Recommendations for the Management of Symptomatic Hiatal Hernia in Saudi Arabia, With Regional Input From the Middle...

Gastroesophageal reflux disease (GERD) is prevalent in the Middle East, with hiatal hernia (HH) reported in nearly 30% of patients with GERD in Saudi Arabia. Management primarily involves lifestyle modifications and proton pump inhibitor therapy; however, patients with persistent symptoms may require surgical intervention. This study sought to establish expert-driven, best-practice recommendations to improve clinical outcomes in the management of HH through a Saudi-led structured expert consensus that also incorporated perspectives from the wider Middle East region.

A structured expert consensus approach was conducted. A steering group of four experts collaboratively developed and ratified 32 Likert-scale statements encompassing five clinical domains: referral criteria, mesh utilization, risk mitigation, best practices, and guideline requirements. The ratified statements were subsequently distributed through a single-round online survey to surgeons performing HH repair across the Middle East, with a predefined consensus threshold of ≥75% agreement for each statement.

A total of 61 responses were analyzed, including 54 (88.5%) from Saudi Arabia and 7 (11.5%) from other Middle Eastern countries (Jordan, Qatar, Kuwait, Egypt, and the United Arab Emirates). Respondents comprised general surgeons (n = 42), thoracic surgeons (n = 8), upper gastrointestinal/bariatric surgeons (n = 8), and other specialists (n = 3). Nearly 40% of respondents had more than 10 years of specialty experience. Of the 32 statements, 31 (96.9%) achieved consensus (≥75%), with only one statement-regarding mesh use for hernias 4-6 cm-not reaching consensus (67%). Based on these findings, nine recommendations were developed addressing referral pathways, diagnostic evaluation, surgical indications, and mesh utilization.

Strong agreement across 31 of 32 statements among predominantly Saudi surgical experts reflects a shared recognition of challenges and areas for improvement in GERD and HH management. These findings provide a foundation for the future development of standardized care pathways for the diagnosis, referral, and surgical management of symptomatic HH, primarily within Saudi Arabia while also informing broader clinical practice across the Middle East.