Long-term objective hiatal hernia recurrence after magnetic sphincter augmentation versus laparoscopic fundoplication: a multicenter cohort study of moderate and large hiatal hernias

BACKGROUND: Recurrent hiatal hernia is a leading cause of long-term failure after antireflux surgery and the most common indication for revisional surgery. Although magnetic sphincter augmentation (MSA) has demonstrated favorable outcomes following repair of moderate and large hiatal hernias, its long-term anatomical durability compared with laparoscopic fundoplication remains unclear. We compared the durability of hiatal hernia repair following MSA versus fundoplication in patients with moderate and large hiatal hernias using objective assessment of postoperative hiatal hernia recurrence. METHODS: This multicenter observational cohort study analyzed prospectively maintained registries from six high-volume foregut centers. Adult patients undergoing primary repair of moderate (3-5 cm) or large (> 5 cm or paraesophageal) hiatal hernias with MSA or laparoscopic fundoplication who underwent protocol-directed objective follow-up 3 years after surgery were included. The primary outcome was objective hiatal hernia recurrence. Secondary outcomes included GERD-HRQL, proton pump inhibitor use, patient satisfaction, and revisional surgery. RESULTS: A total of 258 patients underwent antireflux surgery, including 196 (76.0%) treated with MSA and 62 (24.0%) with fundoplication. At 3 years, objective hiatal hernia recurrence was significantly lower following MSA than fundoplication (6.1% vs 21.0%; P = 0.002). On multivariable analysis, fundoplication was significantly associated with 3-year objective hiatal hernia recurrence (OR, 4.67; 95% CI, 1.11-19.59; P = 0.035). Despite lower recurrence after MSA, GERD-HRQL, dysphagia, bloating, patient satisfaction, and revisional surgery rates were similar between groups, whereas postoperative proton pump inhibitor use was lower following MSA (11.5% vs 27.5%; P = 0.022). CONCLUSIONS: MSA was associated with lower objective hiatal hernia recurrence than laparoscopic fundoplication, but patient-reported outcomes were similar between procedure groups. Long-term anatomical durability should be considered alongside patient-reported outcomes when selecting the optimal antireflux procedure.