ABSTRACT

Introduction

Chronic nausea and vomiting are symptoms of a wide range of gastrointestinal and non-gastrointestinal conditions. Diagnosis can be challenging and requires a systematic and well-structured approach. If the initial investigation for structural, toxic and metabolic disorders is negative, digestive motility and gut-brain interaction disorders should be assessed. United European Gastroenterology (UEG) and the European Society for Neurogastroenterology and Motility (ESNM) identified the need for an updated, evidence-based clinical guideline for the management of chronic nausea and vomiting.

Methods

A multidisciplinary team of experts in the field, including European specialists and national societies, participated in the development of the guideline. Relevant questions were addressed through a literature review and statements were developed and voted on according to a Delphi process.

Results

Ninety-eight statements were identified and voted following the Delphi process. Overall agreement was high, although the grade of scientific evidence was low in many areas. Disagreement was more evident for some pharmacological treatment options. A diagnostic algorithm was developed, focussing on the differentiating features between gastrointestinal motility and gut-brain interaction disorders with predominant nausea and vomiting.

Conclusion

These guidelines provide an evidence-based framework for the evaluation and treatment of patients with chronic nausea and vomiting.

ABSTRACT

Abstract

Background

New evidence has emerged since latest guidelines on the management of paraesophageal hernia, and guideline development methodology has evolved. Members of the European Association for Endoscopic Surgery have prioritized the management of paraesophageal hernia to be addressed by pertinent recommendations.

Objective

To develop evidence-informed clinical practice recommendations on paraesophageal hernias, through evidence synthesis and a structured evidence-to-decision framework by an interdisciplinary panel of stakeholders.

Methods

We performed three systematic reviews, and we summarized and appraised the certainty of the evidence using the GRADE methodology. A panel of general and upper gastrointestinal surgeons, gastroenterologists and a patient advocate discussed the evidence in the context of benefits and harms, the certainty of the evidence, acceptability, feasibility, equity, cost and use of resources, moderated by a Guidelines International Network-certified master guideline developer and chair. We developed the recommendations in a consensus meeting, followed by a modified Delphi survey.

Results

The panel suggests surgery over conservative management for asymptomatic/minimally symptomatic paraesophageal hernias (conditional recommendation), and recommends conservative management over surgery for asymptomatic/minimally symptomatic paraesophageal hernias in frail patients (strong recommendation). Further, the panel suggests mesh over sutures for hiatal closure in paraesophageal hernia repair, fundoplication over gastropexy in elective paraesophageal hernia repair, and gastropexy over fundoplication in patients who have cardiopulmonary instability and require emergency paraesophageal hernia repair (conditional recommendation). A strong recommendation means that the proposed course of action is appropriate for the vast majority of patients. A conditional recommendation means that most patients would opt for the proposed course of action, and joint decision-making of the surgeon and the patient is required. Accompanying evidence summaries and evidence-to-decision frameworks should be read when using the recommendations. This guideline applies to adult patients with moderate to large paraesophageal hernias type II to IV with at least 50% of the stomach herniated to the thoracic cavity. The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/j7q7Gn.

Conclusion

An interdisciplinary panel provides recommendations on key topics on the management of paraesophageal hernias using highest methodological standards and following a transparent process.

Guideline registration number

PREPARE-2023CN018.

Keywords: Paraesophageal hernia, Hiatal hernia, Diaphragmatic hernia, Mesh, Guidelines

Background

The global incidence of colorectal cancer (CRC) continues to increase, accompanied by improvements in overall and disease-specific survival. Consequently, there are about 5 million survivors of CRC worldwide, with a range of unmet needs affecting physical, psychological, and social functioning. Gastrointestinal dysfunction is a common problem following surgical treatment for CRC, with a reported incidence of up to 50% at 10 years post-operatively. It presents with a constellation of symptoms, including abdominal pain and distension and variable bowel habits (e.g. constipation, diarrhoea, fragmentation), all of which require different management strategies. These long-term sequelae can have a significant impact on patients' overall well-being and quality of life (QoL). Recent studies have shown that a specific cause for gastrointestinal symptoms was found in 80% of patients when examined in a clinic dedicated to late sequelae after colorectal surgery. Additionally, 70% of these patients experienced improvement after treatment. Similar outcomes were observed in a nurse-led clinic, highlighting the clinical and socio-economic value of recognising and addressing of these complications.