Management of paraesophageal hiatus hernia: recommendations following a European expert Delphi consensus
Authors: Gerdes Stephan , Schoppmann Sebastian F. , Bonavina Luigi , Boyle Nicholas , Müller-Stich Beat P. , Gutschow Christian A. ,   the Hiatus Hernia Delphi Collaborative Group, Gisbertz Suzanne Sarah , Köckerling Ferdinand , Lehmann Thorsten G. , Lorenz Dietmar , Granderath Frank Alexander , Rosati Riccardo , Wullstein Christoph , Lundell Lars , Cheong Edward , Nafteux Philippe , Olmi Stefano , Mönig Stefan , Biebl Matthias , Leers Jessica , Zehetner Joerg , Kristo Ivan , Berrisford Richard George , Skrobić Ognjan M. , Simić Aleksandar P. , Pera Manuel , Grimminger Peter Philipp , Gockel Ines , Zarras Konstantinos , Nieuwenhuijs Vincent Bernard , Gossage James A. , van Berge Henegouwen Mark i. , Stein Hubert J. , Markar Sheraz R. , Hueting Willem Eduard , Targarona Eduardo M. , Johansson Jan , Macaulay Graeme D. , Wijnhoven Bas P.L. , Benedix Frank , Attwood Stephen E. , Hölscher Arnulf Heinrich , Priego Pablo , Fuchs Karl-Hermann , Luyer Misha D.P. , Griffiths Ewen A. , Søvik Torgeir Thorson , Theodorou Dimitrios , Sgromo Bruno , Salo Jarmo A. , Singhal Rishi , Thorell Anders , Zaninotto Giovanni , Bitenc Marko , D’journo Xavier Benoit , Fullarton Grant M. , Horbach Thomas 
Published: February 2023

Abstract
Aims
There is considerable controversy regarding optimal management of patients with paraesophageal hiatus hernia (pHH). This survey aims at identifying recommended strategies for work-up, surgical therapy, and postoperative follow-up using Delphi methodology.

Methods
We conducted a 2-round, 33-question, web-based Delphi survey on perioperative management (preoperative work-up, surgical procedure and follow-up) of non-revisional, elective pHH among European surgeons with expertise in upper-GI. Responses were graded on a 5-point Likert scale and analyzed using descriptive statistics. Items from the questionnaire were defined as “recommended” or “discouraged” if positive or negative concordance among participants was > 75%. Items with lower concordance levels were labelled “acceptable” (neither recommended nor discouraged).

Results
Seventy-two surgeons with a median (IQR) experience of 23 (14–30) years from 17 European countries participated (response rate 60%). The annual median (IQR) individual and institutional caseload was 25 (15–36) and 40 (28–60) pHH-surgeries, respectively. After Delphi round 2, “recommended” strategies were defined for preoperative work-up (endoscopy), indication for surgery (typical symptoms and/or chronic anemia), surgical dissection (hernia sac dissection and resection, preservation of the vagal nerves, crural fascia and pleura, resection of retrocardial lipoma) and reconstruction (posterior crurorrhaphy with single stitches, lower esophageal sphincter augmentation (Nissen or Toupet), and postoperative follow-up (contrast radiography). In addition, we identified “discouraged” strategies for preoperative work-up (endosonography), and surgical reconstruction (crurorrhaphy with running sutures, tension-free hiatus repair with mesh only). In contrast, many items from the questionnaire including most details of mesh augmentation (indication, material, shape, placement, and fixation technique) were “acceptable”.

Conclusions
This multinational European Delphi survey represents the first expert-led process to identify recommended strategies for the management of pHH. Our work may be useful in clinical practice to guide the diagnostic process, increase procedural consistency and standardization, and to foster collaborative research.