Gastropexy in the Repair of Patients With Paraesophageal Hernias

Study Overview
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Brief Summary
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Patients scheduled for surgery for primary paraesophageal herniation are randomized to either conventional surgical hernia repair or with the addition of gastropexy.

Detailed Description
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Patient undergoing surgery for primary paraesophageal herniation, are randomized to either the control group or interventional group. The control group have a crural repair alone to which is added a short and floppy Nissen fundoplication. The interventional arm contains the addition of a gastropexy which incorporates fixation of the left part of the wrap to the diaphragm as well as the posterior part to the right crus. Finally the minor curvature of the stomach is sutured left to the midline of the abdominal wall. The patients are examined by computed tomography before surgery and at 1 and 3 years after surgery. SF-36 (global quality of Life instrument), GSRS (Gastrointestinal Symptoms Rating Scale), Reflux frequency issues and Watson's dysphagia score are completed before and at 3 and 6 month as well as 1 and 3 years after surgery.

Official Title
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Can Gastropexy Improve the Efficacy of the Crural Repair in Patients With Paraesophageal Hernias? A Double Blind, Randomized, Multicenter Clinical Trial

Conditions
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Paraesophageal Hernia

Intervention / Treatment
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* Procedure: Gastropexy


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: all patients with primary hiatus hernia type II-IV who are deemed suitable for surgery Exclusion Criteria: American Society of Anesthesiologists physical status-system (ASA) >III inability to understand the nature of the purpose of the study and/or to give informed consent. Achalasia or another severe esophageal motor disorder Previous major upper GI surgery(including previous hiatal hernia repair)

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Conventional paraesophageal hernia repair with the addition of gastropexy
Masking: Triple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: Standard paraesophageal hernia repair<br>Standard paraesophageal hernia repair(Crura suture with total (Nissen) fundoplication)) | |
| Active Comparator: Standard paraesophageal hernia repair +gastropexy<br>Standard paraesophageal hernia repair with the addition of gastropexy(anterior, posterior and left gastropexy) | Procedure: Gastropexy<br>* In the intervention group, the following three additional attachment points between the stomach and surrounding anatomical structures will be completed with non-absorbable suture material: The left lateral part of the fundus flap is adapted to the diaphragm at its flat tendinous part of the diaphragm lateral to the hiatus, with a 2-3 cm long continuous non-absorbable suture (left postero-lateral gastropexy). The anterior stomach wall is attached to the abdominal wall with a 2-3 cm long continuous non-absorbable suture (anterior gastropexy). The posterior fundus is adapted to the right crus with a 2-3 cm long non-absorbable suture (right-posterior gastropexy).<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Recurrence of hernia at 1 year after surgery | Computer tomography of abdomen and thorax | 1 year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Recurrence of hernia at 3 years after surgery | Computer tomography of abdomen and thorax | 3 year | 
| Complications after surgery | Symptomatic recurrence | at approximately 10 weeks after surgery | 
| Changes in the patients perception of quality of life after surgery | SF-36 (Quality of Life issues) The SF-36 is comprised of 36 items that assess eight health concepts: physical functioning, role limitations caused by physical health problems, role limitations caused by emotional problems, social functioning, emotional well-being, energy/fatigue, pain, and general health perceptions. Higher scores mean a better outcome. Scoring is from 0-100. A mean score of 50 has been articulated as normative value. | 3 months, 12 months, 24 months and 36 months | 
| Changes in the patients perception of gastrointestinal symptoms after surgery | GSRS = The Gastrointestinal Symptom Rating Scale. Scoring;The questionnaire, which contains 15 items, uses a seven-graded Likert scale, where 1 represents the most positive option and 7 the most negative one. A mean value for the items in each dimension should be calculated: Diarrhoea syndrome: 11. Increased passage of stools 12. Loose stools 14. Urgent need for defecation Indigestion syndrome: 6. Borborygmus 7. Abdominal distension 8. Eructation 9. Increased flatus Constipation syndrome: 10. Decreased passage of stools 13. Hard stools 15. Feeling of incomplete evacuation Abdominal pain syndrome: 1. Abdominal pain 4. Sucking sensations 5. Nausea and vomiting Reflux syndrome: 2. Heartburn 3. Acid regurgitation) Watson dysphagia score and clinical evaluation. The questionnaire, which contains 15 items, uses a seven-graded Likert scale, where 1 represents the most positive option and 7 the most negative one. | 3 months, 12 months, 24 months and 36 months | 
| Changes in the patients perception of dysphagia after surgery - Dakkak | The Dakkak dysphagia score is a questionnaire for assessing benign dysphagia, including nine questions regarding the frequency (always, sometimes, or never) of swallowing difficulties with different food consistencies (liquid, semisolid, and solid foods). The final score ranges from 0 to 45, where 45 represents the most severe dysphagia. | 3 months, 12 months, 24 months and 36 months | 
| Changes in the patients perception of dysphagia after surgery | Dysphagia for liquids and solids were recorded within a four-graded scale stating the frequency of dysphagia episodes with an arbitrary (empirical) cut off for clinical significance. The same dysphagia scoring was also used in a previous rct, from the same institution, comparing different types of antireflux procedures in open surgery. | 3 months, 12 months, 24 months and 36 months | 
| Length of stay at the hospital after surgery | Information from patients journal | at approximately 10 weeks after surgery | 
| Number of study participants administered post-operative analgetics in addition to standard baseline postoperative analgetic regime. | Information from patients eletcronic drug journal | at approximately 10 weeks after surgery | 
| Manometric characteristics of the oesophagus | To assess oesophageal function at 1 yr postoperative High resolution manometry(HRM) will be performed. Postoperative primary peristalsis will be classified according to the Chicago classification. | 1 year | 
| Esophageal distensibility characteristics of the oesophagus | To assess oesophageal function at 1 yr postoperative functional lumen imaging probe (endoFLIP) will be performed. Postoperative secondary peristalsis and distensibility in the distal oesophagus will be characterized with the endo-FLIP system. Measurement unit is mm2/mmHg. | 1 year |