Laparoscopic paraesophageal hernia repair, a challenging operation: medium-term outcome of 116 patients . J Gastrointest Surg 2003 ; 7 : 59 – 67 ; discussion 66–7 . Google Scholar CrossRef Search ADS PubMed 17 Collet D , Luc G , Chiche L . Management of large para-esophageal hiatal hernias . J Visceral Surg 2013 ; 150 : 395 – 402 . Google Scholar CrossRef Search ADS 18 van der Peet D L , Klinkenberg-Knol E C , Alonso Poza A , Sietses C , Eijsbouts Q A , Cuesta M A . Laparoscopic treatment of large paraesophageal hernias both excision of the sac and gastropexy are imperative for adequate surgical treatment . Surg Endosc 2000 ; 14 : 1015 – 8 . Google Scholar CrossRef Search ADS PubMed 19 Davis S S Jr. Current controversies in paraesophageal hernia repair . Surg Clin North Am 2008 ; 88 : 959 – 78 , vi . Google Scholar CrossRef Search ADS PubMed 20 United Nations . World Population Ageing. Department of Economic and Social Affairs, Population Division 2013 [cited 2 Jul 2015.] Available from: http://www.un.org/en/development/desa/population/publications/pdf/ageing/WorldPopulationAgeing2013.pdf . 21 Larusson H J , Zingg U , Hahnloser D , Delport K , Seifert B , Oertli D . Predictive factors for morbidity and mortality in patients undergoing laparoscopic paraesophageal hernia repair: age, ASA score, and operation type influence morbidity . World J Surg , 2009 ; 33 : 980 – 5 . Google Scholar CrossRef Search ADS PubMed 22 Molena D , Mungo B , Stem M , Feinberg R L , Lidor A O . Outcomes of operations for benign foregut disease in elderly patients: a National Surgical Quality Improvement Program database analysis . Surgery 2014 ; 156 : 352 – 60 . Google Scholar CrossRef Search ADS PubMed 23 Liberati A , Altman D G , Tetzlaff J et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration . BMJ 2009 ; 339 : b2700 . Google Scholar CrossRef Search ADS PubMed 24 Deeks J J , Dinnes J , D’Amico R et al. Evaluating non-randomised intervention studies . Health Technol Assess 2003 ; 7 : iii–x , 1 – 173 . Google Scholar CrossRef Search ADS 25 Centre for Evidence-Based Medicine . Levels of Evidence . 2009 [cited 2015 10 Aug] Available from: http://www.cebm.net/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/ . 26 Ballian N , Luketich J D , Levy R M et al. A clinical prediction rule for perioperative mortality and major morbidity after laparoscopic giant paraesophageal hernia repair . J Thorac Cardiovasc Surg 2013 ; 145 : 721 – 9 . Google Scholar CrossRef Search ADS PubMed 27 Paul S , Mirza F M , Nasar A et al. Prevalence, outcomes, and a risk-benefit analysis of diaphragmatic hernia admissions: An examination of the National Inpatient Sample database . J Thorac Cardiovasc Surg 2011 ; 142 : 747 – 54 . Google Scholar CrossRef Search ADS PubMed 28 Poulose B K , Gosen C , Marks J M et al. Inpatient mortality analysis of paraesophageal hernia repair in octogenarians . J Gastrointest Surg 2008 ; 12 : 1888 – 92 . Google Scholar CrossRef Search ADS PubMed 29 Spaniolas K , Laycock W S , Adrales G L , Trus T L . Laparoscopic paraesophageal hernia repair: advanced age is associated with minor but not major morbidity or mortality . J Am Coll Surg 2014 ; 218 : 1187 – 92 . Google Scholar CrossRef Search ADS PubMed 30 Parker D M , Rambhajan A A , Horsley R D , Johanson K , Gabrielsen J D , Petrick A T . Laparoscopic paraesophageal hernia repair is safe in elderly patients . Surg Endosc 2017 ; 31 : 1186 – 91 . Google Scholar CrossRef Search ADS PubMed 31 Gangopadhyay N , Perrone J M , Soper N J et al. Outcomes of laparoscopic paraesophageal hernia repair in elderly and high-risk patients . Surgery 2006 ; 140 : 491 – 9 ; discussion 498–9 . Google Scholar CrossRef Search ADS PubMed 32 Louie B E , Blitz M , Farivar A S , Orlina J , Aye R W . Repair of symptomatic giant paraesophageal hernias in elderly (>70 years) patients results in improved quality of life . J Gastrointest Surg 2011 ; 15 : 389 – 96 . Google Scholar CrossRef Search ADS PubMed 33 Hazebroek E J , Gananadha S , Koak Y , Berry H , Leibman S , Smith G S . Laparoscopic paraesophageal hernia repair: quality of life outcomes in the elderly . Dis Esophagus 2008 ; 21 : 737 – 41 . Google Scholar CrossRef Search ADS PubMed 34 Hashemi M , Peters J H , DeMeester T R et al. Laparoscopic repair of large type III hiatal hernia: objective followup reveals high recurrence rate11No competing interests declared . J Am Coll Surg 2000 ; 190 : 553 – 60 ; discussion 560–1 . Google Scholar CrossRef Search ADS PubMed 35 Muller-Stich B P , Achtstätter V , Diener M K et al. Repair of paraesophageal hiatal hernias-is a fundoplication needed? A randomized controlled pilot trial . J Am Coll Surg 2015 ; 221 : 602 – 10 . Google Scholar CrossRef Search ADS PubMed 36 Casabella F , Sinanan M , Horgan S , Pellegrini C A . Systematic use of gastric fundoplication in laparoscopic repair of paraesophageal hernias . Am J Surg 1996 ; 171 : 485 – 9 . Google Scholar CrossRef Search ADS PubMed 37 Svetanoff W J , Pallati P , Nandipati K , Lee T , Mittal S K . Does the addition of fundoplication to repair the intra-thoracic stomach improve quality of life? Surg Endosc 2016 ; 30 : 4590 – 7 . Google Scholar CrossRef Search ADS PubMed 38 Edye M B , Canin-Endres J , Gattorno F , Salky B A . Durability of laparoscopic repair of paraesophageal hernia . Ann Surg 1998 ; 228 : 528 – 35 . Google Scholar CrossRef Search ADS PubMed 39 Antoniou S A , Müller-Stich B P , Antoniou G A et al. Laparoscopic augmentation of the diaphragmatic hiatus with biologic mesh versus suture repair: a systematic review and meta-analysis . Langenbecks Arch Surg 2015 ; 400 : 577 – 83 . Google Scholar CrossRef Search ADS PubMed 40 Oelschlager B K , Pellegrini C A , Hunter J et al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial . Ann Surg 2006 ; 244 : 481 – 90 . Google Scholar PubMed 41 Oelschlager B K , Pellegrini C A , Hunter J et al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair: long-term follow-up from a multicenter, prospective, randomized trial . J Am Coll Surg 2011 ; 213 : 461 – 8 . Google Scholar CrossRef Search ADS PubMed 42 Watson D I , Thompson S K , Devitt P G et al. Laparoscopic repair of very large hiatus hernia with sutures versus absorbable mesh versus nonabsorbable mesh . Ann Surg 2015 ; 261 : 282 – 9 . Google Scholar CrossRef Search ADS PubMed 43 Koetje J H , Irvine T , Thompson S K et al. Quality of life following repair of large hiatal hernia is improved but not influenced by use of mesh: results from a randomized controlled trial . World J Surg 2015 ; 39 : 1465 – 73 . Google Scholar CrossRef Search ADS PubMed 44 Varga G , Cseke L , Kalmar K , Horvath O P . Laparoscopic repair of large hiatal hernia with teres ligament: midterm follow-up . Surg Endosc 2008 ; 22 : 881 – 4 . Google Scholar CrossRef Search ADS PubMed 45 Ghanem O , Doyle C , Sebastian R , Park A . New surgical approach for giant paraesophageal hernia repair: closure of the esophageal hiatus anteriorly using the left triangular ligament . Dig Surg 2015 ; 32 : 124 – 8 . Google Scholar CrossRef Search ADS PubMed 46 Park A E , Hoogerboord C M , Sutton E . Use of the falciform ligament flap for closure of the esophageal hiatus in giant paraesophageal hernia . J Gastrointest Surg 2012 ; 16 : 1417 – 21 . Google Scholar CrossRef Search ADS PubMed 47 Furnee E , Hazebroek E . Mesh in laparoscopic large hiatal hernia repair: a systematic review of the literature . Surg Endosc 2013 ; 27 : 3998 – 4008 . Google Scholar CrossRef Search ADS PubMed 48 Memon M A , Memon B , Yunus R M , Khan S . Suture cruroplasty versus prosthetic hiatal herniorrhaphy for large hiatal hernia . Ann Surg 2016 ; 263 : 258 – 66 . Google Scholar CrossRef Search ADS PubMed 49 Muller-Stich B P , Kenngott H G , Gondan M et al. Use of mesh in laparoscopic paraesophageal hernia repair: a meta-analysis and risk-benefit analysis . PLoS One 2015 ; 10 : e0139547 . Google Scholar CrossRef Search ADS PubMed 50 Tam V , Winger D G , Nason K S . A systematic review and meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair . Am J Surg 2016 ; 211 : 226 – 38 . Google Scholar CrossRef Search ADS PubMed 51 Crespin O M , Yates R B , Martin A V , Pellegrini C A , Oelschlager B K . The use of crural relaxing incisions with biologic mesh reinforcement during laparoscopic repair of complex hiatal hernias . Surg Endosc 2016 ; 30 : 2179 – 85 . Google Scholar CrossRef Search ADS PubMed 52 Alicuben E T , Worrell S G , DeMeester S R . Impact of crural relaxing incisions, Collis gastroplasty, and non-cross-linked human dermal mesh crural reinforcement on early hiatal hernia recurrence rates . J Am Coll Surg 2014 ; 219 : 988 – 92 . Google Scholar CrossRef Search ADS PubMed 53 Greene C L , DeMeester S R , Zehetner J , Worrell S G , Oh D S , Hagen J A . Diaphragmatic relaxing incisions during laparoscopic paraesophageal hernia repair . Surg Endosc , 2013 ; 27 : 4532 – 8 . Google Scholar CrossRef Search ADS PubMed 54 Puri V , Jacobsen K , Bell J M et al. Hiatal hernia repair with or without esophageal lengthening: is there a difference? Innovations (Phila) 2013 ; 8 : 341 – 7 . Google Scholar CrossRef Search ADS PubMed 55 Oelschlager B K , Pellegrini C A , Hunter J et al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair: long-term follow-up from a multicenter, prospective, randomized trial . J Am Coll Surg 2011 ; 213 : 461 – 8 . Google Scholar CrossRef Search ADS PubMed © The Authors 2018. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Diseases of the EsophagusOxford University Press

Published: Jul 1, 2018

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