Mesh migration into the esophageal wall after mesh hiatoplasty: comparison of two alloplastic materials

[Surgical strategy for hiatal hernias]

The indications for surgical treatment of hiatus hernias differentiate between type I and types II, III and IV hernias. The indications for a type I hernia should include a proven reflux disease but the indications for surgical treatment of types II, III and IV hernias are mandatory due to the symptoms with problems in the passage of food and due to the sometimes very severe possible complications. The primary aims of surgery are the repositioning of the herniated contents and a hiatoplasty, which includes a surgical narrowing of the esophageal hiatus by suture implantation. In addition, depending on the clinical situation other procedures, such as hernia sac removal, mesh implantation, gastropexy and fundoplication can be considered. There are various approaches to the repair, all of which have individual advantages and disadvantages. An adaptation to the specific needs situation of the patient and the expertise of the surgeon is therefore essential.

Complications, caused by application of the net implants in the hiatal hernias plasty

Objective. Studying of complications, connected with application of the net implants in patients with large hiatal hernias. Materials and methods. Retrospective investigation was conducted with objective to study complications, connected with application of the net implants in patients with large hiatal hernias, operated in the clinic during period from 2008 to 2018 yr. Of 1168 patients operated on and suffering gastro-esophageal reflux disease as well as hiatal hernias, 817 have had large hernias. In 353 patients with large hernias for strengthening of cruroraphy sutures the net implants were applied. There were used low-weighted implant-net Ultrapro, the composite net Parietex, self-fixating surgical net ProGrip, absorbable net Vicryl, polytetrafluoroethylene net with nitinol carcass, biological net Bio-A. All the patients symptoms were registered, and the quality of life studied. Results. Complications, caused by the net implants impact, were revealed in 17 (1.5%) patients. In all 17 patients the esophageal structuring have occurred due to pronounced cicatrization in region of the net implant installation. In 6 patients dysphagia due to the net ingrowth into esophageal tissue was observed, and in 2 – chronic inflammatory process in place of the net installation. One patient have had small esophageal perforation with restricted mediastinitis. In 3 patients, in whom the polytetrafluoroethylene nets were installed, their migration into esophageal lumen was revealed. Reoperations were done in all 17 patients. In 7 patients the net was removed completely. In 1 patient the net was removed and mediastinum drained. In 3 patients, in whom polytetrafluoroethylene nets have migrated into esophageal lumen, they were removed endoscopically with further installation of special stents. Results of reoperations were estimated as good in 15 patients. In 2 patients after reoperations dysphagia was observed, which needed a second time balloon dilatation and installation of stent in 1 of them. Conclusion. Nonabsorbable nets ought to be applied with high technical accuracy, it is necessary to prevent their contact with the esophagus. Application of the polytetrafluoroethylene nets with nitinol carcass for plasty of large hiatal hernias must be forbidden.

Mesh-related complications in paraoesophageal repair: a systematic review

BACKGROUND

Paraoesophageal hernias (PEH) have a high recurrence rate, prompting surgeons to consider the use of mesh reinforcement of the hiatus. The risks and benefits of mesh augmentation in PEH repair are debated. Mesh-related complications including migration and erosion are considered in this publication.

DESIGN

A systematic literature review of articles published between 1970 and 2019 in Medline, OVID, Embase, and Springer database was conducted, identifying case reports, case series and observational studies of PEH repair reporting mesh-related complications.

RESULTS

Thirty-five case reports/series of 74 patients and 20 observational studies reporting 75 of 4200 patients with mesh complications have been included. The incidence of mesh-related erosions in this study is 0.035%. PTFE, ePTFE, composite and synthetic meshes were frequently associated with mesh erosion requiring intervention. Complete erosions are often managed endoscopically while partial erosions may require surgery and resection of the oesophagus and/or stomach.

CONCLUSIONS

Mesh-related complication is rare with dysphagia a common presenting feature. Mesh erosion is associated with synthetic mesh more frequently in the reported literature. A mesh registry with long-term longitudinal data would help in understanding the true incidence of mesh-related complications.

Case of complete mesh migration into the stomach after mesh hiatoplasty for a hiatal hernia

Mesh migration is a rare complication of surgery for a hiatal hernia. Here, we present the case of a 72-year-old who complained of dysphasia and bodyweight loss. Upper gastrointestinal endoscopy revealed incarcerated mesh in the lumen of the esophagogastric junction. Surgery was performed under both endoscopy and laparoscopy, and the mesh was successfully removed via gastrostomy. To the best of our knowledge, our case is the first in which mesh that had migrated into the esophagogastric junction was removed by a combination of laparoscopic and endoscopic procedure, although the cases of 17 patients in which mesh migrated into the stomach after mesh hiatoplasty have previously been reported in the literature.

Biologic Keyhole Mesh in Hiatal Hernia Repair

Background and Objectives

Laparoscopic paraesophageal hernia repair (LPEHR) is the new standard, but the use of mesh is still debated. Biologic mesh has shown great promise, but only the U-shaped onlay has been extensively studied. Postoperative dysphagia has historically been a concern with the use of synthetic keyhole mesh and subsequently slowed its adoption. The purpose of our study was to identify the incidence of postoperative dysphagia in a series of patients who underwent laparoscopic paraesophageal hernia repair with novel placement of keyhole biologic mesh.

Methods

Thirty consecutive patients who underwent hernia repair with primary suture cruroplasty and human acellular dermal matrix keyhole mesh reinforcement were reviewed over a 2-year period. All procedures were performed at a single institution. Postoperative symptoms were retrospectively identified. Any postoperative hernia on imaging was defined as radiographic recurrence.

Results

Of the 30 consecutive patients who underwent hernia repair, 3 (10%) had mild preoperative dysphagia. The number remained unchanged after LPEHR with keyhole mesh. Return of mild reflux symptoms occurred in 6 (20%) patients. Repeat imaging was performed in 11 patients (37%) at an average of 8 months with 2 slight recurrences. All hernias were classified on preoperative imaging as large hiatal hernias. There were no postoperative complications.

Conclusion

Laparoscopic paraesophageal hernia repair with biologic keyhole mesh reinforcement has a low recurrence rate and no increase in postoperative dysphagia. The traditional belief that keyhole mesh has a higher incidence of dysphagia was not evident in this series.

International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Late esophageal wall injury after mesh repair for large esophageal hiatal hernia: a case report

Background

Plication of an esophageal hiatus during surgery for esophageal hiatal hernia is a common practice; however, a mesh may be used if the hiatus is markedly enlarged. Recently, various late complications occurring as a result of mesh-induced esophageal and/or gastric wall injuries have been reported.

Case presentation

A 71-year-old woman presented at a neighborhood clinic in November 2010 with chief complaints of respiratory distress on exertion and heartburn. She was diagnosed as having a large esophageal hiatal hernia and was treated at our hospital using a laparoscopic Toupet fundoplication with mesh repair of the esophageal hiatus. Two years and 1 month after the operation, the patient complained of a bowel obstruction. An upper gastrointestinal endoscopy revealed that part of the mesh had extruded into the esophageal lumen, resulting in ulceration and stricture of the esophageal wall. Endoscopic balloon dilatation failed to improve the esophageal stricture. In July 2012, the patient underwent a lower esophagectomy with proximal gastrectomy and was discharged on the 25th hospital day.

Conclusions

We experienced a rare case requiring surgical treatment for a mesh-induced esophageal wall injury after surgery for a giant esophageal hiatal hernia. The selection of a soft, durable mash and its firm securement at a position distant from the gastrointestinal wall may be important to avoid late esophageal wall injury.

From intraperitoneal onlay mesh repair to preperitoneal onlay mesh repair

Laparoscopic repair for ventral and incisional hernias was first reported in the early 1990s. It uses intraperitoneal only mesh placement to achieve a tension-free repair of the hernia. However, in recent years, there has been greater concern about long-term complication involving intraperitoneal mesh placement. Many case reports and case series have found evidence of mesh adhesion, mesh fistulation, and mesh migration into hollow organs including the esophagus, small bowel, and large bowel, resulting in various major acute abdominal events. Subsequent management of these complications may require major surgery that is technically demanding and difficult; in such cases, laparotomy and bowel resection have often been performed. Because of these significant, but not common, adverse events, many surgeons favor open sublay repair for ventral and incisional hernias. Investigators are therefore searching for a laparoscopic approach for ventral and incisional hernias that might overcome the mesh-induced visceral complications seen after intraperitoneal only mesh placement repair. Laparoscopic preperitoneal onlay mesh is one such approach. This article will explore the fundamental of intraperitoneal only mesh placement and its problems, the currently available peritoneal visceral-compatible meshes, and upcoming developments in laparoscopic ventral and incisional hernia repair. The technical details of preperitoneal onlay mesh, as well as its potential advantages and disadvantages, will also be discussed.

Urinary bladder matrix scaffolds strengthen esophageal hiatus repair

BACKGROUND

Laparoscopic repair of the hiatal hernia is associated with a recurrence rate between 12% and 42% depending on the defect size. Although the impact of hiatal reinforcement on long-term recurrence remains controversial, the main limitation of this approach has been the risk of adverse events related with the use of synthetic materials in the vicinity of the esophagus.

METHODS

A total of 14 female domestic pigs underwent laparoscopic primary hiatal hernia repair of a simulated defect in the esophageal hiatus. Seven of the hiatal repairs were reinforced with an extracellular matrix (ECM) scaffold, whereas the remaining seven served as primary repair controls. Animals were survived for 8 wk. At necropsy, after gross morphologic evaluation, samples were sent for mechanical testing and histology.

RESULTS

The repaired defect site reinforced with ECM scaffolds showed a robust closure of the crura in all cases with a smooth peritoneal-like structure covering the entire repair. Average load at failure of the treated group was found to be significantly stronger than that of the controls (185.8 ± 149.7 g versus 57.5 ± 57.5 g, P < 0.05). Similarly, the stiffness was significantly higher in the treated animals (57.5 ± 26.9 g/mm versus 19.1 ± 17.5 g/mm; P < 0.01). Interestingly, there was no difference in elongation at failure (7.62 ± 2.02 mm versus 7.87 ± 3.28 mm; P = 0.44).

CONCLUSIONS

In our animal survival model, we have provided evidence that the addition of an ECM to augment a primary hiatal repair leads to tissue characteristics that may decrease the possibility of early failure of the repair. This may translate to decreased recurrence rates. Further study is necessary.

Outcome for Asymptomatic Recurrence Following Laparoscopic Repair of Very Large Hiatus Hernia

BACKGROUND

Radiological follow-up following repair of large hiatus hernias have identified recurrence rates of 20-30%, although most are small and asymptomatic. Whether patients will eventually develop clinical problems is uncertain. This study evaluated the outcome for individuals identified with an asymptomatic hiatus hernia following previous repair vs. asymptomatic controls.

METHODS

One hundred fifteen asymptomatic patients who had previously undergone sutured repair of a large hiatus hernia and then underwent barium meal X-ray 6-60 months after surgery within a clinical trial were identified and divided into two cohorts: with (n = 41) vs. without (n = 74) an asymptomatic hernia. Heartburn, dysphagia, and satisfaction with surgery were assessed prospectively using a standardized questionnaire applying analogue scales. Consumption of antisecretory medication and revision surgery were also determined. To determine the natural history of asymptomatic recurrent hiatus hernia, outcomes for the two groups were compared at 1 and 5 years and at most recent (late) follow-up.

RESULTS

Outcomes were available at 1 year for 98.2% and 5 years or the latest follow-up (range 6-237 months) for 100%. Heartburn and dysphagia scores were low and satisfaction scores high in both groups at all follow-up points, but heartburn scores and medication use were higher in the recurrent hernia group. At late follow-up, 94.6% of the recurrent hernia group vs. 98.5% without a hernia regarded their original decision for surgery to be correct. Two patients in recurrent hernia group underwent revision surgery.

CONCLUSIONS

Patients with an initially asymptomatic recurrent hiatus hernia are more likely to report heartburn and use antisecretory medication at later follow-up than controls. However, overall clinical outcomes remain good, with high satisfaction and low surgical revision rates. Additional interventions to reduce the risk of recurrence might not be warranted.

Polypropylene, polyester or polytetrafluoroethylene-is there an ideal material for mesh augmentation at the esophageal hiatus? Results from an experimental study in a porcine model

PURPOSE

Knowledge about the influence of underlying biomaterial on behavior of surgical meshes at the esophageal hiatus is rare, but essential for safe and effective hiatal hernia surgery. This study aimed to characterize the influence of polymer material on mesh behavior at the hiatus.

METHODS

24 pigs in three groups of eight underwent implantation of either polypropylene (PP), polyester (PET) or polytetrafluoroethylene (PTFE) mesh placed circularly at the esophageal hiatus. After 8 weeks, necropsy and measurements were performed evaluating mesh deformation, adhesion formation, fixation of the esophagogastric junction and mesh position. Foreign body reaction was assessed by mononuclear cell count and immunostaining of Ki-67. Tissue integration was evaluated by immunostaining of type I and type III collagen fibers.

RESULTS

Mesh shrinkage was the highest for PTFE, lower for PP and the lowest for PET (34.9 vs. 19.8 vs. 12.1 %; p = 0.002). Mesh aperture for the esophagus showed an enlargement within all groups, which was highest for PTFE compared to PP and PET (100.8 vs. 47.0 vs. 35.9 %; p = 0.001). The adhesion score was highest for PP, lower for PTFE and the lowest for PET (11.0 vs. 9.5 vs. 5.0; p = 0.001) and correlated positively with the score of esophagogastric fixation (r s = 0.784, p < 0.001). No mesh migration, erosion or stenosis of the esophagus occurred. Evaluation of foreign body reaction and tissue integration showed no significant differences.

CONCLUSIONS

In this experimental setting, PP-meshes showed the most appropriate characteristics for augmentation at the hiatus. Due to solid fixation of the esophagogastric junction and low shrinkage tendency, PP-meshes may be effective in preventing hiatal hernia recurrence. The use of PTFE-mesh at the hiatus may be disadvantageous due to high shrinkage rates and correlating enlargement of the aperture for the esophagus.

Influence of weight and structure on biological behavior of polypropylene mesh prostheses placed at the esophageal hiatus

BACKGROUND

Experimental knowledge about mesh behavior at the esophageal hiatus is rare, but such information is essential in order to find a safe and effective method of mesh reinforcement. This study aimed to investigate the influence of mesh structure on the biological behavior of polypropylene prostheses placed at the hiatus.

MATERIALS AND METHODS

Twenty-four pigs in three groups of eight underwent implantation of heavyweight small-porous (HW-SP), heavyweight large-porous (HW-LP), or lightweight large-porous (LW-LP) circular polypropylene mesh at the hiatus. Eight weeks later, the meshes were explanted. Macroscopic analysis was performed evaluating mesh deformation, adhesions, and position relative to the hiatal margin. Histological analysis comprised evaluation of foreign body reaction and tissue integration by mononuclear cell count and immunostaining of Ki-67, collagen type I, and collagen type III.

RESULTS

No mesh-related complications occurred. Mesh shrinkage was observed within all groups and was the lowest for HW-LP, higher for HW-SP, and highest for LW-LP (13.8% versus 19.5% versus 25.5%; P<.001). The adhesion score was highest for HW-SP, lower for HW-LP, and lowest for LW-LP (11.0 versus 8.0 versus 6.0; P<.001). The collagen type I/III ratio was higher for HW-SP compared with HW-LP and LW-LP (3.1 versus 2.2 versus 1.8; P=.014).

CONCLUSIONS

Heavyweight polypropylene meshes may be advantageous for application at the hiatus. They provide a solid fixation of the esophagogastric junction by adhesions, which may contribute to a reduction of hernia recurrence. In heavyweight meshes, the large-porous structure is associated with superior form stability, and small-porous meshes are superior with regard to solidity of tissue integration, which may prevent mesh migration.

Laparoscopic Nissen versus Toupet fundoplication: assessment of operative outcomes

BACKGROUND

This study was designed to analyze the outcomes of Nissen fundoplication (NF) versus Toupet fundoplication (TF) in patients undergoing laparoscopic antireflux surgery (LARS).

METHODS

All perioperative data, operative/postoperative complications, and follow-up data were prospectively recorded. All patients were seen on the 2nd month postoperatively and by yearly intervals thereafter. All patients have at least 12-month follow-up. Using SPSS software, groups were compared by t-test and chi-square tests as appropriate.

RESULTS

One thousand consecutive patients underwent primary LARS from May 2004 to August 2009. Six hundred eighty-four patients had NF and 316 had TF fundoplication. The mean follow-up of the NF (51.26 months) group was slightly longer than the TF group (43.53 months) (P=.018). There was no mortality and conversion. Esophageal perforation, jejunal perforation, and pulmonary emboli were the sole three major complications in separate patients. Dysphagia occurred in 15.4% and 9.9% in NF and TF, respectively (P=.001). Corresponding numbers for bloating were 19.6% and 10.8% in NF and TF, respectively (P=.001). Seventeen patients underwent reinterventions such as dilatation and re-do surgery and all 17 were in the NF group (P<.05). All other minor complications were similar except hiccups, which were seen in 30 patients and all were in the NF group (P<.05). Recurrence of reflux was observed in 1.8% and 2.2% of the NF and TF, respectively (P=.620).

CONCLUSION

Both NF and TF are effective procedures in controlling the acid-reflux symptoms. The functional side effects appear more often in the NF group. These side effects can be minimized and reinterventions for severe/prolonged dysphagia can be avoided with TF.

Biocompatibility of prosthetic meshes in abdominal surgery

Surgical meshes today represent a group of implants mainly used for hernia repair. Modern hernia surgery is no longer imaginable without the application of these special biomaterials leading to millions of implantations each year worldwide. Because clinical trials are insufficient to evaluate the distinct effects of modified mesh materials in regard to tissue biocompatibility and functionality, a basic understanding of the physicochemical properties of mesh materials, as well as the underlying cause for hernia formation, is essential for a rational selection of the most appropriate device. The most important properties of meshes were found to be the type of filament, tensile strength, and experimental data, which indicate that particularly the mesh's porosity is of outstanding importance.

Laparoscopic repair of large hiatal hernia without prosthetic reinforcement: late results and relevance of anterior gastropexy

BACKGROUND

Laparoscopic treatment of large hiatal hernias seems to be associated with a high recurrence rate that some authors suggest to bring down by performing prosthetic closure of the hiatus. However, prosthetic repair remains controversial owing to severe and still underestimated complications. The aims of this study were to assess the long-term functional and objective results of laparoscopic treatment without prosthetic patch, and to identify the risk factors of recurrence.

METHODS

From November 1992 to March 2009, 89 patients underwent laparoscopic treatment of a large hiatal hernia without prosthetic patch, involving excision of the hernial sac, cruroplasty, fundoplication, and often anterior gastropexy. The postoperative assessment consisted of a barium esophagram on day 2, an office visit at 2 months with a 24-h pH study, an esophageal manometry, and then a long-term prospective yearly follow-up with a barium esophagram at 2 years.

RESULTS

Out of the 89 laparoscopic procedures, four required a conversion (4.4%). Seventy-seven patients underwent a Boerema's anterior gastropexy (86.5%). The morbidity rate was 7.8%, and the mortality rate was nil. Eleven patients (12.3%) were lost to follow-up. We had 91.5% of very good early functional results and 75.3% of good results after a mean follow-up of 57.5 months. Fourteen recurrences of hiatal hernias (15.7%) were identified, four of which (28.6%) occurred early after surgery. Three factors seemed significantly associated with recurrence: the absence of anterior gastropexy (p = 0.0028), the group of younger patients (p = 0.03), and a history of abdominal surgery (p = 0.01).

CONCLUSION

Large hiatal hernias can be treated by laparoscopy without prosthetic patch with a satisfying long-term result. Performing anterior gastropexy seems to significantly reduce the recurrences.

Impact of mesh positioning on foreign body reaction and collagenous ingrowth in a rabbit model of open incisional hernia repair

BACKGROUND

Incisional hernia remains as one of the most common surgical complications. Different mesh techniques are used in 75-80% of hernia repair. The aim of this study was to evaluate the dependence of mesh positioning and the type of mesh implanted on foreign body reaction and collagenous ingrowth.

MATERIALS AND METHODS

In 24 male Chinchilla rabbits, an incisional hernia repair was performed with mesh reinforcement either by sublay (n = 12) or by onlay technique (n = 12). In each group, two different types of mesh prosthesis were investigated: polypropylene (PP, Prolene) and polypropylene-polyglecaprone 25 composite (PP-PG, UltraPro). On postoperative day 60, the inflammatory and connective tissue formation was characterised by measuring the diameter of inner cellular infiltrate and outer fibrous capsule of the foreign body granuloma, and by verifying the collagen type I/III ratio. Furthermore, the expression of matrix metalloproteinase-2 (MMP-2) was analysed.

RESULTS

Microscopic investigation of the mesh/host-tissue interface showed typical formation of foreign body granuloma. The diameters of the inner part of the foreign body granuloma representing the amount of inflammatory cell infiltrate were significantly increased in the PP mesh compared to the PP-PG mesh, both in the sublay group (PP 13.1 +/- 1.21 microm vs. PP-PG 11.7 +/- 0.34 microm; P = 0.026) and in the onlay group (PP 13.1 +/- 1.24 microm vs. PP-PG 11.2 +/- 0.55 microm; P = 0.009). The diameter of the fibrous capsule as the outer ring of the granuloma was significantly increased when investigating the PP mesh in sublay position (29.5 +/- 1.12 microm) compared to the PP mesh in onlay position (27.9 +/- 0.73 microm) (P = 0.026). Investigating the quality of perifilamentary collagen deposition expressed as collagen type I/III ratio, the sublay group showed significantly elevated values compared to the onlay group (PP sublay 3.1 +/- 0.18 vs. PP onlay 2.4 +/- 0.41; P = 0.004) (PP-PG sublay 3.5 +/- 0.34 vs. PP-PG onlay 2.6 +/- 0.13; P = 0.002). The analysis of MMP-2 expression revealed no significant differences.

CONCLUSION

The beneficial results of mesh reinforcement in the sublay technique might be due to a superior quality of postoperative connective tissue formation. Mesh incorporation, irrespective of positioning, is favourable in low-weight, large, porous mesh material represented by a reduced inflammatory part of the foreign body granuloma.

Laparoscopic circular biomesh hiatoplasty during paraesophageal hernia repair

Laparoscopic approaches for paraesophageal hernia repair and the use of prosthetic reinforcement materials during crural repair have become standard. However, the search for the optimal prosthetic material and techniques for placement and fixation methods are still controversial and under investigation. The authors aimed to determine the technical feasibility of the use of human acellular dermal matrix for hiatoplasty in a circular fashion during paraesophageal hernia repair in a small series of patients. The short-term outcomes of patients who underwent laparoscopic repair of large paraesophageal hernias with biomesh circular hiatal reinforcement were analyzed. Laparoscopic circular hiatal reinforcement with acellular dermal matrix is feasible and reproducible with no associated short-term morbidity. The acellular dermal matrix mesh is very elastic and has excellent intracorporeal handling characteristics during hiatoplasty.

Long-term results of hiatal hernia mesh repair and antireflux laparoscopic surgery

BACKGROUND

Laparoscopic antireflux surgery (LARS) represents the gold standard in the treatment of gastroesophageal reflux disease with or without hiatal hernia. It offers excellent long-term results and high patient satisfaction. Nevertheless, several studies have reported a high rate of intrathoracic wrap migration or paraesophageal hernia recurrence. To reduce the incidence of this complication, the use of prosthetic meshes has been advocated. This study retrospectively evaluated the long-term results of LARS with or without the use of a mesh in a series of patients treated from 1992 to 2007.

METHODS

From November 1992 to May 2007, 297 patients underwent laparoscopic antireflux surgery in the authors' department. Crural closure was performed by means of two or three interrupted nonabsorbable sutures for 93 patients (group A), by tailored 3 x 4-cm polypropylene mesh placement for 113 patients (group B), and by nonabsorbable suture plus superimposed tailored mesh for 91 patients (group C).

RESULTS

The mean follow-up period for the entire group was 95.1 +/- 38.7 months, specifically 95.2 +/- 49 months for group A, 117.6 +/- 18 months for group B, and 69.3 +/-.17.6 months for group C. Intrathoracic Nissen wrap migration or hiatal hernia recurrence occurred for nine patients (9.6%) in group A, two patients (1.8%) in group B, and only one patient (1.1%) in group C. Esophageal erosion occurred in only one case (0.49%). Functional results and the long-term quality-of-life evaluation after surgery showed a significant and durable improvement with no significant differences related to the type of hiatoplasty.

CONCLUSION

Over a long-term follow-up period, the use of a prosthetic polypropylene mesh in the crura for hiatal hernia proved to be effective in reducing the rate of postoperative intrathoracic wrap migration or hernia recurrence, with a very low incidence of mesh-related complications.

Current controversies in paraesophageal hernia repair

The management of paraesophageal hernia (PEH) has become one of the most widely debated and controversial areas in surgery. PEHs are relatively uncommon, often presenting in patients entering their seventh or eighth decades of life. Patients who have PEH often bear complicating medical comorbidities making them potentially poor operative candidates. Taking this into account makes surgical management of these patients all the more complex. Many considerations must be taken into account in formulating a management strategy for patients who have PEHs, and these considerations have led surgeons into ongoing debates in recent decades.

Is a circular polypropylene mesh appropriate for application at the esophageal hiatus? Results from an experimental study in a porcine model

BACKGROUND

Mesh reinforcement in hiatal hernia surgery is debated. Randomized controlled trials have shown that recurrences may be reduced, but there is also the fear of mesh-related complications. Experimental studies on the characteristics of specific mesh types with regard to the risk of such complications are rare. The current study aimed to investigate the properties of a circular heavy-weight polypropylene mesh in terms of stenosis, migration, erosions, and adhesions in a porcine model.

METHODS

A 55 x 55-mm heavy-weight polypropylene mesh with a 16.5-mm eccentric hole for the esophagus corresponding to a calculated mesh area of 2811 mm(2) and a hole area of 214 mm(2) were implanted in nine German Landrace pigs. Six weeks later, the meshes were explanted and investigated for size, shrinkage, migration and adhesions.

RESULTS

The total mesh area shrank to a mean of 2,040 +/- 178 mm(2) (p < 0.001), and the hole for the esophagus showed a trend toward an increase to 239 +/- 38 mm(2) (p = 0.108). In not a single location did the mesh overhang the hiatal margin. The mean distance of retraction from the hiatal margin was 4.3 +/- 2.8 mm. Therefore, no stenoses, migrations, or erosions occurred.

CONCLUSIONS

A circular heavy-weight polypropylene mesh seems to be appropriate for the application at the esophageal hiatus in terms of safety and stability. This means that it is characterized by a position-stable centered fixation around the esophagus without a tendency toward stenosis, migration, or erosion.

Different tissue reaction of oesophagus and diaphragm after mesh hiatoplasty. Results of an animal study

BACKGROUND

Laparoscopic mesh-reinforcement of the hiatal region in the treatment of gastroesophageal reflux disease (GERD) and paraesophageal hernia (PEH) reduces the risk of recurrence. However, there are still controversies about the technique of mesh placement, shape, structure and material. We therefore compared tissue integration and scar formation after implantation of two different polypropylene-meshes in a rabbit model.

METHODS

A total of 20 female chinchilla rabbits were included in this study. Two different meshes (Polypropylene PP, Polyglecaprone 25 Composite PP-PG) were implanted on the abdominal diaphragm around the oesophagus. After 3 months the implanted meshes were excised en-bloc. Histological and morphological analyses were carried out accordingly proliferation rate, apoptosis and collagen type I/III ratio.

RESULTS

Regarding proliferation rate of oesophagus PP (9.31 +/- 3.4%) and PP-PG (13.26 +/- 2.54%) differ in a significant (p = 0.0097) way. In the diaphragm we found a significant (p = 0.00066) difference between PP (9.43 +/- 1.45%) and PP-PG (18.73 +/- 5.92%) respectively. Comparing oesophagus and diaphragm we could prove a significant difference within PP-PG-group (p = 0.0195). Within PP-group the difference reached no statistical significance (p = 0.88). We found analogous results regarding apoptosis.Furthermore, there is a significant (p = 0.00013) difference of collagen type I/III ratio in PP-PG (12.28 +/- 0.8) compared to PP (8.44 +/- 1,63) in case of oesophageal tissue. Concerning diaphragm we found a significant difference (p = 0.000099) between PP-PG (8.85 +/- 0.81) and PP (6.32 +/- 1.07) as well.

CONCLUSION

The histologic and morphologic characteristics after prosthetic enforcement of the hiatus in this animal model show a more distinct tissue integration using PP-PG compared to PP. Additionally, different wound healing and remodelling capability influence tissue integration of the mesh in diaphragm and oesophagus.