Long-term outcomes of diaphragmatic relaxing incisions during challenging primary and revisional hiatal reconstruction: A propensity-matched analysis.
Publication Title
The Journal of thoracic and cardiovascular surgery
Document Type
Article
Publication Date
7-5-2025
Keywords
diaphragmatic reconstruction; diaphragmatic relaxing incision; diaphragmatic tension; hiatal hernia.; washington; swedish; swedish thoracic surgery
Abstract
OBJECTIVES: Diaphragmatic relaxing incisions reduce radial tension and may aid in preventing recurrences, but they lack long-term data. We describe the long-term outcomes after diaphragmatic relaxing incisions used during hiatal reconstruction.
METHODS: We performed a propensity-matched analysis of elective primary and revisional minimally invasive hiatal hernia repairs with and without diaphragmatic relaxing incisions between 2008 and 2020. Primary repairs with diaphragmatic relaxing incisions (N = 125) were matched 1:1 for age, Barrett's esophagus length, hernia axial size, and type to primary controls, whereas the 43 revisional repairs with diaphragmatic relaxing incisions were similarly matched, excluding type, to revisional controls. Outcomes were radiological/endoscopic recurrence (>2 cm), gastroesophageal reflux disease health-related quality of life, and diaphragmatic relaxing incision-related complications.
RESULTS: The primary repair cohorts were similar except the diaphragmatic relaxing incision group had more male patients, Nissen fundoplications, Collis gastroplasties, and hiatal mesh use. Median imaging follow-up was 58 months, and recurrences were similar (26/107 [24%] vs 27/106 [26%], P = .84). Gastroesophageal reflux disease health-related quality of life was also similar (2.5 [interquartile range, 0.0-6.5] vs 2.0 [interquartile range, 0.0-7.0], P = .82). The revisional groups were well matched except more male patients underwent diaphragmatic relaxing incisions. At a median follow-up of 63 months, recurrence between those with and without diaphragmatic relaxing incisions (9/38 [24%] vs 9/35 [26%], P = .84) was similar. There was no difference in gastroesophageal reflux disease health-related quality of life (4.0 [interquartile range, 1.5-7.5] vs 6.0 [interquartile range, 1.0-9.0], P = .47). During follow-up, 4 patients (2%) herniated through their diaphragmatic relaxing incisions, all requiring operative repair. No symptomatic diaphragmatic paralysis or other long-term diaphragmatic relaxing incision complications were identified.
CONCLUSIONS: With approximately 5 years of follow-up, diaphragmatic relaxing incisions during primary and revisional hiatal reconstruction resulted in recurrence and quality of life similar to those undergoing repair without the need for diaphragmatic relaxing incisions.
Area of Special Interest
Cardiovascular (Heart)
Area of Special Interest
Digestive Health
Area of Special Interest
Cancer
Specialty/Research Institute
Oncology
Specialty/Research Institute
Gastroenterology
DOI
10.1016/j.jtcvs.2025.06.034
