Quality of Life Following Repair of Large Hiatal Hernia is Improved but not Influenced by Use of Mesh: Results From a Randomized Controlled Trial. World J Surg. 2015;39:1465-1473. [PMID: 25651955 DOI: 10.1007/s00268-015-2970-3]

Patients report significant improvement in quality of life following hiatal hernia repair-despite recurrence

BACKGROUND

Hiatal hernia (HH) repairs have been associated with high recurrence rates. This study aimed to investigate if changes in patient's self-reported GERD health-related quality of life (HRQL) scores over time are associated with long-term surgical outcomes.

METHODS

Retrospective chart reviews were conducted on all patients who had laparoscopic or robotic HH repairs between 2018 and 2022 at a tertiary care center. Information was collected regarding initial BMI, endoscopic HH measurement, surgery, and pre- and post-operative HRQL scores. Repeat imaging at least a year following surgical repair was then evaluated for any evidence of recurrence. Paired t tests were used to compare pre- and post-operative HRQL scores. Wilcoxon ranked-sum tests were used to compare the HRQL scores between the recurrence cohort and non-recurrence cohorts at different time points.

RESULTS

A total of 126 patients underwent HH repairs and had pre- and post-operative HRQL scores. Mesh was used in 23 repairs (18.25%). 42 patients had recorded HH recurrences (33.3%), 35 had no evidence of recurrence (27.7%), and 49 patients (38.9%) had no follow-up imaging. The average pre-operative QOL score was 24.99 (SD ± 14.95) and significantly improved to 5.63 (SD ± 8.51) at 2-week post-op (p < 0.0001). That improvement was sustained at 1-year post-op (mean 7.86, SD ± 8.26, p < 0.0001). The average time between the initial operation and recurrence was 2.1 years (SD ± 1.10). Recurrence was significantly less likely with mesh repairs (p = 0.005). There was no significant difference in QOL scores at 2 weeks, 3 months, 6 months, or 1 year postoperatively between the cohorts (p = NS).

CONCLUSION

Patients had significant long-term improvement in their HRQL scores after surgical HH repair despite recurrences. The need to re-intervene in patients with HH recurrence should be based on their QOL scores and not necessarily based on established recurrence.

EAES Multidisciplinary Rapid Guideline: systematic review, meta-analysis, GRADE assessment and evidence-informed recommendations on the surgical management of paraesophageal hernias

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.

5-Year Collis-Nissen Gastroplasty Outcomes for Type III-IV Hiatal Hernia with Short Esophagus: A Prospective Observational Study

BACKGROUND

To assess the 5-year outcomes of patients undergoing Collis-Nissen gastroplasty for type III-IV hiatal hernia with short esophagus.

STUDY DESIGN

From a prospective observational cohort of patients who underwent antireflux surgery for type III-IV hiatal hernia between 2009 and 2020, those with short esophagus (abdominal length <2.5 cm) in whom a Collis-Nissen procedure was performed and reached at least 5 years of follow-up were identified. Hernia recurrence, patients' symptoms, and quality of life were assessed annually by barium meal x-ray, upper endoscopy, and validated symptoms and Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaires.

RESULTS

Of the 114 patients with Collis-Nissen gastroplasty, 80 patients who completed a 5-year follow-up were included (mean age 71 years). There were no postoperative leaks or deaths. Recurrent hiatal hernia (any size) was identified in 7 patients (8.8%). Heartburn, regurgitation, chest pain, and cough were significantly improved at each follow-up interval (p < 0.05). Preoperative dysphagia disappeared or improved in 26 of 30 patients, while new-onset dysphagia occurred in 6. Mean postoperative QOLRAD scores significantly improved at all dimensions (p < 0.05).

CONCLUSIONS

Collis gastroplasty combined with Nissen fundoplication provides low hernia recurrence, good control of symptoms, and improved quality of life in patients with large hiatal hernia and short esophagus.

Evolution of biomimetic ECM scaffolds from decellularized tissue matrix for tissue engineering: A comprehensive review

Tissue engineering is essentially a technique for imitating nature. Natural tissues are made up of three parts: extracellular matrix (ECM), signaling systems, and cells. Therefore, biomimetic ECM scaffold is one of the best candidates for tissue engineering scaffolds. Among the many scaffold materials of biomimetic ECM structure, decellularized ECM scaffolds (dECMs) obtained from natural ECM after acellular treatment stand out because of their inherent natural components and microenvironment. First, an overview of the family of dECMs is provided. The principle, mechanism, advances, and shortfalls of various decellularization technologies, including physical, chemical, and biochemical methods are then critically discussed. Subsequently, a comprehensive review is provided on recent advances in the versatile applications of dECMs including but not limited to decellularized small intestinal submucosa, dermal matrix, amniotic matrix, tendon, vessel, bladder, heart valves. And detailed examples are also drawn from scientific research and practical work. Furthermore, we outline the underlying development directions of dECMs from the perspective that tissue engineering scaffolds play an important role as an important foothold and fulcrum at the intersection of materials and medicine. As scaffolds that have already found diverse applications, dECMs will continue to present both challenges and exciting opportunities for regenerative medicine and tissue engineering.

A protocol for developing core outcome sets for laparoscopic hiatal hernia repair

Background

Hiatal hernias negatively damage patients’ health and life quality. Laparoscopic hiatal hernia repair is currently the gold standard for the treatment of hiatal hernia (LHHR). Numerous clinical trials on laparoscopic hiatal hernia repair have been done, but the published findings are highly variable due to the lack of unique outcome sets. Basic outcome sets have ever been established over the previous decade for a few procedures, but not for hiatal hernia repair yet. This protocol outlines the procedure to develop a core outcome set for laparoscopic hiatal hernia repair COS-LHHR). COS-LHHR will provide a unique criteria for clinical investigations.

Methods

This study will be conducted in four phases: (1) scoping reviews of existing qualitative studies and outcome reporting in randomized controlled trials to develop a list of potential outcome domains; (2) qualitative interviews with patients to explore the impact of laparoscopic hiatal hernia repair and the outcomes that they care most; (3) a multi-round e-Delphi study to achieve preliminary consensus on the core outcome set; and (4) an evidence-based consensus on a core outcome set will be achieved through a structured group consensus meeting, recommending best assessment outcome sets.

Discussion

The development the COS-LHHR will guide clinical research of laparoscopic hiatal hernia repair with unique outcome assessment. This would improve comparative analyses among studies.

Comparing anterior gastropexy to no anterior gastropexy for paraesophageal hernia repair: a study protocol for a randomized control trial

BACKGROUND

More than half of patients undergoing paraesophageal hernia repair (PEHR) will have radiographic hernia recurrence at 5 years after surgery. Gastropexy is a relatively low-risk intervention that may decrease recurrence rates, but it has not been studied in a prospective manner. Our study aims to evaluate the effect of anterior gastropexy on recurrence rates after PEHR, compared to no anterior gastropexy.

METHODS

This is a two-armed, single-blinded, registry-based, randomized controlled trial comparing anterior gastropexy to no anterior gastropexy in PEHR. Adult patients (≥18 years) with a symptomatic paraesophageal hernia measuring at least 5 cm in height on computed tomography, upper gastrointestinal series, or endoscopy undergoing elective minimally invasive repair are eligible for recruitment. Patients will be blinded to their arm of the trial. All patients will undergo laparoscopic or robotic PEHR, where some operative techniques (crural closure techniques and fundoplication use or avoidance) are left to the discretion of the operating surgeon. During the operation, after closure of the diaphragmatic crura, participants are randomized to receive either no anterior gastropexy (control arm) or anterior gastropexy (treatment arm). Two hundred forty participants will be recruited and followed for 1 year after surgery. The primary outcome is radiographic PEH recurrence at 1 year. Secondary outcomes are symptoms of gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular, and pulmonary symptoms as well as patient satisfaction in the immediate postoperative period and at 1-year follow-up. Outcome assessors will be blinded to the patients' intervention.

DISCUSSION

This randomized controlled trial will examine the effect of anterior gastropexy on radiographic PEH recurrence and patient-reported outcomes. Anterior gastropexy has a theoretical benefit of decreasing PEH recurrence; however, this has not been proven beyond a suggestion of effectiveness in retrospective series. If anterior gastropexy reduces recurrence rates, it would likely become a routine component of surgical PEH management. If it does not reduce PEH recurrence, it will likely be abandoned.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04007952 . Registered on July 5, 2019.

Sutured Versus Mesh-augmented Hiatus Hernia Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

This meta-analysis systematically reviewed published randomized control trials comparing sutured versus mesh-augmented hiatus hernia (HH) repair. Our primary endpoint was HH recurrence at short- and long-term follow-up. Secondary endpoints were: surgical complications, operative times, dysphagia and quality of life.

SUMMARY BACKGROUND DATA

Repair of large HHs is increasingly being performed. However, there is no consensus for the optimal technique for hiatal closure between sutured versus mesh-augmented (absorbable or nonabsorbable) repair.

METHODS

A systematic review of Medline, Scopus (which encompassed Embase), Cochrane Central Register of Controlled Trials, Web of Science, and PubMed was performed to identify relevant studies comparing mesh-augmented versus sutured HH repair. Data were extracted and compared by meta-analysis, using odds ratio and mean differences with 95% confidence intervals.

RESULTS

Seven randomized control trials were found which compared mesh-augmented (nonabsorbable mesh: n = 296; absorbable mesh: n = 92) with sutured repair (n = 347). There were no significant differences for short-term hernia recurrence (defined as 6-12 months, 10.1% mesh vs 15.5% sutured, P = 0.22), long-term hernia recurrence (defined as 3-5 years, 30.7% mesh vs 31.3% sutured, P = 0.69), functional outcomes and patient satisfaction. The only statistically significant difference was that the mesh repair required a longer operation time (P = 0.05, OR 2.33, 95% confidence interval 0.03-24.69).

CONCLUSIONS

Mesh repair for HH does not offer any advantage over sutured hiatal closure. As both techniques deliver good and comparable clinical outcomes, a suture only technique is still an appropriate approach.

Laparoscopic Paraesophageal Hernia Repair: To Mesh or not to Mesh. Systematic Review and Meta-analysis

OBJECTIVE

This study aimed to compare outcomes after laparoscopic paraesophageal hernia repair (LPEHR) with mesh or primary repair alone.

SUMMARY OF BACKGROUND DATA

High recurrence rates after LPEHR have been reported. Whether the use of mesh improves outcomes remains elusive.

METHODS

A systematic literature search was performed to identify randomized controlled trials (RCTs) comparing LPEHR with mesh repair versus suture repair alone. Early (≤6 months) and late (>6 months) recurrence rates were used as primary endpoints to assess efficacy. Intraoperative complications, overall morbidity, and reoperation rates were used as secondary endpoints to assess safety. A meta-analysis was conducted using relative risks (RR) with 95% confidence intervals (CI) for the analyzed outcomes.

RESULTS

Seven RCTs comparing mesh (n = 383) versus suture only (n = 352) repair were included for analysis. Patients undergoing LPEHR with mesh reinforcement had similar early (RR = 0.74, 95% CI = 0.26-2.07, P = 0.46) and late (RR = 0.75, 95% CI = 0.27-2.08, P = 0.48) recurrence rates as those with primary repair. Similar recurrence rates were also found when stratifying the analysis by the type of mesh utilized (absorbable and nonabsorbable). Intraoperative complications (RR = 1.03, 95% CI = 0.33-3.28, P = 0.92) and reoperation rates (RR = 0.75, 95% CI = 0.29-1.92, P = 0.45) were also similar in both groups. Overall morbidity, however, was higher after mesh repair with nonabsorbable mesh (RR = 1.45, 95% CI = 1.24-1.71, P < 0.01).

CONCLUSIONS

Patients undergoing LPEHR have similar early and late recurrence rates with either mesh reinforcement or suture only repair, regardless of the type of mesh utilized. Overall morbidity, however, seems to be higher in patients repaired with nonabsorbable mesh.

Management of the Crura During Laparoscopic Sleeve Gastrectomy

METHODS

This is a retrospective cohort study that evaluated patients undergoing LSG performed by a single surgeon in a 7-year period. Data were collected via chart review. The primary endpoint was hiatal hernia presence at 5 years post-operatively. Secondary endpoints included post-procedural complications (nausea, vomiting, dysphagia, or reflux) at 30 days post-operatively.

RESULTS

A total of 361 patients were included in the analysis: 154 without crural closure, 164 primary crural closure, and 43 primary crural closure with mesh reinforcement. Rates of hiatal hernia occurrence at 5 years were 9.7% (no closure), 14.0% (primary closure), and 16.3% (closure with mesh reinforcement), respectively, and did not differ significantly among the 3 cohorts (P = .37). Overall rates of 30-day complications were 11.5%, 21.5%, and 28.6%, respectively (P = .015).

CONCLUSION

Rates of hiatal hernia after sleeve gastrectomy do not differ, regardless of management of the crura. In addition, and perhaps more significantly, avoidance of crural closure was associated with fewer 30-day complications. In fact, the highest rate of 30-day complications was seen in the group that received closure with mesh reinforcement. These data suggest that crural closure during LSG should be avoided. Further prospective study of these findings is warranted.

Prosthetic Reinforcement in Hiatal Hernia Repair, Does Mesh Material Matter? A Systematic Review and Network Meta-Analysis

Background: Hiatal hernia repair (HHR) is a complex surgical procedure and its management is not standardized. Several meta-analyses have compared cruroplasty with hiatus reinforcement with mesh, and crura augmentation appears to have better outcomes. However, heterogeneity in type of mesh and placement techniques has differed significantly. Materials and Methods: A systematic review and network meta-analysis were carried out. An electronic systematic research was carried out throughout Pubmed, CENTRAL, and Web of Science, of articles analyzing HHR with cruroplasty, nonabsorbable mesh (NAM), and absorbable mesh (AM) reinforcement. Results: Seventeen articles based on 1857 patients were enrolled in this article. The point estimation showed that when compared against the control group (NAM), the HH recurrence risk in AM and cruroplasty group was higher (relative ratio [RR] 2.3; CrI 0.8-6.3, RR 3.6; CrI 2.0-8.3, respectively). Postoperative complication rates were alike in all groups. The prevalence of mesh erosion after HHR is low. Conclusions: This network meta-analysis showed that prosthetic reinforcement significantly reduced HH recurrence when compared with cruroplasty alone. However, there is not enough evidence to compare different mesh compositions.

Quality of life after giant hiatus hernia repair: A systematic review

BACKGROUND

Elective surgery is the treatment of choice for symptomatic giant hiatus hernia (GHH), and quality of life (QoL) has become an important outcome measure following surgery. The aim of this study is to review the literature assessing QoL following repair of GHH.

METHODOLOGY

A systematic literature search was performed by two reviewers independently to identify original studies evaluating QoL outcomes after GHH surgery. MeSH terms such as paraoesophageal; hiatus hernia; giant hiatus hernia and quality of life were used in the initial search. Original studies in English language using validated questionnaires on humans were included. Review articles, conference abstracts and case reports and studies with duplicate data were excluded.

RESULTS

Two hundred and eight articles were identified on initial search, of which 38 studies (4404 patients) were included. Studies showed a significant heterogeneity in QoL assessment tools, surgical techniques and follow-up methods. All studies assessing both pre-operative and post-operative QoL (n = 31) reported improved QoL on follow-up after surgical repair of GHH. Improvement in QoL following GHH repair was not affected by patient age, surgical technique or the use of mesh. Recurrence of GHH after surgery may, however, adversely impact QoL.

CONCLUSION

Surgical repair of GHH improved QoL scores in all the 38 studies. The impact of recurrence on QoL needs further assessment. The authors also recommend uniform reporting of surgical outcomes in future studies.

Narrative review of management controversies for paraesophageal hernia

Objective

To review management controversies in paraesophageal hernia and options for surgical repair.

Background

Paraesophageal hernia is an increasingly common problem. There are controversies over whether and when paraesophageal hernias should be surgically repaired. In addition, if these hernias are to be repaired, the method of repair, need for mesh reinforcement, need for fundoplication, and need for gastropexy are not uniformly accepted.

Methods

Recent literature was reviewed on need for repair, approach (open, laparoscopic or robotic surgery), method of repair (primary suture, use of relaxing incisions, use of mesh reinforcement), materials and configuration of mesh reinforcement, need and type of fundoplication, and need for gastropexy, with emphasis on surgical outcomes.

Conclusions

The extant literature suggests that paraesophageal hernia should be approached in a patient-centered, precision medicine manner. In general, hernia reduction, sac excision and primary suture approximation of the hiatal crura are mandatory. Use of mesh should be based on individual risk factors; if mesh is used, biological meshes appear to have a more favorable safety profile, with the “reverse C” or keyhole configuration allowing for increase in crural tensile strength at it most vulnerable areas. Use and choice of fundoplication or magnetic sphincter augmentation should be based on individual considerations. Finally, gastropexy is generally ineffective and should be used only in extreme circumstances.

Systematic review on reporting of components and outcomes in randomized clinical trials of paraoesophageal hernia mesh repair

BACKGROUND

Surgical interventions, such as paraoesophageal hernia (POH) repair, are complex with multiple components that require consideration in the reporting of clinical trials. Many aspects of POH repair, including mesh hiatal reinforcement and fundoplication type, are contentious. This review summarizes the reporting of components and outcomes in RCTs of POH repair.

METHODS

Systematic searches identified RCTs of POH repair published from 1995 to 2020. The patient selection criteria for RCT involvement were noted. The components of the surgical interventions in these RCTs were recorded using the CONSORT guidelines for non-pharmacological treatments, Template for Intervention Description and Replication (TIDieR) and Blencowe frameworks. The outcomes were summarized and definitions sought for critical variables, including recurrence.

RESULTS

Of 1918 abstracts and 21 screened full-text articles, 12 full papers reporting on six RCTs were included in the review. The patient selection criteria and definitions of POH between trials varied considerably. Although some description of trial interventions was provided in all RCTs, this varied in depth and detail. Four RCTs described efforts to standardize the trial intervention. Outcomes were reported inconsistently, were rarely defined fully, and overall trial conclusions varied during follow-up.

CONCLUSION

This lack of detail on the surgical intervention in POH repair RCTs prevents full understanding of what exact procedure was evaluated and how it should be delivered in clinical practice to gain the desired treatment effects. Improved focus on the definitions, descriptions and reporting of surgical interventions in POH repair is required for better future RCTs.

Decellularized xenografts in regenerative medicine: From processing to clinical application

Decellularized xenografts are an inherent component of regenerative medicine. Their preserved structure, mechanical integrity and biofunctional composition have well established them in reparative medicine for a diverse range of clinical indications. Nonetheless, their performance is highly influenced by their source (ie species, age, tissue) and processing (ie decellularization, crosslinking, sterilization and preservation), which govern their final characteristics and determine their success or failure for a specific clinical target. In this review, we provide an overview of the different sources and processing methods used in decellularized xenografts fabrication and discuss their effect on the clinical performance of commercially available decellularized xenografts.

Does composite repair of giant paraoesophageal hernia improve patient outcomes?

BACKGROUND

Paraoesophageal hernia (PEH) is often symptomatic and reduces patients' quality of life (QoL). There is ongoing debate regarding the most effective surgical technique to repair giant PEH. This study aimed to see if an elective laparoscopic non-mesh composite technique of giant PEH repair offered an advantage in symptom control, hernia recurrence, QoL, morbidity and mortality.

METHODS

Data were extracted from a prospectively maintained database of patients undergoing hiatal hernia repair. Composite hernia repairs from inception for giant PEH between March 2009 and December 2015 were included. Perioperative mortality, complications, hernia recurrence rates, prevalence, recurrence of symptoms and QoL were included in analysis.

RESULTS

Inclusion criteria were met by 218 patients. Mean age was 70 (49-93). The average hernia size was 62% (range 30-100%; SD 21). There was one perioperative death and three significant complications (Clavien-Dindo grade III and IV). Recurrence rate was 24.8%. Without recurrence, QoL improved significantly across all domains. Recurrence of hiatus hernia reduced QoL. Surgery resulted in resolution of symptoms other than dysphagia which was incompletely improved. Patients' overall satisfaction with surgery was high.

CONCLUSION

Composite repair of giant PEH is safe with overall good outcomes. Majority of hernia recurrence are small and asymptomatic. Hernia recurrence negatively affected long-term QoL scores.

Paraesophageal Hernia: To Mesh or Not to Mesh? The Controversy Continues

Introduction: Paraesophageal hernias represent 5%-10% of all primary hiatal hernias and are becoming increasingly more common with the aging of the population. Surgical treatment includes closure of the wide hiatal gap. Achieving tension-free closure is difficult, and several studies have reported lower recurrence rates with the use of mesh reinforcement. The use of this technique, however, is controversial. Objective and Materials and Methods: Narrative revision of the literature revising: (1) evidence-based surgery and clinical studies, (2) what the experts say (Delphi), (3) complications of mesh, and (4) long-term results of laparoscopic treatment impact on the quality of life. Results: Consensus about the type of mesh continues to be elusive, and we clearly need a higher level of evidence to address the controversy. Conclusion: Mesh reinforcement can effectively reduce the hernia recurrence rate. Mesh-associated complications are few, but because they are serious, most experts recommend mesh use only in specific circumstances, particularly those in relation to the size of the hiatal defect and the quality of the crura.

Assessment of short-term outcome with TiO2 mesh in laparoscopic repair of large paraesophageal hiatal hernias

Background

Laparoscopic large para-oesophageal hiatal hernia (LPHH) repair using mesh reinforcement significantly reduces postoperative recurrence rates compared to conventional suture repair, especially within short follow-up times. However, the ideal strategy for repairing LPHH remains disputable because no clear guidelines are given regarding indications, mesh type, shape or position. The aim of this study was to survey our short-term results of LPHH management with a biosynthetic monofilament polypropylene mesh coated with titanium dioxide to enhance biocompatibility (TiO₂Mesh™).

Methods

A retrospective study was performed at Ramon y Cajal University Hospital, Spain from December 2014 to October 2018. Data were collected on 27 consecutive patients with extensive hiatal hernia defects greater than 5 cm for which a laparoscopic repair was performed by primary suture and additional reinforcement with a TiO₂Mesh™. Study outcomes were investigated, including clinical and radiological recurrences, dysphagia and mesh-related drawbacks.

Results

Twenty-seven patients were included in our analysis; 10 patients were male, and 17 were female. The mean age was 73 years (range, 63–79 years). All operations were performed laparoscopically. The median postoperative hospital stay was 3 days. After a mean follow-up of 18 months (range, 8-29 months), only 3 patients developed clinical recurrence of reflux symptoms (11%), and 2 had radiological recurrences (7%). No mesh-related complications occurred.

Conclusions

TiO₂Mesh™ was found to be safe for laparoscopic repair of LPHH with a fairly low recurrence rate in this short-term study. Long-term studies conducted over a period of years with large sample sizes will be essential for confirming whether this mesh is suitable as a standard method of care with few drawbacks.

Use of absorbable meshes in laparoscopic paraesophageal hernia repair

Paraesophageal hernia (PEH) repair is one of the most challenging upper gastrointestinal operations. Its high rate of recurrence is due mostly to the low quality of the crura and size of the hiatal defect. In an attempt to diminish the recurrence rates, some clinical investigators have begun performing mesh-reinforced cruroplasty with nonabsorbable meshes like polypropylene or polytetrafluoroethylene. The main problem with these materials is the occurrence, in some patients, of serious mesh-related morbidities, such as erosions into the stomach and the esophagus, some of which necessitate subsequent esophagectomy or gastrectomy. Absorbable meshes can be synthetic or biological and were introduced in recent years for PEH repair with the intent of diminishing the recurrence rates observed after primary repair alone but, theoretically, without the risks of morbidities presented by the nonabsorbable meshes. The current role of absorbable meshes in PEH repair is still under debate, since there are few data regarding their long-term efficacy, particularly in terms of recurrence rates, morbidity, need for revision, and quality of life. In this opinion review, we analyze all the presently available evidence of reinforced cruroplasty for PEH repair using nonabsorbable meshes (synthetic or biological), focusing particularly on recurrence rates, mesh-related morbidity, and long-term quality of life.

Delayed Gastric Emptying Following Laparoscopic Repair of Very Large Hiatus Hernias Impairs Quality of Life

BACKGROUND

Delayed gastric emptying (DGE) following hiatus hernia surgery may affect a substantial number of patients with adverse clinical consequences. Here, we aim to evaluate the impact of DGE following laparoscopic repair of very large hiatus hernias on patients' quality of life, gastrointestinal symptomatology, and daily function.

METHODS

Analysis of data collected from a multicenter prospective randomised trial of patients who underwent laparoscopic mesh versus sutured repair of very large hiatus hernias (>50% of stomach in chest). DGE was defined as gastric food retention visualised at endoscopy after 6 h of fasting at 6 months post-surgery. Quality of life (QOL), gastrointestinal symptomatology, and daily function were assessed with the SF-36 questionnaire, Visick scoring and structured surveys administered prior to surgery and at 1, 3, 6 and 12 months after surgery.

RESULTS

Nineteen of 102 (18.6%) patients had DGE 6 months after surgery. QOL questionnaires were completed in at least 80% of patients across all time points. Compared with controls, the DGE group demonstrated significantly lower SF-36 physical component scores, delayed improvement in health transition, more adverse gastrointestinal symptoms, higher Visick scores and a slower rate of return to normal daily activities. These differences were still present 12 months after surgery.

CONCLUSIONS

DGE following large hiatus hernia repair is associated with a negative impact on quality of life at follow-up to 12 months after surgery.

Treatment of paraesophageal hiatal hernia in octogenarians: a systematic review and retrospective cohort study

Over the coming years octogenarians will make up an increasingly large proportion of the population. With the rise in octogenarians more paraesophageal hiatal hernias may be identified. In research for the optimal treatment for paraesophageal hiatal hernias, octogenarians are often omitted and the optimal surgical strategy for this patient group remains unclear. A systematic search in PubMed, Embase, and The Cochrane Library was conducted, including articles compromising 'surgery,' 'paraesophageal hiatal hernia,' and 'octogenarians.' Selection of articles was based on independent review by two authors. Alongside, a retrospective cohort study was conducted including all type II-IV hiatal hernia repairs performed in the VU Medical Center in Amsterdam, The Netherlands, from 2005 to 2015. A total of 486 papers were eligible for selection. After careful selection, a total of eight articles were included. All articles were retrospective cohort studies describing different proportions of octogenarians. The populations and surgical techniques were very heterogeneous. Elective paraesophageal hiatal hernia repair was performed safely in symptomatic octogenarians in all studies. Additional analysis of 84 patients, of which 9.5% octogenarians, was performed at our tertiary referral center. A larger hernia type, more acute interventions and a higher morbidity and mortality rate was observed in octogenarians compared to patients aged <80 years. In conclusion, elective paraesophageal hiatal hernia repair can be performed in octogenarians, especially in patients without comorbidity. Findings suggest improvement in symptoms in short-term follow up, with minimal morbidity and mortality. With regard to surgical techniques, laparoscopy and fundoplication were performed safely. Octogenarians need to be included in future clinical trials to further evaluate the optimal surgical intervention. Preoperative risk assessment by clinical prediction rules should guide operative intervention, in order to evaluate risks and benefits in this challenging population.

Primary paraesophageal hernia repair with Gore® Bio-A® tissue reinforcement: long-term outcomes and association of BMI and recurrence

BACKGROUND

Laparoscopic repair remains the gold-standard treatment for paraesophageal hernia (PEH). We analyzed long-term symptomatic outcomes and surgical reintervention rates after primary PEH repair with onlay synthetic bioabsorbable mesh (W. L. Gore & Associates, Inc., Flagstaff, AZ) and examined body mass index (BMI) as a possible risk factor for poor outcomes and for recurrence.

METHODS

We queried a prospectively maintained database to identify patients who underwent laparoscopic primary PEH repair with onlay patch of a bioprosthetic absorbable mesh (Bio-A® Gore®) between 05/28/2009 and 12/31/2013. Electronic health records were accessed to record demographic and operative data and were reviewed up to the present to identify any repeat procedures. Patients were grouped according to preoperative BMI (A: BMI < 25; B: BMI = 25-29.9; C: BMI = 30-34.9; D: BMI ≥ 35). Patients completed standardized satisfaction and symptom surveys.

RESULTS

In total, 399 patients were included. Most patients (n = 261; 65.4%) were women. Mean age was 59.6 ± 13.4 years; mean BMI was 29.9 ± 5.0 kg/m². The patients were grouped as follows: A, 53 patients (13.3%); B, 166 (41.6%); C, 115 (28.8%); D: 65 (16.3%). Four procedures (1.0%) were converted from laparoscopy to open procedures. All patients underwent an antireflux procedure (225 Nissen, 170 Toupet, 4 Dor). A mean follow-up of 44.7 ± 22.8 months was available for 305 patients (76.4%). 24/305 patients (7.9%) underwent reoperation, and the number of reoperations did not differ among groups (P = 0.64). Long-term symptomatic outcomes were available for 217/305 patients (71.1%) at a mean follow-up of 54.0 ± 13.1  months; no significant difference was observed among groups. 194/217 patients (89.4%) reported good to excellent satisfaction, with no significant differences among the groups.

CONCLUSIONS

Laparoscopic primary PEH repair with onlay Bio-A® mesh is a safe and feasible procedure with excellent long-term patient-centered outcomes and acceptable symptomatic recurrence rate. BMI does not appear to be related to the need for surgical reintervention.

Thinking About Hiatal Hernia Recurrence After Laparoscopic Repair: When Should It Be Considered a True Recurrence? A Different Point of View

Background:

High rates of recurrence after laparoscopic hiatal hernia repair have been published. Most of these recurrences are asymptomatic and only diagnosed by endoscopic or radiologic studies. The definition of hiatal hernia recurrence is still under discussion.

Objective:

This study aimed to define a true hiatal hernia recurrence using a score and classification criteria considering the presence of symptoms and size of the recurrence.

Patients and Methods:

A total of 153 patients with giant hiatal hernia larger than 10 cm in diameter underwent an operation using a laparoscopic approach. Of these patients, 129 had a complete follow-up (3–5 years) after surgery, and they were the only ones included in this study. The IT system of our hospital was our database for data registration. A score and classification were designed for definition of a “true” hiatal hernia recurrence, based on postoperative symptoms and the presence or not of a hiatal hernia in both radiologic and endoscopic evaluations.

Results:

Hiatal hernia recurrence based on endoscopic and/or radiologic hiatal hernia was found in 55 patients (42.6%), and only 28 of them (50.9%) had recurrent symptoms. Applying the score and proposed classification, no recurrence was considered in 18 patients (13.9%). Symptomatic and true recurrence were considered in 22.9% of patients (29 patients). Reoperation was needed for 7 patients (5.4%) because of symptomatic and radiologic recurrence.

Conclusions:

Postoperative symptoms, endoscopic findings, or radiologic findings are important for the definition of the type of recurrence and for the indication of appropriate treatment. The proposed score and classification are useful in order to specify the hiatal hernia recurrence and treatment.

Risk factors for delayed gastric emptying following laparoscopic repair of very large hiatus hernias

Background

Delayed gastric emptying can complicate surgery for hiatus hernia. The aim of this study was to quantify its incidence following laparoscopic repair of very large hiatus hernias, identify key risk factors for its occurrence and determine its impact on clinical outcomes.

Methods

Data collected from a randomized trial of patients who underwent laparoscopic mesh versus sutured repair of very large hiatus hernias (more than 50 per cent of stomach in chest) were analysed retrospectively. Delayed gastric emptying was defined as endoscopic evidence of solid food in the stomach after fasting for 6 h at 6 months after surgery.

Results

Delayed gastric emptying occurred in 19 of 102 patients (18·6 per cent). In univariable analysis, type 2 paraoesophageal hernia (relative risk (RR) 3·15, 95 per cent c.i. 1·41 to 7·06), concurrent anterior and posterior hiatal repair (RR 2·66, 1·14 to 6·18), hernia sac excision (RR 4·85, 1·65 to 14·24), 270°/360° fundoplication (RR 3·64, 1·72 to 7·68), division of short gastric vessels (RR 6·82, 2·12 to 21·90) and revisional surgery (RR 3·69, 1·73 to 7·87) correlated with delayed gastric emptying. In multivariable analysis, division of short gastric vessels (RR 6·27, 1·85 to 21·26) and revisional surgery (RR 6·19, 1·32 to 28·96) were independently associated with delayed gastric emptying. Delayed gastric emptying correlated with adverse gastrointestinal symptomatology, including higher rates of bloating, nausea, vomiting and anorexia, as well as reduced patient satisfaction with the operation and recovery.

Conclusion

Delayed gastric emptying following large hiatus hernia repair is common and associated with adverse symptoms and reduced patient satisfaction. Division of short gastric vessels and revisional surgery were independently associated with its occurrence.

Systematic review and meta-analysis of laparoscopic mesh versus suture repair of hiatus hernia: objective and subjective outcomes

Background

Hiatus hernia (HH) contributes to the pathophysiology of gastroesophageal reflux disease (GERD). Mesh-augmentation of surgical repair might be associated with a reduced risk of recurrence and GERD. However, recurrence rates, mesh-associated complications and quality of life (QOL) after mesh versus suture repair are debated. The aim of this meta-analysis was to determine HH recurrence following mesh-augmentation versus suture repair. Secondary aims were to compare complications, mortality, QOL and GERD symptoms following different repair techniques.

Methods

A systematic literature search of the PubMed, Medline, Embase, Cochrane Library, and Springer database was performed to identify relevant studies comparing mesh-augmentation versus suture repair of the esophageal hiatus. Data pertinent to the benefit versus risk outcomes for these techniques were extracted and compared by meta-analysis. The odd ratio (OR) and mean differences (MD) with 95% confidence intervals were calculated.

Results

Eleven studies (4 randomized, 9 non-randomized) comparing mesh (n = 719) versus suture (n = 755) repair were identified. Mesh-augmentation was associated with a reduced overall recurrence rate compared to suture repair [2.6 vs. 9.4%, OR 0.23 (95% CI 0.14–0.39), P < 0.00001]. There was no significant difference in the incidence of complications (P = 0.400) between groups. Improvement in QOL measured by SF-36 was greater following biological mesh-augmentation compared to suture repair (MD = 13.68, 95% CI 2.51–24.85, P = 0.020), as well as GERD-HRQL. No differences were seen for the GIQLI scores with permanent mesh (P = 0.530). Dysphagia improvements were better following suture repair (MD = 1.47, 95% CI 0.20–2.74, P = 0.020).

Conclusions

Mesh repair of HH conferred some advantages and disadvantages at short-term follow-up. Compared to a suture repair alone, mesh-augmentation might be associated with less short-term recurrences, and biological mesh was associated with improved short-term QOL. However, these advantages were offset by more dysphagia. Long-term outcomes are still needed to determine the place of mesh repair of HH.

Crura augmentation with Bio-A® mesh for laparoscopic repair of hiatal hernia: single-institution experience with 100 consecutive patients

BACKGROUND

The potential utility of both non-absorbable and absorbable meshes to reinforce the esophageal hiatus and prevent recurrent hernia has been investigated in observational studies and a few randomized clinical trials. Use of absorbable mesh has been associated with lesser side-effects, but the long-term safety and effectiveness are still debated. This rather scanty clinical evidence is due to heterogeneity and bias regarding the type of mesh and operation used, the modalities of follow-up, and the reporting of objective results.

OBJECTIVES

The aim of the study was to assess safety, quality of life, and recurrence-free probability after laparoscopic repair of hiatal hernia reinforced with a synthetic absorbable mesh.

METHODS

Observational, retrospective, single-center cohort study. All patients with hiatal hernia who underwent laparoscopic crura repair using a biosynthetic mesh (Gore Bio A^® tissue reinforcement, Flagstaff, AZ) were included. Pre- and post-operative symptoms were assessed with the GERD-HRQL questionnaire. Objective follow-up consisted of upper gastrointestinal endoscopy and barium swallow study.

RESULTS

From September 2011 to March 2016, a total of 100 patients underwent hiatal hernia repair using a Bio-A^® mesh. All surgical procedures were completed laparoscopically. Postoperative morbidity rate was 10%. All patients had a minimum follow-up of 6 months, and the median follow-up was 30 (IQR = 22) months. No mesh-related complications occurred. The incidence of recurrent hernia ≥2 cm was 9%, and eight of the nine patients had a preoperative type III hernia. The median GERD-HRQL score was significantly reduced after operation (p < 0.001). The recurrence-free probability at 1 and 5 years was, respectively, 0.99 (CI 0.97-1.00) and 0.84 (CI 0.74-0.97), and no reoperation was required. No association was found between age, BMI, hernia size, previously failed surgical repairs and hernia recurrence.

CONCLUSIONS

The use of a synthetic absorbable mesh to reinforce the esophageal hiatus is safe and appears to be effective and durable over a medium-term follow-up.

Laparoscopic management of large hiatus hernia: five-year cohort study and comparison of mesh-augmented versus standard crura repair

OBJECTIVES

To evaluate objective and subjective outcomes of patients undergoing laparoscopic repair of large hiatal hernia, either with or without resorbable mesh augmentation. The primary outcome of the study was anatomical recurrence rate as measured by endoscopy. Secondary outcomes were safety, efficacy, and long-term quality of life.

METHODS

This was an observational cohort study. Patients who underwent laparoscopic repair of large (≥5 cm) type III hiatal hernia were included. Criteria of exclusion were previously failed hiatus hernia repair and emergency procedures. Patients were stratified into mesh group (mesh-augmented crura repair plus fundoplication) and non-mesh group (standard crura repair plus fundoplication). Preoperative and postoperative symptoms were assessed using the GERD-HRQL questionnaire. Upper gastrointestinal endoscopy was routinely performed between 6 and 12 months postoperatively and was repeated over the follow-up every 1-2 years or as needed. Anatomical hernia recurrence was defined as the maximum vertical length of stomach being at least 2 cm above the diaphragm.

RESULTS

A total of 84 patients, 41 in the mesh group and 43 in the non-mesh group, operated between October 2009 and October 2014, were included in the study. All surgical procedures were completed laparoscopically. The median follow-up was 24 (IQR 29) months. There were 12 endoscopic recurrences, 4 in the mesh group and 8 in the non-mesh group. The five-year recurrence-free probability was similar in the two groups, but an earlier failure rate was noted in the non-mesh group at 12 months (p = 0.299). Three of the 12 patients with anatomical recurrence were symptomatic but did not require a reoperation. Univariate Cox proportional hazard analysis indicated that Toupet fundoplication may reduce the recurrence rate compared to Nissen fundoplication. No mesh-related complications occurred.

CONCLUSIONS

Laparoscopic repair of large hiatal hernia is effective and durable. Crura reinforcement with a resorbable synthetic mesh is safe and may protect from early anatomical recurrence.

[Report of 12 years experience in the surgical treatment of 286 paraesophageal hernias]

BACKGROUND

In contrast to axial hiatus hernias, paraesophageal hernias are rare but can lead to chronic iron deficiency anemia and severe acute complications. Treatment is manifold and consistent standards are lacking.

OBJECTIVES

The aim of this study was to describe our experiences of 286 patients with paraesophageal hernias, who underwent surgery from 2003 to 2014 at a tertiary referral center. The study was particularly concerned with morbidity, mortality, quality of life and recurrence rates.

MATERIAL AND METHODS

In 12 years a total of 286 paraesophageal hernias were surgically treated, 255 with a minimally invasive procedure and 31 with an open approach. In 138 patients (48 %) the suture-based hiatoplasty was reinforced by means of a lightweight mesh, which was fixed with fibrin glue in 90 cases. Abdominal fixation of the stomach consisted of a gastropexy and anterior (n = 244) or posterior (n = 42) fundoplication.

RESULTS

Complications arose in 8.4 % of the patients. The mean hospital stay was 5.3 (± 2.8) days for elective surgery and 24.7 (± 17.8) days for emergency operations. The gastrointestinal quality of life index according to Eypasch significantly increased from mean preoperative values of 92.8 (± 22.5) to 109.6 (± 20.2) in the postoperative course (p < 0.001). Of the patients 20 (7 %) suffered a recurrence requiring surgery, including 7 early and 13 late recurrences. During the immediate postoperative period radiographically detected recurrences were promptly revised. The strategy of late recurrences in the long-term course was based on patient symptoms and asymptomatic hernias were treated conservatively while symptomatic hernias were surgically treated. Symptomatic late recurrences developed in 4.6 % of the patients, including 7.4 % (11 out of 148) without and 1.4 % (2 out of 138) with primary mesh repair.

CONCLUSION

The repair of paraesophageal hernias in 286 patients provided excellent patient satisfaction and symptom improvement with low perioperative morbidity and mortality. Mesh reinforcement reduced the recurrence rate. The quality of life index is a suitable clinical course parameter for evaluation of paraesophageal hernias.