Could "Low Quality of Life" Rather Than "Significant Symptoms" Be Better Criteria for the Selection of Patients for the Repair of a Giant Hiatus Hernia?

Purpose Giant hiatus hernia (GHH) repair is undertaken electively in symptomatic patients, to prevent complications such as gastric volvulus and subsequent mortality. Advances in laparoscopy and perioperative care have reduced the risk of GHH repair, and improvement in quality of life (QoL) has become an important outcome measure. In our unit, we have been assessing QoL in all the operated as well as non-operated patients with GHH, using the "Quality of Life in Reflux and Dyspepsia" (QOLRAD) questionnaire. We sought to evaluate differences in QoL between patients who were managed conservatively for GHH and those who underwent GHH repair over a two-year period. Methods All patients seen in the Upper Gastrointestinal Tertiary Unit in Lancashire Teaching Hospitals NHS Trust with GHH between January 2015 and December 2022 were identified from a prospectively kept database. QOLRAD scores were analyzed and compared between conservatively and operatively managed patients using the Mann-Whitney U test. Demographic and operative outcome data were also collected. Results Eighty-seven patients with GHH were included. QoL of 51 patients improved significantly after elective surgery. Five out of 36 patients, who were initially treated conservatively, elected to have repair during their follow-up period. These 5 Patients had a lower initial QOLRAD score in comparison to those whose management remained conservative (2.72 vs 5.05, Mann Whitney U test p=0.034), and their QOLRAD scores also improved significantly after the operation. QOLRAD scores in conservatively managed patients remained stable over a two-year follow-up period. Conclusion Objectively calculated low QoL may be a more useful tool than subjective symptoms in selecting patients for elective repair of GHH.