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Acute paraesophageal hernia with gastric volvulus. Results of surgical treatment: a systematic review and meta-analysis

World Journal of Emergency Surgery volume 20, Article number: 41 (2025) Cite this article

Abstract

Introduction

Acute gastric volvulus (AGV), is an uncommon complication of large paraesophageal hernias (PEH), resulting in closed-loop obstruction that may lead to incarceration and strangulation. The aim of this study was to summarize the evidence on clinical characteristics, surgical treatment, postoperative complications (POC), recurrence, and 30-day mortality (30DM), in patients undergoing surgery for AGV secondary to PEH.

Methods

A systematic review including studies on AGV secondary to PEH was conducted. Searches were performed in WoS, Embase, Medline, Scopus, BIREME-BV and SciELO. Primary outcomes included POC, 30DM and recurrence. Secondary outcomes comprised publication date, study origin and design, number of patients, volvulus type, hospital stay length, treatments; and methodological quality (MQ) of studies assessed using MInCir-T and MInCir-Pr2 scales. Descriptive statistics, weighted averages (WA), least squares logistic regression for comparisons, and meta-analysis of POC prevalence and HM were applied.

Results

Of 1049 studies 171 met selection criteria, encompassing 15,178 patients. The WA age of patients was 75.3 ± 13.9 years, with 51.3% female. Most studies originated from USA (31.6%), with 52.6% published in the last decade. The WA of hospital stay was 7.9 ± 5.3 days. Among patients, 32.0% experienced POC, 7.6% required reinterventions and HM was 5.7%. MQ scores averaged 8.9 ± 2.3 (MInCir-T) and 13.4 ± 5.4 (MInCir-Pr2). When comparing 1990–2014 and 2015–2024 periods, there were significant differences in age, reinterventions, readmissions and recurrence rates.

Conclusions

Despite surgical and resuscitative advancements, AGV prognosis remains poor, with high POC rates, prolonged hospitalization and significant 30DM. These findings emphasize the importance of early diagnosis and timely intervention for acute PEH to improve surgical outcomes.

Background

Acute gastric volvulus (AGV) can occur secondary to a paraesophageal hernia (PEH). Although AGV/PEH combination is a rare, it represents a serious clinical condition with poorly defined incidence and risk factors. Approximately 1% of patients with PEH present acute symptoms and require emergency surgery annually [1, 2]. While its incidence and prevalence remain unclear, AGV is more frequently observed from the fifth decade of life [2]. Typically associated with Borchardt’s triad–vomiting, epigastric pain, and inability to pass a nasogastric tube – this classical presentation is reported in fewer than 70% of cases [3].

Markar et al., analyzed data from 12,441 patients with acute PEH in the English Hospital Episode Statistics (HES database (1977–2012) [3]. Their study revealed 30- and 90-day mortality rates of 7.0% and 11.5%, respectively. Interestingly, after propensity-matching, demonstrated that high-volume centers significantly reduced emergency surgery when compared with medium and low-volume, and that low and medium hospital volume was independently associated with increased 30-day and 90-day mortality for acute PEH [3].

Similarly, a cohort study from the US General Thoracic Surgery Database comprising 2,082 patients emergently or urgently operated for PEH, reported high operative times, longer hospital stays, higher intraoperative blood transfusions and greater morbidity and mortality compared to elective PEH [4]. Additionally, it has been observed that patients over 80 years old undergoing emergent operations exhibited the highest morbidity and mortality rates, reflecting disease severity and comorbidities [4, 5].

Regarding surgical approach and techniques, literature supports the safety of fundoplication in acute PEH [6] and reports laparoscopic techniques successful in over 70% of urgent cases, despite open repair being more common, compared to elective cases [7, 8].

Although evidence exists regarding the management of acute diaphragmatic hernias [9]—which can include paraesophageal hernias (PEH) among other causes—no prior systematic reviews have specifically focused on the management of AGV/PEH in adults. As a result, key questions remain unresolved, including the optimal timing of intervention, choice of surgical techniques, and preferred operative approaches. Given these uncertainties, evaluating surgical outcomes is essential to inform and tailor treatment strategies to individual patients [9].

The study aims to review evidence on clinical characteristics, surgical treatment, POC and 30DM, observed in patients undergoing surgery for AGV/PEH.

Methods

This manuscript has been prepared in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [10] and the AMSTAR (Assessing the methodological quality of systematic reviews) standards [11].

Study protocol

Registered in PROSPERO (International prospective register of systematic reviews, NIHR), ID: CRD42024620580.

Study design

Systematic review (SR).

Eligibility criteria

All types of primary studies (experimental and observational) reporting POC and 30DM of patients treated for AGV/PEH, diagnosed by radiology, computed tomography, or magnetic resonance imaging, published between 1990 and 2024 were included. No language or geographic restrictions were applied to the selection of manuscripts. Editorials, letters to the editor, narrative reviews, consensus documents and discussions were excluded. Additionally, articles involving patients treated for uncomplicated diaphragmatic hernias, regardless of their size and etiology, chronic gastric volvulus, or gastric volvulus following surgery for PEH or gastroesophageal reflux disease, or other thoracic or abdominal conditions, were also excluded.

Information sources

The following metasearch engines, libraries, and databases were reviewed: Web of Sciences (WoS), Embase, Medline, Scopus, BIREME-BV and SciELO. The search and recruitment of articles closed on December 30, 2024. Manual searches of cross-referenced articles and grey literature were conducted.

Search strategies

This was carried out using the PECO components (population study [P: patients with AGV], exposure [E: Surgery], comparator [C: none], and result [O: POC and 30DM]). Sensitive searches were conducted by adapting the search strategy for each information source, considering the use of MeSH, DeCS, and Emtree terms, as well as free terms incorporated using Boolean operators (Table 1). A manual and cross-reference search was also carried out.

Table 1 Search strategies and results obtained for each information source(N = 1,049)
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Regarding the selection of MeSH terms from the National Library of Medicine, given the absence of concepts for acute paraesophageal hernia (PEH) and acute gastric volvulus (AGV), the following terms were chosen: “Stomach Volvulus” (ID: D013277), defined as the twisting of the stomach, which may lead to gastric ischemia and gastric outlet obstruction (often associated with diaphragmatic hernia) and encompasses the concept of gastric volvulus; “Gastric Volvulus, Intrathoracic” (ID: C564989), classified as a supplementary concept; and “Hernia, Hiatal” (ID: D006551), which includes paraesophageal hernia.

Selection process

Identified documents from each information source were managed using COVIDENCE® software with duplicates removed both automatically and manually. Subsequently they were screened by title and abstract by four authors (CM, EB, JR, MP), using the eligibility criteria. Then, full-text reports of potentially eligible studies were retrieved and independently assessed by the same four authors, all of whom have extensive experience in searching and analyzing biomedical studies. Discrepancies at any stage were resolved by consensus; if necessary, a fifth reviewer (LG) was consulted to reach a decision.

Data collection

The data extraction process was conducted independently by at least two reviewers, using a previously validated and standardized form developed based on the CHARMS-PF tool. Any inconsistencies were resolved by consensus among the reviewers. Then, data was collected in an Excel spreadsheet using a validated matrix [12, 13].

Data items and outcomes

Primary outcome variables were POC and 30DM. POC were defined as any pathologic processes that affect patients after surgery in patients with AGV due to PEH. POC may or may not be related to the underlying disease or the surgery itself. POC were assessed dichotomously (present or absent) and graded using the Clavien-Dindo classification [14]. Thirty-day mortality was defined as the rate of death from any cause within 30 days after surgery for AGV and was measured dichotomously (alive or not). Secondary outcome variables included the year of publication of primary articles (reported as in percentages), geographical origin of the studies, study designs and level of evidence based on Centre for Evidence-Based Medicine [15], the number of cases considered in each study, main clinical manifestation (reported as in percentages), type of volvulus, surgical procedure performed, other associated therapeutics interventions (reported in percentages), length of hospital stay (in days) and need for reoperations.

Study risk of bias

MQ of primary studies was determined applying MInCir scales for therapeutic procedures (MInCir-T) and prognosis (MInCir-Pr2) [16, 17]. Both used scales are valid (demonstrating face and content validity, and construct validity for extreme groups) and reliable (interobserver reliability). MInCir-T scale comprises 3 domains and 6 items: the first related to the study design; the second to the population sample size, and the third to the used methodology. A score is generated by summing the 3 domains yield a total score ranging from 6 to 36 points (6 points represent the lowest MQ study and 36 the highest). A score of 18 serves as the cut-off point to define acceptable MQ [16]. The MInCir-Pr2 scale includes 4 domains and 11 items, covering study design, population sample size, methodology, analysis and conclusions. The sum of these 4 domains generates a score ranging from 7 to 60 points (7 being the lowest MQ study and 60 the highest), with a cut-off of 33 to define acceptable MQ [17]. Both scores were applied to each article by a pair of investigators, who resolved any discrepancies by consensus. Data were then entered into a spreadsheet, and weighted averages (WA) were calculated. A weighted least squares regression model was applied to compared results, using the number of patients of each scientific article as the weighting factor.

Statistics

Descriptive statics were applied, including the calculation of percentages, averages and WA. A meta-analysis was performed to compare the behavior of the study variables across two time periods (1990–2015, period A vs. 2016–2024, period B), aiming to verify whether significant differences in the variables under study emerged over time. The cutoff point was established based on the 50th percentile of the number of studies (52% vs. 48%) and a proportionally balanced distribution of patients (41% vs. 59%), respectively. This analysis utilized a weighted least squares regression model, where weights were based on the number of patients of each scientific article. The time periods were dichotomized based on an exploratory data analysis, which verified that this division provided a balance sample.

Additional analyses

In addition, meta-analyses of proportions were performed for POC and 30DM, in those primary articles with at least 10 subjects. A random-effects model was employed using the Hartung-Knapp-adjusted inverse variance method and proportions were transformed using the Freeman-Tukey method. Heterogeneity was assessed using I2 statistics and subgroup analyses were conducted to evaluate the causes of methodological heterogeneity considering the research design. Comparison between fixed- and random-effects meta-analyses were also made. Publication bias was assessed qualitatively and by Funnel Plot. All analyses were conducted using the R Studio Version 4.4.2.

The behavior of the study variables was determined using the WA of each variable. The WA was calculated as the sum of the product of the study variable by the sample size of where the article came from, divided by the sum of methodological quality scores of all the study articles. The following formula was applied (𝑾𝑨 = 𝚺𝐗𝐢∗𝐞𝐢 / 𝚺𝐞𝐢), in which WA is weighted average; Xi, the value achieved for the outcome in the study “I” (for all outcomes); “ei”, represents the sample size of the study I; and “Σei”, correspond to the sum of the scores obtained in all the studies [16, 17].

Ethics

To reduce possible biases in the selection and analysis, masking of authors and study centers were implemented, coding and masking the primary articles, and deleting the names of authors and centers. Human Ethics and Consent to Participate declarations: not applicable.

Results

Study selection

A total of 1,049 studies were identified. Of these, 484 were excluded due to duplication of information sources. The remaining 565 articles underwent title and abstract screening, leading the exclusion of 330 unrelated articles. Of the 235 articles reviewed in full, 4 could not be retrieved and 81 were excluded based on eligibility criteria. In addition, 21 studies were identified through cross referencing, resulting in 171 studies included in the final analysis [18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120,121,122,123,124,125,126,127,128,129,130,131,132,133,134,135,136,137,138,139,140,141,142,143,144,145,146,147,148,149,150,151,152,153,154,155,156,157,158,159,160,161,162,163,164,165,166,167,168,169,170,171,172,173,174,175,176,177,178,179,180,181,182,183,184,185,186,187,188] (Fig. 1).

Fig. 1
figure 1

Flow chart of the analyzed studies

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Study characteristics

The selected studies included 141 cases reports (82.5%), 18 retrospective case series (10.5%), and 12 observational studies (7.0%), consisting of 7 retrospective cohorts, 2 propensity score analyses, 2 population surveys, and 1 case control study. These studies encompassed 15,178 patients, with a WA age of 75.3 ± 13.9 years, and 51.3% were female. The primary studies provide levels of evidence for treatment studies of 3b (2.9%) and 4 (97.1%), while levels of evidence for prognosis studies were 2b (7.1%) and 4 (92.9%).

Synthesis of results

Over half (52.6% were published in the last decade (Table 2). Just over 50% of the publications come from four countries, of which the United States is the largest producer (54 studies, 31.6%; Table 3).

Table 2 Year of publication of the included studies (N = 171)
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Table 3 Origin of included studies (N = 171)
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The clinical and demographic characteristics and outcomes of the patients included in the review are detailed in Tables 4 and 5. In summary, it is noteworthy that WA of intrathoracic stomach volume was 84.1% and the majority of PEH and AGV were classified as type III PEH (222 cases, 31.6%) and organo-axial (202 cases, 73.9%). In addition, most cases were operated on emergency basis and the open approach was the most used (9934 cases, 86.2%). The most frequent techniques were Nissen fundoplication (39.1%) and gastropexy (23.9%). Table 4 highlights differences between study periods. Notable findings from the more recent period include a significantly older population (p = 0.011), a substantial reduction in emergency surgery indications (p = 0.003; OR: 1.7 [95% CI: 1.2–2.5]), and a decline in the use of the laparoscopic approach (p < 0.001; OR: 2.4 [95% CI: 2.1–2.7]). Additionally, there was an increase in reinterventions (p = 0.035), along with a marked reduction in readmission and recurrence rates (p = 0.0001 and p < 0.008 respectively).

Table 4 Clinical characteristics and outcomes of the patients
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Table 5 Clinical characteristics and outcomes of patients and studies in the two different time periods
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The WA of surgical time was 165 ± 67 min. Finally, the WA of time follow-up was 15.7 ± 10.7 months, with 11% of readmissions rate and a 22.2% of recurrence. The WA of POC occurrence was 32.0% with a mortality rate of 5.7%. The most frequent POC were deep vein thrombosis, myocardial infarction, pulmonary thromboembolism and stroke) account for more than 80% of reported events (Table 6).

Table 6 Reported postoperative complications (n = 1,989 cases)*
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The meta-analysis identified a POC rate of 0.30 (95% CI: 0.23–0.37) and a 30DM rate of 0.03 (95% CI: 0.02–0.05). In both cases, high heterogeneity was observed, with I² values of 94% and 93%, respectively (Figs. 2 and 3).

Fig. 2
figure 2

Meta-analyses of prevalence of POC. A) Forrest plot. POC rate was 30% (95% CI: 23-37%). B) Funnel plot. There was great heterogeneity (I2: 94%)

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Fig. 3
figure 3

Meta-analyses of prevalences of 30-day mortality. A) Forrest plot. 30DM rate was 3% (95% CI: 2-5%). B) Funnel plot. There was great heterogeneity (I2: 93%)

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MQ of primary studies assessed using MInCir-Therapy scale, had a WA score of 8.9 ± 2.3, with only 4 articles scoring exceeding the cutoff. Using the MInCir-Pr2 scale, the MQ was 13.4 ± 5.4, with 6 studies exceeding the cutoff. This indicates a high likelihood of inaccuracy in causal effect estimates. No statistical differences in MQ were observed between the pre-2015 and post-2015 periods (Table 5).

Finally, statistically significant improvements were observed post-2015 in patient age and reinterventions, while readmission and recurrence rates worsened. Non-significant trends suggested slight improvements in surgical time and POC, but a worsening of 30DM (Table 5).

Possible biases in the review process

Additional information was requested from the authors to expand or verify certain study data; however, no response was received. As a result, missing data may introduce bias into this review. To mitigate the risk of missing studies, cross-references were thoroughly examined.

Risk of bias between studies

There may be publication bias due to the concentration of studies originating from a few countries and limited global representation (Table 5). Finally, is important to highlight that only 4 studies for therapy and 6 on prognosis scores above the cut-off point defining acceptable MQ.

Discussion

Summary of the evidence

This SR confirms that the prognosis for AGV/PEH remains poor, with high rates of morbidity and mortality despite advances in medical and surgical care.

There are several valuable reviews in the literature addressing the management of complicated diaphragmatic hernias, such as the one published outlining the WSES position on the topic [9]. However, studies specifically focused on AGV and PEH are limited [187, 188], and most examine populations different from the one analyzed in our SR.

The first SR included 97 studies focusing pediatric populations (n = 125; median age 24 months) [187]. Reported rates of mortality, postoperative complications, and recurrence were 6,4%, 18,9% and 0.8%, respectively. The second SR evaluated outcomes of surgery—elective or non-elective— based on eight retrospective cohort studies, involving 84 patients. It compared outcomes between 76 patients under 80 years of age (mean age 63.9 ± 9.5 years) and 8 patients aged 80 or older (mean age 85.4 ± 3.5 years). The study found a significantly higher proportion of type IV hernias in ≥ 80 age patients (50.0% vs. 14.5%, p = 0.037) as well as a higher rate of emergency surgery (37.5% vs. 11.8%, p = 0.049). Although the emergency surgery group included only three octogenarians, this subgroup demonstrated longer hospital stays (median 9 vs. 5 days, p = 0.049) and significantly higher in-hospital mortality (25.0% vs. 0.0%, p < 0.001) compared to younger patients [188].

In this context, we believe ours is the first SR specifically focused on AGV secondary to PEH in adults. It compiles data from six major sources spanning 35 years, encompassing 167 primary studies and a total of 14,989 patients. Notably, more than half of the included studies originate from just four countries: the United States, Japan, Spain, and the United Kingdom.

A key strength of our SR is the inclusion of a temporal analysis aimed at assessing the potential impact of recent technical improvements. To this end, we com-pared outcomes across two potential periods (pre- and post-2015) and found no significant improvements in clinical outcomes. Notably, half of the patients included in the 35-years period study were treated in the last decade, suggesting that advances in surgical techniques may lead to a shift toward operative management over conservative approaches. This trend likely coincides with an aging global population, in which acute presentations are increasingly common. In fact, mortality increased in the more recent period (6.7% vs. 4.1%), likely due to an older and more frail patient population (mean age: 77.6 vs. 70.1 years). Morbidity remained high at 33%, with most complications classified as severe (Clavien-Dindo ≥ IIIa). On a more positive note, readmission and recurrence rates did show significant improvement after 2015.

Interestingly, mortality was higher in the more recent period (6.7% vs. 4.1%), likely reflecting the treatment of older and more medically complex patients (mean age: 77.6 vs. 70.1 years). Morbidity remained substantial at 33%, with the majority of complications classified as severe (Clavien-Dindo ≥ IIIa). On a more encouraging note, both readmission and recurrence rates showed significant improvement after 2015.

In summary, in the adult population, the overall prognosis for AGV secondary to PEH does not appear to have improved substantially, although some indicators suggest a modest trend toward better outcomes, despite advances in resuscitation and surgical techniques. Perhaps most concerning is the inability to clearly identify prognostic variables—other than age—that would allow healthcare professionals to stratify patients and tailor treatment based on individual risk profiles [189].

Limitations

The available evidence is limited to level 4 studies, including case reports and small retrospective series. The inclusion of case reports in a SR is debatable. From a strict methodological standpoint, their inclusion is generally discouraged; how-ever, in the context of rare or low-prevalence conditions, there is a degree of consensus that such an approach is appropriate [190, 191]. In this review, case reports contributed valuable clinical data, preoperative evaluation and surgical procedure details that might have otherwise gone unnoticed.

Conducting subgroup analyses would have been valuable—particularly to better under-stand the impact of the surgical approach, the specific techniques employed, and the surgical volume or experience of the teams involved in esophagogastric and/or thoracic procedures. Unfortunately, such information was not consistently reported.

Moreover, the methodological quality of the primary studies was generally poor, with MInCir-T and MInCir-Pr2 scores below respective thresholds [16, 17]. Publication bias is also evident as the asymmetrical distribution in funnel plots observed in the meta-analyses of POC and mortality outcomes.

Notably, just four countries—one from North America, two from Europe, and one from Asia—accounted for 90 of the included studies; 52.6% of the studies included in this review. These studies collectively involved 14,861 patients (97.9% of the total sample), introducing a representativeness bias and significantly limiting the external validity of the findings. Additionally, not all studies reported data for the variables under analysis, reducing the completeness and representativeness of the summary statistics for each variable. Finally, although several high-impact studies with large patient cohorts were included, they often provided limited detail on key variables. Due to their size, these studies had a disproportionate influence on the overall results.

Conclusions

AGV, a severe complication of PEH, continues to carry a poor prognosis despite medical advancements. Outcomes are characterized by prolonged hospital stays, high rates of severe complications, and substantial mortality. Early diagnosis and prompt treatment appear to be critical for improving clinical outcomes.

Data availability

No datasets were generated or analysed during the current study.

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Authors and Affiliations

  1. Center for Morphological and Surgical Studies, Universidad de La Frontera, Temuco, Chile

    Carlos Manterola

  2. PhD. Program in Medical Science, Universidad de La Frontera, Temuco, Chile

    Carlos Manterola & Josue Rivadeneira

  3. Department of Surgery, Universidad de Concepción, Concepción, Chile

    Enrique Biel

  4. Department of Surgery, Universitat Autònoma de Barcelona, Barcelona, Spain

    Enrique Biel, Manuel Pera & Luis Grande

  5. Section of Gastrointestinal Surgery, Hospital del Mar, Barcelona, Spain

    Enrique Biel & Manuel Pera

  6. Zero Biomedical Research, Quito, Ecuador

    Josue Rivadeneira

  7. Hospital del Mar Research Institute (IMIM), Barcelona, Spain

    Manuel Pera & Luis Grande

  8. Reial Acadèmia de Medicina de Catalunya, Barcelona, Spain

    Manuel Pera & Luis Grande

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Contributions

CM: Conceptualization, data collection, extraction, analysis, prepared Figs. 1, 2 and 3, and manuscript writing. EB: Data collection and extraction, manuscript preparation and review. JR: Conceptualization, data collection, analysis, manuscript preparation, prepared Figs. 1, 2 and 3, and review.MP: Conceptualization, overall project supervision and manuscript review.LG: Conceptualization, analysis, overall project supervision and manuscript review.

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Manterola, C., Biel, E., Rivadeneira, J. et al. Acute paraesophageal hernia with gastric volvulus. Results of surgical treatment: a systematic review and meta-analysis. World J Emerg Surg 20, 41 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13017-025-00617-3

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Keywords

World Journal of Emergency Surgery

ISSN: 1749-7922