Sometimes the simpler operation is the right one
Por décadas, a cirurgia de hérnia paraesofágica seguiu um protocolo quase imutável, como se a complexidade do procedimento fosse garantia de sua eficácia. Um novo estudo publicado no Surgical Endoscopy questiona essa ortodoxia ao demonstrar que a gastropexia isolada — uma técnica mais simples, que ancora o estômago ao diafragma sem a fundoplicatura — apresenta taxas de recorrência e qualidade de vida comparáveis ao reparo tradicional em pacientes selecionados sem refluxo significativo. A ciência, aqui, não abandona o passado, mas convida o cirurgião a distinguir entre o que é necessário e o que se tornou hábito.
- A fundoplicatura, considerada indispensável por décadas, é agora questionada em pacientes com hérnia paraesofágica sem doença do refluxo documentada.
- O estudo retrospectivo com 126 pacientes revelou que a recorrência anatômica foi menor no grupo da gastropexia (14,6%) do que no grupo com fundoplicatura (20,5%), diferença sem significância estatística, mas clinicamente relevante.
- A técnica simplificada reduz o risco de disfagia pós-operatória, um efeito adverso real que compromete a qualidade de vida de parte dos pacientes submetidos à fundoplicatura.
- Para idosos, portadores de múltiplas comorbidades ou em situações de emergência, a gastropexia oferece uma via mais rápida e segura sem sacrificar os resultados.
- A seleção rigorosa de pacientes — excluindo aqueles com DRGE confirmada por monitoramento de pH ou esofagite grave — é apontada como condição essencial para o sucesso da abordagem.
- Estudos com seguimento mais prolongado são necessários para confirmar se os benefícios observados em 22 meses se sustentam ao longo dos anos.
Por décadas, o reparo cirúrgico da hérnia paraesofágica seguiu um roteiro fixo: reduzir o conteúdo herniado, remover o saco, fechar o hiato e, quase sempre, adicionar uma fundoplicatura — um envolvimento do esôfago inferior para prevenir o refluxo. A técnica se consolidou porque as alternativas pareciam arriscadas, associadas a altas taxas de recorrência e ao risco de induzir doença do refluxo em pacientes que não a tinham.
Um estudo publicado no Surgical Endoscopy propõe uma revisão dessa ortodoxia. Pesquisadores avaliaram se a gastropexia isolada — que ancora o fundo gástrico à face inferior do diafragma esquerdo, restaurando o ângulo de His sem a fundoplicatura — poderia ser igualmente eficaz em um grupo específico: pacientes com hérnias grandes e sem refluxo significativo. O estudo retrospectivo pareou 63 duplas de pacientes operados entre 2010 e 2022, todos com hérnias de cinco centímetros ou mais, excluindo aqueles com DRGE confirmada.
Os resultados desafiaram as premissas estabelecidas. Após seguimento médio de 22 meses por imagem, a recorrência anatômica ocorreu em 14,6% do grupo com gastropexia e em 20,5% do grupo com fundoplicatura — diferença sem significância estatística. A qualidade de vida relacionada ao refluxo foi semelhante entre os grupos, e o controle sintomático permaneceu satisfatório, ainda que os pacientes com gastropexia tenham usado medicação supressora de ácido com maior frequência.
O que torna o achado relevante é a vantagem prática da técnica mais simples: menor tempo cirúrgico, menor risco de disfagia pós-operatória e maior segurança para pacientes idosos ou em situações de emergência. Os autores são cuidadosos ao posicionar a gastropexia como uma ferramenta para uma população selecionada, não como substituta universal da fundoplicatura. A avaliação pré-operatória rigorosa permanece indispensável. O recado central é preciso: nem sempre a operação mais complexa é a mais adequada — saber quando simplificar também é arte cirúrgica.
For decades, surgeons have approached paraesophageal hernias the same way: reduce the contents, remove the sac, close the hiatus, and almost always add a fundoplication—a wrap around the lower esophagus meant to prevent reflux. It has been the standard because the alternatives seemed risky. Repair without that wrap carried a reputation for high recurrence rates and a troubling tendency to trigger acid reflux disease in patients who didn't have it before.
But a new study published in Surgical Endoscopy asks whether that orthodoxy needs rethinking. Researchers looked at whether isolated gastropexia—a simpler procedure that anchors the stomach to the diaphragm without the fundoplication—might work just as well in a specific group: patients with large paraesophageal hernias who don't have significant reflux disease to begin with.
The study was retrospective, matching 63 pairs of patients who underwent minimally invasive hiatal repair between 2010 and 2022. All had hernias five centimeters or larger. The key difference was that one group received gastropexia alone, while the other received the traditional approach with fundoplication. Patients with documented reflux disease—confirmed by pH monitoring or severe esophagitis—were excluded. The gastropexia technique itself was straightforward: surgeons sutured the gastric fundus to the underside of the left diaphragm, aiming to restore the angle of His, the natural bend that helps prevent reflux.
The results challenged the old assumptions. After a median imaging follow-up of 22 months, anatomical recurrence—defined as hernia larger than two centimeters on imaging—occurred in 14.6 percent of the gastropexia group and 20.5 percent of the fundoplication group. The difference was not statistically significant. Most recurrences in the gastropexia group were small and involved sliding rather than paraesophageal herniation. On quality-of-life measures related to reflux, both groups scored similarly low, meaning both controlled symptoms well. The gastropexia patients did use acid-suppressing medication more often after surgery, but their overall symptom control remained satisfactory.
What makes this finding meaningful is the practical advantage gastropexia offers. It is simpler, faster, and avoids the postoperative swallowing difficulty that fundoplication can cause. For elderly patients with multiple medical problems, or in emergency situations where the goal is rapid stabilization, that matters. The omission of fundoplication also reduces the risk of postoperative dysphagia—difficulty swallowing—a real quality-of-life concern for some patients.
The authors are careful to frame this as a tool for a selected population, not a wholesale replacement for traditional repair. The critical prerequisite is rigorous preoperative evaluation to exclude patients with genuine reflux disease, who still need the mechanical barrier that fundoplication provides. In patients with presbyesophagus—age-related changes to the esophagus—gastropexia may be particularly useful. The message is not to abandon the technique but to know when to use it.
Longer follow-up studies and standardized technical protocols will be needed to confirm these benefits hold over years, not just months. But the study suggests that surgical decision-making need not be automatic. The patient's history, age, comorbidities, and the urgency of the situation all belong in the calculation. Sometimes the simpler operation is the right one.
Citas Notables
For patients with large paraesophageal hernias without pre-existing significant reflux, gastropexia with hiatal closure offers quality-of-life results and recurrence rates equivalent to fundoplication in short to medium-term follow-up— Study authors, Surgical Endoscopy
We should not simply abolish the technique but know when to use it—especially in elderly patients with presbyesophagus, gastropexia may be a viable alternative— Editorial commentary
La Conversación del Hearth Otra perspectiva de la historia
Why has fundoplication been the default for so long if gastropexia works just as well?
Because the early evidence showed high recurrence rates and reflux disease developing after gastropexia alone. Those reports created a kind of surgical consensus that stuck. But this study suggests that consensus may have been too broad—it was based partly on patients who actually had reflux disease to begin with, which changes the calculus entirely.
So the key is patient selection. What makes someone a good candidate for gastropexia instead?
Exactly. You need a large paraesophageal hernia—five centimeters or more—but no significant reflux disease on objective testing. If someone has acid reflux already, they need the fundoplication. But if the hernia is causing symptoms like chest discomfort or early satiety, and reflux isn't the problem, gastropexia alone may be enough.
What about those patients who needed more acid-suppressing medication after gastropexia?
That's the trade-off. They used proton pump inhibitors more often, but their quality of life was still good. It's not ideal, but it's better than the swallowing problems some patients get from fundoplication, especially older patients.
Why does age matter so much here?
Older patients often have presbyesophagus—the esophagus loses elasticity and function with age. A fundoplication can make swallowing harder in that context. Gastropexia is faster, less invasive in that sense, and avoids adding another mechanical problem on top of what age has already done.
Is this study the final word?
No. The follow-up was only 22 months. We need longer studies to see if recurrence rates stay low at five or ten years. And the technique needs standardization—different surgeons may do it slightly differently. But it opens a door that was closed before.