Abstract：
BACKGROUND: The surgical management of hiatal hernia remains controversial. We aimed to compare outcomes of mesh versus no mesh and fundoplication versus no fundoplication in symptomatic patients; surgery versus observation in asymptomatic patients; and redo hernia repair versus conversion to Roux-en-Y reconstruction in recurrent hiatal hernia.
METHODS: We searched PubMed, Embase, CINAHL, Cochrane Library and the ClinicalTrials.gov databases between 2000 and 2022 for randomized controlled trials (RCTs), observational studies, and case series (asymptomatic and recurrent hernias). Screening was performed by two trained independent reviewers. Pooled analyses were performed on comparative data. Risk of bias was assessed using the Cochrane Risk of Bias tool and Newcastle Ottawa Scale for randomized and non-randomized studies, respectively.
RESULTS: We included 45 studies from 5152 retrieved records. Only six RCTs had low risk of bias. Mesh was associated with a lower recurrence risk (RR = 0.50, 95%CI 0.28, 0.88; I2 = 57%) in observational studies but not RCTs (RR = 0.98, 95%CI 0.47, 2.02; I2 = 34%), and higher total early dysphagia based on five observational studies (RR = 1.44, 95%CI 1.10, 1.89; I2 = 40%) but was not statistically significant in RCTs (RR = 3.00, 95%CI 0.64, 14.16). There was no difference in complications, reintervention, heartburn, reflux, or quality of life. There were no appropriate studies comparing surgery to observation in asymptomatic patients. Fundoplication resulted in higher early dysphagia in both observational studies and RCTs ([RR = 2.08, 95%CI 1.16, 3.76] and [RR = 20.58, 95%CI 1.34, 316.69]) but lower reflux in RCTs (RR = 0.31, 95%CI 0.17, 0.56, I2 = 0%). Conversion to Roux-en-Y was associated with a lower reintervention risk after 30 days compared to redo surgery.
CONCLUSIONS: The evidence for optimal management of symptomatic and recurrent hiatal hernia remains controversial, underpinned by studies with a high risk of bias. Shared decision making between surgeon and patient is essential for optimal outcomes.
METHODS: We searched PubMed, Embase, CINAHL, Cochrane Library and the ClinicalTrials.gov databases between 2000 and 2022 for randomized controlled trials (RCTs), observational studies, and case series (asymptomatic and recurrent hernias). Screening was performed by two trained independent reviewers. Pooled analyses were performed on comparative data. Risk of bias was assessed using the Cochrane Risk of Bias tool and Newcastle Ottawa Scale for randomized and non-randomized studies, respectively.
RESULTS: We included 45 studies from 5152 retrieved records. Only six RCTs had low risk of bias. Mesh was associated with a lower recurrence risk (RR = 0.50, 95%CI 0.28, 0.88; I2 = 57%) in observational studies but not RCTs (RR = 0.98, 95%CI 0.47, 2.02; I2 = 34%), and higher total early dysphagia based on five observational studies (RR = 1.44, 95%CI 1.10, 1.89; I2 = 40%) but was not statistically significant in RCTs (RR = 3.00, 95%CI 0.64, 14.16). There was no difference in complications, reintervention, heartburn, reflux, or quality of life. There were no appropriate studies comparing surgery to observation in asymptomatic patients. Fundoplication resulted in higher early dysphagia in both observational studies and RCTs ([RR = 2.08, 95%CI 1.16, 3.76] and [RR = 20.58, 95%CI 1.34, 316.69]) but lower reflux in RCTs (RR = 0.31, 95%CI 0.17, 0.56, I2 = 0%). Conversion to Roux-en-Y was associated with a lower reintervention risk after 30 days compared to redo surgery.
CONCLUSIONS: The evidence for optimal management of symptomatic and recurrent hiatal hernia remains controversial, underpinned by studies with a high risk of bias. Shared decision making between surgeon and patient is essential for optimal outcomes.
摘要：
背景：食管裂孔疝的外科治疗仍存在争议。我们的目的是比较有症状患者的网片与无网片和胃底折叠术与无胃底折叠术的结果；无症状患者的手术与观察；复发性食管裂孔疝的重做疝修补与转换为Roux-en-Y重建。
方法：我们搜索了PubMed，Embase,CINAHL,CochraneLibrary和ClinicalTrials.gov数据库在2000年至2022年间用于随机对照试验（RCT），观察性研究，和病例系列（无症状和复发性疝）。筛选由两名训练有素的独立评审员进行。对比较数据进行汇总分析。使用Cochrane偏差风险工具和纽卡斯尔渥太华量表进行随机和非随机研究，评估偏差风险。分别。
结果：我们纳入了5152个检索记录中的45项研究。只有六个随机对照试验的偏倚风险较低。在观察性研究中，网格与较低的复发风险（RR=0.50，95CI0.28，0.88；I2=57％）相关，但与RCT无关（RR=0.98，95CI0.47，2.02；I2=34％），根据5项观察性研究(RR=1.44,95CI1.10,1.89;I2=40%),但在随机对照试验中没有统计学意义(RR=3.00,95CI0.64,14.16).并发症没有差异，再干预,胃灼热,反流,或生活质量。没有适当的研究将手术与无症状患者的观察结果进行比较。在观察性研究和RCT中，胃底折叠导致较高的早期吞咽困难([RR=2.08,95CI1.16,3.76]和[RR=20.58,95CI1.34,316.69])，但在RCT中反流较低(RR=0.31,95CI0.17,0.56,I2=0%)。与重做手术相比，转换为Roux-en-Y与30天后较低的再干预风险相关。
结论：最佳治疗有症状和复发性食管裂孔疝的证据仍存在争议，以偏倚风险较高的研究为基础。外科医生和患者之间的共同决策对于最佳结果至关重要。
方法：我们搜索了PubMed，Embase,CINAHL,CochraneLibrary和ClinicalTrials.gov数据库在2000年至2022年间用于随机对照试验（RCT），观察性研究，和病例系列（无症状和复发性疝）。筛选由两名训练有素的独立评审员进行。对比较数据进行汇总分析。使用Cochrane偏差风险工具和纽卡斯尔渥太华量表进行随机和非随机研究，评估偏差风险。分别。
结果：我们纳入了5152个检索记录中的45项研究。只有六个随机对照试验的偏倚风险较低。在观察性研究中，网格与较低的复发风险（RR=0.50，95CI0.28，0.88；I2=57％）相关，但与RCT无关（RR=0.98，95CI0.47，2.02；I2=34％），根据5项观察性研究(RR=1.44,95CI1.10,1.89;I2=40%),但在随机对照试验中没有统计学意义(RR=3.00,95CI0.64,14.16).并发症没有差异，再干预,胃灼热,反流,或生活质量。没有适当的研究将手术与无症状患者的观察结果进行比较。在观察性研究和RCT中，胃底折叠导致较高的早期吞咽困难([RR=2.08,95CI1.16,3.76]和[RR=20.58,95CI1.34,316.69])，但在RCT中反流较低(RR=0.31,95CI0.17,0.56,I2=0%)。与重做手术相比，转换为Roux-en-Y与30天后较低的再干预风险相关。
结论：最佳治疗有症状和复发性食管裂孔疝的证据仍存在争议，以偏倚风险较高的研究为基础。外科医生和患者之间的共同决策对于最佳结果至关重要。
