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Shiroud Heidari B, Dodda JM, El-Khordagui LK, Focarete ML, Maroti P, Toth L, Pacilio S, El-Habashy SE, Boateng J, Catanzano O, Sahai N, Mou L, Zheng M. Emerging materials and technologies for advancing bioresorbable surgical meshes. Acta Biomater 2024; 184:1-21. [PMID: 38879102 DOI: 10.1016/j.actbio.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 05/22/2024] [Accepted: 06/10/2024] [Indexed: 06/29/2024]
Abstract
Surgical meshes play a significant role in the treatment of various medical conditions, such as hernias, pelvic floor issues, guided bone regeneration, and wound healing. To date, commercial surgical meshes are typically made of non-absorbable synthetic polymers, notably polypropylene and polytetrafluoroethylene, which are associated with postoperative complications, such as infections. Biological meshes, based on native tissues, have been employed to overcome such complications, though mechanical strength has been a main disadvantage. The right balance in mechanical and biological performances has been achieved by the advent of bioresorbable meshes. Despite improvements, recurrence of clinical complications associated with surgical meshes raises significant concerns regarding the technical adequacy of current materials and designs, pointing to a crucial need for further development. To this end, current research focuses on the design of meshes capable of biomimicking native tissue and facilitating the healing process without post-operative complications. Researchers are actively investigating advanced bioresorbable materials, both synthetic polymers and natural biopolymers, while also exploring the performance of therapeutic agents, surface modification methods and advanced manufacturing technologies such as 4D printing. This review seeks to evaluate emerging biomaterials and technologies for enhancing the performance and clinical applicability of the next-generation surgical meshes. STATEMENT OF SIGNIFICANCE: In the ever-transforming landscape of regenerative medicine, the embracing of engineered bioabsorbable surgical meshes stands as a key milestone in addressing persistent challenges and complications associated with existing treatments. The urgency to move beyond conventional non-absorbable meshes, fraught with post-surgery complications, emphasises the necessity of using advanced biomaterials for engineered tissue regeneration. This review critically examines the growing field of absorbable surgical meshes, considering their potential to transform clinical practice. By strategically combining mechanical strength with bioresorbable characteristics, these innovative meshes hold the promise of mitigating complications and improving patient outcomes across diverse medical applications. As we navigate the complexities of modern medicine, this exploration of engineered absorbable meshes emerges as a promising approach, offering an overall perspective on biomaterials, technologies, and strategies adopted to redefine the future of surgical meshes.
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Affiliation(s)
- Behzad Shiroud Heidari
- Centre for Orthopaedic Research, Medical School, The University of Western Australia, Nedlands, WA, Australia
| | - Jagan Mohan Dodda
- New Technologies - Research Centre (NTC), University of West Bohemia, Univerzitní 8, 301 00 Pilsen, Czech Republic.
| | | | - Maria Letizia Focarete
- Department of Chemistry "Giacomo Ciamician" and INSTM UdR of Bologna, University of Bologna, Italy. Health Sciences & Technologies (HST) CIRI, University of Bologna, Via Tolara di Sopra 41/E, 40064 Ozzano Emilia, Italy
| | - Peter Maroti
- University of Pecs, Medical School, 3D Printing and Visualization Centre, Hungary, University of Pecs, Medical Skills Education and Innovation Centre, Hungary
| | - Luca Toth
- University of Pecs, Medical School, Institute for Translational Medicine, Hungary, University of Pecs, Medical School, Department of Neurosurgery, Hungary
| | - Serafina Pacilio
- Department of Chemistry "Giacomo Ciamician" and INSTM UdR of Bologna, University of Bologna, Italy. Health Sciences & Technologies (HST) CIRI, University of Bologna, Via Tolara di Sopra 41/E, 40064 Ozzano Emilia, Italy; Department of Biomedical and Neuromotor Sciences DIBINEM, Alma Mater Studiorum-University of Bologna, Italy
| | - Salma E El-Habashy
- Department of Pharmaceutics, Faculty of Pharmacy, Alexandria University, Egypt
| | - Joshua Boateng
- Faculty of Engineering and Science, University of Greenwich, Medway Campus, UK
| | - Ovidio Catanzano
- Institute for Polymers, Composites and Biomaterials (IPCB-CNR), Via Campi Flegrei 34, 80078 Pozzuoli, NA, Italy
| | - Nitin Sahai
- University of Pecs, Medical School, 3D Printing and Visualization Centre, Hungary, University of Pecs, Medical Skills Education and Innovation Centre, Hungary; Department of Biomedical Engineering, North Eastern Hill University, Meghalaya, India
| | - Lingjun Mou
- WA Liver and Kidney Transplant Department, Sir Charles Gairdner Hospital, Western Australia, Australia
| | - Minghao Zheng
- Centre for Orthopaedic Research, Medical School, The University of Western Australia, Nedlands, WA, Australia; Perron Institute for Neurological and Translational Science, Nedlands, WA, Australia
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Hanna NM, Kumar SS, Collings AT, Pandya YK, Kurtz J, Kooragayala K, Barber MW, Paranyak M, Kurian M, Chiu J, Abou-Setta A, Ansari MT, Slater BJ, Kohn GP, Daly S. Management of symptomatic, asymptomatic, and recurrent hiatal hernia: a systematic review and meta-analysis. Surg Endosc 2024; 38:2917-2938. [PMID: 38630179 DOI: 10.1007/s00464-024-10816-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND The surgical management of hiatal hernia remains controversial. We aimed to compare outcomes of mesh versus no mesh and fundoplication versus no fundoplication in symptomatic patients; surgery versus observation in asymptomatic patients; and redo hernia repair versus conversion to Roux-en-Y reconstruction in recurrent hiatal hernia. METHODS We searched PubMed, Embase, CINAHL, Cochrane Library and the ClinicalTrials.gov databases between 2000 and 2022 for randomized controlled trials (RCTs), observational studies, and case series (asymptomatic and recurrent hernias). Screening was performed by two trained independent reviewers. Pooled analyses were performed on comparative data. Risk of bias was assessed using the Cochrane Risk of Bias tool and Newcastle Ottawa Scale for randomized and non-randomized studies, respectively. RESULTS We included 45 studies from 5152 retrieved records. Only six RCTs had low risk of bias. Mesh was associated with a lower recurrence risk (RR = 0.50, 95%CI 0.28, 0.88; I2 = 57%) in observational studies but not RCTs (RR = 0.98, 95%CI 0.47, 2.02; I2 = 34%), and higher total early dysphagia based on five observational studies (RR = 1.44, 95%CI 1.10, 1.89; I2 = 40%) but was not statistically significant in RCTs (RR = 3.00, 95%CI 0.64, 14.16). There was no difference in complications, reintervention, heartburn, reflux, or quality of life. There were no appropriate studies comparing surgery to observation in asymptomatic patients. Fundoplication resulted in higher early dysphagia in both observational studies and RCTs ([RR = 2.08, 95%CI 1.16, 3.76] and [RR = 20.58, 95%CI 1.34, 316.69]) but lower reflux in RCTs (RR = 0.31, 95%CI 0.17, 0.56, I2 = 0%). Conversion to Roux-en-Y was associated with a lower reintervention risk after 30 days compared to redo surgery. CONCLUSIONS The evidence for optimal management of symptomatic and recurrent hiatal hernia remains controversial, underpinned by studies with a high risk of bias. Shared decision making between surgeon and patient is essential for optimal outcomes.
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Affiliation(s)
- Nader M Hanna
- Department of Surgery, Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
| | - Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Yagnik K Pandya
- Department of Surgery, MetroWest Medical Center, Framingham, MA, USA
| | - James Kurtz
- Department of Surgery, Providence Portland Medical Center, Portland, OR, USA
| | | | - Meghan W Barber
- Department of Surgery, University of Toledo College of Medicine, Toledo, OH, USA
| | - Mykola Paranyak
- Department of General Surgery, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Marina Kurian
- Department of Surgery, NYU Langone Health, New York, NY, USA
| | | | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | | | | | - Geoffrey P Kohn
- Department of Surgery, Monash University, Melbourne, Australia
- Melbourne Upper GI Surgical Group, Melbourne, Australia
| | - Shaun Daly
- Department of Surgery, University of California Irvine, Irvine, USA
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Latorre-Rodríguez AR, Rajan A, Mittal SK. Cruroplasty with or without mesh? A systematic literature review with a novel time-organized proportion meta-analysis. Surg Endosc 2024; 38:1685-1708. [PMID: 38351425 DOI: 10.1007/s00464-024-10683-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/30/2023] [Indexed: 04/02/2024]
Abstract
BACKGROUND Improved outcomes with the use of non-absorbable mesh (NAM) for inguinal hernia repairs led to its rapid adoption for hiatal hernia (HH) repairs; however, feared complications occurred, and the trend shifted toward using absorbable mesh (AM). We aimed to analyze the literature assessing objective HH recurrence rates after primary laparoscopic cruroplasty with or without the use of different mesh types. METHODS A systematic literature review with both pairwise and time-organized proportion meta-analyses of articles published between January 1993 and September 2022 was performed using the MEDLINE, EMBASE, and Taylor & Francis databases to identify relevant studies comparing groups undergoing cruroplasty with suture repair (SR) alone, AM, NAM, or partially absorbable mesh (PAM). Studies documenting an objective follow-up ≥ 6 months were included. The primary outcome was the HH recurrence rate confirmed by barium esophagram or upper GI endoscopy. RESULTS A total of 34 studies met the inclusion criteria, including 6 randomized clinical trials, 25 retrospectives studies, and 3 prospective cohort studies. A total of 2170 subjects underwent laparoscopic HH repair and completed an objective follow-up ≥ 6 months after surgery; the objective recurrence rate was 20.8% (99/477) at a mean follow-up of 25.8 ± 16.4 months for the SR group, 20.6% (244/1187) at 28.1 ± 13.8 months for the AM group, 13.7% (65/475) at 30.8 ± 15.3 months for the NAM group, and 0% (0/31) at 32.5 ± 13.5 months for the PAM group. However, the pairwise meta-analysis revealed that overall mesh use was not superior to SR in preventing long-term HH recurrence. CONCLUSION The use of AM does not appear to reduce HH recurrence compared to SR alone. Although the data favors NAM to decrease objective HH recurrence in the mid-term, the long-term (≥ 48 months) recurrence rate was similar with or without any type of mesh.
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Affiliation(s)
- Andrés R Latorre-Rodríguez
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Suite 500, Phoenix, AZ, 85013, USA
- Universidad del Rosario. Escuela de Medicina y Ciencias de la Salud, Grupo de Investigación Clínica, Bogotá D.C., Colombia
| | - Ajay Rajan
- School of Medicine School, Creighton University, Phoenix, AZ, USA
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Suite 500, Phoenix, AZ, 85013, USA.
- School of Medicine School, Creighton University, Phoenix, AZ, USA.
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Giuffrida M, Perrone G, Abu-Zidan F, Agnoletti V, Ansaloni L, Baiocchi GL, Bendinelli C, Biffl WL, Bonavina L, Bravi F, Carcoforo P, Ceresoli M, Chichom-Mefire A, Coccolini F, Coimbra R, de'Angelis N, de Moya M, De Simone B, Di Saverio S, Fraga GP, Galante J, Ivatury R, Kashuk J, Kelly MD, Kirkpatrick AW, Kluger Y, Koike K, Leppaniemi A, Maier RV, Moore EE, Peitzmann A, Sakakushev B, Sartelli M, Sugrue M, Tian BWCA, Broek RT, Vallicelli C, Wani I, Weber DG, Docimo G, Catena F. Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper. World J Emerg Surg 2023; 18:43. [PMID: 37496073 PMCID: PMC10373334 DOI: 10.1186/s13017-023-00510-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/14/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Diaphragmatic hernia (DH) presenting acutely can be a potentially life-threatening condition. Its management continues to be debatable. METHODS A bibliographic search using major databases was performed using the terms "emergency surgery" "diaphragmatic hernia," "traumatic diaphragmatic rupture" and "congenital diaphragmatic hernia." GRADE methodology was used to evaluate the evidence and give recommendations. RESULTS CT scan of the chest and abdomen is the diagnostic gold standard to evaluate complicated DH. Appropriate preoperative assessment and prompt surgical intervention are important for a clinical success. Complicated DH repair is best performed via the use of biological and bioabsorbable meshes which have proven to reduce recurrence. The laparoscopic approach is the preferred technique in hemodynamically stable patients without significant comorbidities because it facilitates early diagnosis of small diaphragmatic injuries from traumatic wounds in the thoraco-abdominal area and reduces postoperative complications. Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable. Damage Control Surgery is an option in the management of critical and unstable patients. CONCLUSIONS Complicated diaphragmatic hernia is a rare life-threatening condition. CT scan of the chest and abdomen is the gold standard for diagnosing the diaphragmatic hernia. Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias. Open repair is considered necessary in majority of unstable patients in whom Damage Control Surgery can be life-saving.
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Affiliation(s)
| | - Gennaro Perrone
- Department of Emergency Surgery, Maggiore Hospital, Via A. Gramsci 14, 43126, Parma, Italy.
| | - Fikri Abu-Zidan
- Research Office, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Vanni Agnoletti
- Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Luca Ansaloni
- Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Gian Luca Baiocchi
- General Surgery, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Cino Bendinelli
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Walter L Biffl
- Acute Care Surgery at The Queen's Medical Center, John A. Burns School of Medicine, University of Hawai'I, Honolulu, USA
| | - Luigi Bonavina
- Department of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milano, Milan, Italy
| | - Francesca Bravi
- Healthcare Administration, Santa Maria Delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | - Paolo Carcoforo
- Department of Morphology, Surgery and Experimental Medicine, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Marco Ceresoli
- General and Emergency Surgery, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Alain Chichom-Mefire
- Department of Surgery and Obstetrics/Gynaecology, Regional Hospital, Limbe, Cameroon
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- Riverside University Health System Medical Center, , Riverside, California, USA
| | - Nicola de'Angelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Marc de Moya
- Trauma/Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint-Germain-en-Laye Hospitals, Poissy, France
| | - Salomone Di Saverio
- Department of General Surgery, San Benedetto del Tronto General Hospital, San Benedetto del Tronto, Italy
| | - Gustavo Pereira Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP, Brazil
| | - Joseph Galante
- Trauma Department, University of California, Davis, Sacramento, CA, USA
| | - Rao Ivatury
- Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Jeffry Kashuk
- Department of Surgery, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Andrew W Kirkpatrick
- Department of General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Kaoru Koike
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Ernest Eugene Moore
- Department of Surgery, Denver Health Medical Center,, University of Colorado, Denver, CO, USA
| | - Andrew Peitzmann
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | | | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, Letterkenny, Donegal, Ireland
| | - Brian W C A Tian
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Richard Ten Broek
- Surgery Department, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Imtaz Wani
- Department of Minimal Access and General Surgery, Government Gousia Hospital, Srinagar, India
| | - Dieter G Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Giovanni Docimo
- Department of Medical and Advanced Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
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Rajkomar K, Wong CS, Gall L, MacKay C, Macdonald A, Forshaw M, Craig C. Laparoscopic large hiatus hernia repair with mesh reinforcement versus suture cruroplasty alone: a systematic review and meta-analysis. Hernia 2023:10.1007/s10029-023-02783-2. [PMID: 37010656 DOI: 10.1007/s10029-023-02783-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 03/18/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND To compare the difference in outcomes in laparoscopic large hiatus hernia (LHH) repair using suture-based and mesh-based repair techniques. METHODS A systematic search of articles was conducted in PubMed, Medline and Embase using the PRISMA guidelines. Studies comparing recurrences and reoperations in those patients with large hiatal hernia repair (> 30% stomach in the chest, > 5 cm hiatal defect, hiatal surface area > 10 cm2) who had mesh vs no mesh were assessed quantitatively. The impact of mesh on significant intraoperative/postoperative surgical complications was qualitatively assessed. RESULTS Pooled data included six randomized controlled trials and thirteen observational studies with 1670 patients (824 with no mesh, 846 with mesh). There was a significant reduction in the total recurrence rate with mesh (OR 0.44, 95% CI 0.25-0.80, p = 0.007). Mesh use did not cause significant reduction in recurrences > 2 cm (OR 0.94, 95% CI 0.52-1.67, p = 0.83) or in reoperation rates (OR 0.64, 95% CI 0.39-1.07, p = 0.09). None of the specific meshes assessed were found to be superior in the reduction of recurrence or reoperation rates. Cases of mesh erosion with eventual foregut resection were noted and were associated with synthetic meshes only. CONCLUSION Mesh reinforcement seemed protective against total recurrence in LHH although this has to be interpreted with caution given the level of heterogeneity introduced by the inclusion of observational studies in the analysis. There was no significant reduction in large recurrences (> 2 cm) or reoperation rate. If the synthetic mesh is to be used patients need to be informed of the risk of mesh erosion.
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Affiliation(s)
- K Rajkomar
- Upper GI Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G40SF,, UK.
| | - C S Wong
- Upper GI Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G40SF,, UK
| | - L Gall
- Upper GI Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G40SF,, UK
| | - C MacKay
- Upper GI Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G40SF,, UK
| | - A Macdonald
- Upper GI Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G40SF,, UK
| | - M Forshaw
- Upper GI Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G40SF,, UK
| | - C Craig
- Upper GI Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G40SF,, UK
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D'Urbano F, Tamburini N, Resta G, Maniscalco P, Marino S, Anania G. A Narrative Review on Treatment of Giant Hiatal Hernia. J Laparoendosc Adv Surg Tech A 2023; 33:381-388. [PMID: 36927045 DOI: 10.1089/lap.2023.0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
Background: The current gold standard of treatment for giant hiatal hernias (GHHs) is laparoscopic surgery. Laparoscopic surgery was performed as a less invasive procedure for paraesophageal hernias more than 25 years ago. Its viability and safety have almost all been shown. Materials and Methods: A review of recent and current studies' literature was done. Prospective randomized trials, systematic reviews, clinical reviews, and original articles were all investigated. The data were gathered in the form of a narrative evaluation. We examine the state of laparoscopic GHH repair today and outline the GHH management strategy. Results: In this review, we clear up misunderstandings of GHH and address bad habits that may have contributed to poor results, and we have consequently performed a methodical evaluation of GHH. First, we address subcategorizing GHH and provide criteria to define them. The preoperative workup strategies are then discussed, with a focus on any pertinent and frequent atypical symptoms, indications for surgery, timing of surgery, and the importance of surgery. The approach to the techniques and the logic behind surgery are then presented along with some important dissection techniques. Finally, we debate the role of mesh reinforcement and evaluate the data in terms of recurrence, reoperation rate, complications, and delayed stomach emptying. Finally, we suggest a justification for common postoperative investigations. Conclusions: Surgery is the only effective treatment for GHH at the moment. If the right operational therapy principles are applied, this is generally successful. There is a growing interest in laparoscopic paraesophageal hiatal hernia repair as a result of the introduction of laparoscopic antireflux surgery. Today's less invasive procedures provide a better therapeutic choice with a lower risk.
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Affiliation(s)
- Francesco D'Urbano
- Department of Morphology, Experimental Medicine and Surgery, Section of Chirurgia 1, Sant'Anna Hospital, University of Ferrara, Ferrara, Italy
| | - Nicola Tamburini
- Department of Morphology, Experimental Medicine and Surgery, Section of Chirurgia 1, Sant'Anna Hospital, University of Ferrara, Ferrara, Italy
| | - Giuseppe Resta
- Department of Morphology, Experimental Medicine and Surgery, Section of Chirurgia 1, Sant'Anna Hospital, University of Ferrara, Ferrara, Italy
| | - Pio Maniscalco
- Department of Morphology, Experimental Medicine and Surgery, Section of Chirurgia 1, Sant'Anna Hospital, University of Ferrara, Ferrara, Italy
| | - Serafino Marino
- Department of Morphology, Experimental Medicine and Surgery, Section of Chirurgia 1, Sant'Anna Hospital, University of Ferrara, Ferrara, Italy
| | - Gabriele Anania
- Department of Morphology, Experimental Medicine and Surgery, Section of Chirurgia 1, Sant'Anna Hospital, University of Ferrara, Ferrara, Italy
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Does bioabsorbable mesh reduce hiatal hernia recurrence rates? A meta-analysis. Surg Endosc 2023; 37:2295-2303. [PMID: 35951120 DOI: 10.1007/s00464-022-09514-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 07/26/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION The use of bioabsorbable mesh at the hiatus is controversial. Long-term data are scant. We evaluated the world literature and performed a meta-analysis to determine if these meshes were effective in reducing recurrence. METHODS A literature search was performed using PubMed, MEDLINE, and ClinicalKey. We evaluated articles reporting on both Bio-A™ (polyglycolic acid:trimethylene carbonate-PGA:TMC) and Phasix™ (poly-4-hydroxybutyrate-P4HB) used at the hiatus. The DerSimonian-Laird random effects model was used to estimate the overall pooled treatment effect along with a 95% confidence interval (CI). Similar analysis was conducted to compare the clinical outcomes, i.e., recurrence rate, mean surgical time, mean hospital stays and mean follow-up duration between non-Mesh and Mesh group. The I2 statistic was computed to assess the heterogeneity in effect sizes across the studies. RESULTS A total of 21 studies (12 mesh studies with 963 subjects and 9 non-mesh studies with 617 subjects) were included to conduct the meta-analysis. There was one article reporting outcomes on P4HB mesh (73 subjects) and 11 on PGA:TMC mesh (890 subjects). The bioabsorbable mesh group had a significantly lower recurrence rate compared to the non-mesh group (8% vs. 18%; 95%CI 0.08-0.17), pooled p-value < 0.0001. Surgery time was shorter in the mesh group compared to the non-mesh group (136.4 min vs. 150 min) but not statistically significant (p = 0.54). There tended to be a more extended follow-up period after surgery in the non-mesh group compared to the mesh group (27 vs. 25.8 months, range 10.8-54 months); but not statistically significant (ES: 27.4; 95%CI 21.6-33.3; p = 0.92). CONCLUSIONS Hiatal hernia repair with bioabsorbable mesh is more effective at reducing hernia recurrence rate in the mid-term than simple suture cruroplasty. Further studies investigating the long-term outcomes and P4HB mesh are needed.
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Konstantinidis H, Charisis C. Surgical treatment of large and complicated hiatal hernias with the new resorbable mesh with hydrogel barrier (Phasix™ ST): a preliminary study. J Robot Surg 2023; 17:141-146. [PMID: 35397107 DOI: 10.1007/s11701-022-01406-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 03/19/2022] [Indexed: 11/29/2022]
Abstract
Evaluation of the efficacy and safety of the new monofilament fully resorbable mesh with hydrogel barrier (Phasix™ ST), for large and complex hiatal hernia repair. Between December 2017 and December 2020, 60 patients with large or complicated hiatal hernia were treated (40 robotic and 20 laparoscopic procedures). The mesh was placed after primary closure of the hiatal defect, in an onlay fashion around the esophagus, followed by 360o fundoplication. Follow-up at 3, 6, 12, 18, 24 months from intervention included clinical evaluation and upper GI endoscopy. In cases of recurrence, radiologic survey and manometry were utilized. There were no conversions to open repair or significant postoperative incidents. Over a median follow-up of 21 months (range 3-36), no recurrences or mesh related complications were observed. From our early experience, Phasix™ ST mesh seems to be safe and effective for the reinforcement of crural defects in large and complex hiatal hernia.
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Affiliation(s)
- Haris Konstantinidis
- Robotic and M.I.S. General Surgery Department, American Institute of Minimally Invasive Surgery, Limassol, Cyprus
- Robotic General and Oncologic Surgical Department, Interbalkan Medical Centre, Thessaloniki, Greece
| | - Christos Charisis
- Robotic and M.I.S. General Surgery Department, American Institute of Minimally Invasive Surgery, Limassol, Cyprus.
- Robotic General and Oncologic Surgical Department, Interbalkan Medical Centre, Thessaloniki, Greece.
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Varvoglis DN, Farrell TM. Poor Gastric Emptying in Patients with Paraesophageal Hernias: Pyloroplasty, Per-Oral Pyloromyotomy, BoTox, or Wait and See? J Laparoendosc Adv Surg Tech A 2022; 32:1134-1143. [PMID: 35939274 DOI: 10.1089/lap.2022.0342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Gastric emptying delay may be caused with both functional and anatomic derangements. Gastroparesis is suspected in patients presenting with certain foregut symptoms without anatomic obstruction. Data are still emerging regarding the best treatment of this condition. In cases where large paraesophageal hernias alter the upper gastrointestinal anatomy, it is difficult to know if gastroparesis also exists. Management of hiatal hernias is also still evolving, with various strategies to reduce recurrence being actively investigated. In this article, we present a systematic review of the existing literature around the management of gastroparesis and the management of paraesophageal hernias when they occur separately. In addition, since there are limited data to guide diagnosis and management of these conditions when they are suspected to coexist, we provide a rational strategy based on our own experience in patients with paraesophageal hernias who have symptoms or studies that raise suspicion for a coexisting functional disorder.
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Affiliation(s)
- Dimitrios N Varvoglis
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Timothy M Farrell
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Patient-tailored algorithm for laparoscopic cruroplasty standardization: comparison with hiatal surface area and medium-term outcomes. Langenbecks Arch Surg 2022; 407:2537-2545. [PMID: 35585260 DOI: 10.1007/s00423-022-02556-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 05/11/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Different methods have been described for laparoscopic hiatoplasty and hiatus hernia (HH) repair. All techniques are not standardized and the choice to reinforce or not the hiatus with a mesh is left to the operating surgeon's preference. Hiatal surface area (HSA) has been described as an attempt at standardization; in case the area is > 4 cm2, a mesh is used to reinforce the repair. OBJECTIVE The aim of this study was to describe a new patient-tailored algorithm (PTA), compare its performance in predicting crura mesh buttressing to HSA, and analyze outcomes. METHODS Retrospective, single-center, descriptive study (September 2018-September 2021). Adult patients (≥ 18 years old) who underwent laparoscopic HH repair. Outcomes and quality of life measured with the disease-specific gastroesophageal reflux disease health-related quality of life (GERD-HRQL) and reflux symptom index (RSI) were analyzed. RESULTS Fifty patients that underwent laparoscopic hiatoplasty and Toupet fundoplication were included. The median age was 61 years (range 32-83) and the median BMI was 26.7 (range 17-36). According to the PTA, 27 patients (54%) underwent simple suture repair while crural mesh buttressing with Phasix-ST® was used in 23 (46%). According to the HSA, the median hiatus area was 4.7 cm2 while 26 patients had an HSA greater than 4 cm2. The overall concordance rate between PTA and HSA was 94% (47/50). The median hospital stay was 1.9 days (range 1-8) and the 90-day complication rate was 4%. The median follow-up was 18.6 months (range 1-35). Hernia recurrence was diagnosed in 6%. Postoperative dysphagia occurred in one patient (2%). The GERD-HRQL (p < 0.001) and RSI (p = 0.001) were significantly improved. CONCLUSIONS The application of PTA for cruroplasty standardization in the setting of HH repair seems effective. While concordance with HSA is high, the PTA seems easier and promptly available in the operative theater with a potential increase in procedure standardization, reproducibility, and teaching.
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Date AR, Goh YM, Goh YL, Rajendran I, Date RS. Quality of life after giant hiatus hernia repair: A systematic review. J Minim Access Surg 2021; 17:435-449. [PMID: 33885030 PMCID: PMC8486064 DOI: 10.4103/jmas.jmas_233_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Akshay R. Date
- Department of Orthopaedic Surgery, Basildon and Thurrock University Hospital, Basildon, Essex, UK
| | - Yan Mei Goh
- Department of Surgery, Imperial College London, St Mary’s Hospital, London, UK
| | - Yan Li Goh
- National Bowel Research Centre (NBRC), Blizzard Institute, Queen Mary University of London, London, UK
| | - Ilayaraja Rajendran
- Department of Upper GI Surgery, Lancashire Teaching Hospital NHS Foundation Trust, Chorley, UK
| | - Ravindra S. Date
- Department of Upper GI Surgery, The University of Manchester, Manchester Academic Health Science Centre, Lancashire Teaching Hospital NHS Foundation Trust, Chorley, UK
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Neutrophil-to-Lymphocyte Ratio (NLR) and Monocyte-to-Lymphocyte Ratio (MLR) Predict Clinical Outcome in Patients with Stage IIB Cervical Cancer. JOURNAL OF ONCOLOGY 2021; 2021:2939162. [PMID: 34539781 PMCID: PMC8443385 DOI: 10.1155/2021/2939162] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/11/2021] [Accepted: 08/10/2021] [Indexed: 12/15/2022]
Abstract
Introduction Stage IIB cervical cancer (CC) is an advanced stage CC with poor prognosis. Inflammatory response plays a crucial role in the development of CC, and systemic inflammatory indexes were related to the prognosis in several cancers. The objective of the study was to determine the prognostic value of platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), basophil-to-lymphocyte ratio (BLR), and systemic inflammation response index (SIRI) as inflammatory indexes in patients with stage IIB CC. Materials and Methods A retrospective study was performed in 260 patients with stage IIB CC. PLR, NLR, MLR, BLR, and SIRI were obtained from routine blood tests. Prognosis information of the patients was acquired from regular clinical follow-up. Recurrence and response to therapy were determined through electronic medical records (EMRs). Correlations of the inflammatory indexes with overall survival (OS), progression-free survival (PFS), recurrence, and response to therapy were analyzed using SPSS version 26.0 software. Results Receiver operating characteristic (ROC) curve analyses suggested that NLR, MLR, and SIRI had better predictive value than PLR as well as BLR in the prognosis and recurrence risk. Both univariate and multivariate survival analyses showed that higher NLR and MLR were significantly associated with shorter OS as well as PFS, whereas SIRI was not an independent predictive factor of PFS. Chi-square test results revealed that increased NLR was significantly correlated with higher recurrence rate (P=0.046), and increased MLR showed significant correlation with elevated recurrence risk (P=0.002). Univariate and binary logistic regression analyses for response to therapy indicated that elevated NLR was associated with decreased complete remission (CR) rate (P=0.031), and the P value lost statistical significance while being adjusted by tumor size (P=0.108). Conclusions For patients with stage IIB CC, both NLR and MLR are independent prognostic factors as well as risk factors for recurrence; NLR serves as a potential marker for therapeutic response.
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Surgical and clinical outcomes comparison of mesh usage in laparoscopic hiatal hernia repair. Surg Endosc 2020; 35:2724-2730. [PMID: 32556757 DOI: 10.1007/s00464-020-07703-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/09/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Use of absorbable mesh in hiatal hernia (HH) repair has been shown to decrease recurrence rates. Our aim was to compare the efficiency of three meshes in relation to the surgical outcomes of patients undergoing HH repair. METHODS A single-institution retrospective review was done for adult patients who underwent HH repair with mesh between 2004 and 2016. Demographics, intra-operative, and cost data were collected. Esophageal symptoms and medication use were assessed pre- and postoperatively. Surgical outcomes were evaluated at 6-, 12-months, and long-term follow-up. Three groups were created based on type of mesh: human tissue matrix (HTM), biosynthetic mesh (BIOS), or porcine tissue matrix (PTM). Comparisons were performed between groups using SPSS v.26.0 and PC SAS v9.4, α = 0.05. RESULTS 292 patients were included (HTM:N = 162, BIOS:N = 83, PTM:N = 47). Majority were male (60.4%), Caucasian (93.2%), median age, and BMI of 59 years [25-90 years] and 29.19 kg/m2 [18.9-58.0 kg/m2], respectively. 69% had a large HH. Median follow-up time was 27 months [1-166 months]. Overall recurrence rate was 39%, being significantly lower in BIOS at long-term (HTM: 31%, BIOS: 17%, PTM: 19%, p = 0.038). All groups had a significant postoperative improvement of esophageal symptoms, all p < 0.001. 65-70% of the cost difference between the groups was incurred by the cost of mesh alone (HTM: $1072, BIOS: $548, PTM: $1295), with the remainder attributable to the surgery itself. CONCLUSION While outcomes of the three mesh groups were similar in our data, there was a significant difference in mesh cost. Surgeon and hospital preference still play a role in choosing the type of mesh used; however, knowledge of the individual mesh cost will help surgeons make better informed decisions.
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Dreifuss NH, Schlottmann F, Molena D. Management of paraesophageal hernia review of clinical studies: timing to surgery, mesh use, fundoplication, gastropexy and other controversies. Dis Esophagus 2020; 33:5848914. [PMID: 32476002 PMCID: PMC8344298 DOI: 10.1093/dote/doaa045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/14/2020] [Accepted: 05/02/2020] [Indexed: 12/11/2022]
Abstract
Despite paraesophageal hernias (PEH) being a common disorder, several aspects of their management remain elusive. Elective surgery in asymptomatic patients, management of acute presentation, and other technical aspects such as utilization of mesh, fundoplication or gastropexy are some of the debated issues. The aim of this study was to review the available evidence in an attempt to clarify current controversial topics. PEH repair in an asymptomatic patient may be reasonable in selected patients to avoid potential morbidity of an emergent operation. In acute presentation, gastric decompression and resuscitation could allow to improve the patient's condition and refer the repair to a more experienced surgical team. When surgical repair is decided, laparoscopy is the optimal approach in most of the cases. Mesh should be used in selected patients such as those with large PEH or redo operations. While a fundoplication is recommended in the majority of patients to prevent postoperative reflux, a gastropexy can be used in selected cases to facilitate postoperative care.
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Affiliation(s)
- Nicolás H Dreifuss
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina,Address correspondence to: Francisco Schlottmann, MD MPH, Department of Surgery, Hospital Alemán of Buenos Aires, Av. Pueyrredon 1640, C1118AAT Buenos Aires, Argentina.
| | - Daniela Molena
- Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Arcerito M, Perez MG, Kaur H, Annoreno KM, Moon JT. Robotic Fundoplication for Large Paraesophageal Hiatal Hernias. JSLS 2020; 24:JSLS.2019.00054. [PMID: 32206010 PMCID: PMC7065729 DOI: 10.4293/jsls.2019.00054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Purpose: Laparoscopic fundoplication is now a cornerstone in the treatment of gastro-esophageal reflux disease (GERD) with sliding hernia. The best outcomes are achieved in those patients who have some response to medical treatment compared to those who do not. Robotic fundoplication is considered a novel approach in treating GERD with large paraesophageal hiatal hernias. Our goal was to examine the feasibility of this technique. Methods: Seventy patients (23 males and 47 females) with mean age 64 y old (22–92), preoperatively diagnosed with a large paraesophageal hiatal hernia, were treated with a robotic approach. Biosynthetic tissue absorbable mesh was applied for hiatal closure reinforcement. Fifty-eight patients underwent total fundoplication, 11 patients had partial fundoplication, and one patient had a Collis-Nissen fundoplication for acquired short esophagus. Results: All procedures were completed robotically, without laparoscopic or open conversion. Mean operative time was 223 min (180–360). Mean length of stay was 38 h (24–96). Median follow-up was 29 mo (7–51). Moderate postoperative dysphagia was noted in eight patients, all of which resolved after 3 mo without esophageal dilation. No mesh-related complications were detected. There were six hernia recurrences. Four patients were treated with redo-robotic fundoplication, and two were treated medically. Conclusions: The success of robotic fundoplication depends on adhering to a few important technical principles. In our experience, the robotic surgical treatment of gastroesophageal reflux disease with large paraesophageal hernias may afford the surgeon increased dexterity and is feasible with comparable outcomes compared with traditional laparoscopic approaches.
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Affiliation(s)
- Massimo Arcerito
- Riverside Medical Clinic Inc., University of California Riverside School of Medicine, Riverside, California
| | - Martin G Perez
- Riverside Medical Clinic Inc., University of California Riverside School of Medicine, Riverside, California
| | - Harpreet Kaur
- Division of General and Vascular Surgery, Riverside Community Hospital, Riverside, California
| | - Kenneth M Annoreno
- Division of General and Vascular Surgery, Riverside Community Hospital, Riverside, California
| | - John T Moon
- Shawnee Mission Medical Center, Shawnee Mission, Kansas
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Panici Tonucci T, Asti E, Sironi A, Ferrari D, Bonavina L. Safety and Efficacy of Crura Augmentation with Phasix ST Mesh for Large Hiatal Hernia: 3-Year Single-Center Experience. J Laparoendosc Adv Surg Tech A 2020; 30:369-372. [PMID: 31910348 DOI: 10.1089/lap.2019.0726] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: Safety and effectiveness of absorbable meshes for laparoscopic hiatus hernia repair are still debated. This may be due to patient selection, technique of repair, type and shape of mesh, definition of recurrent hernia, and length of follow-up. The aim of this study was to assess safety, short-term efficacy, and quality of life after laparoscopic repair of hiatal hernia reinforced with a biosynthetic absorbable mesh. Materials and Methods: A single-center observational cohort study was conducted in patients with large type III-IV hiatal hernia who underwent laparoscopic crural repair reinforced with Phasix ST®, a monofilament resorbable mesh (poly-4-hydroxybuterate) with a hydrogel barrier on one side. Patient data were extracted from hospital charts and a prospectively updated research database. Both generic Short Form-36 (SF-36) and disease-specific (Gastro-Esophageal Reflux Disease Health-Related Quality of Life [GERD-HRQL]) questionnaires were used to assess preoperative and postoperative quality of life. Results: From January 2017 to July 2019, 73 consecutive patients were implanted with Phasix ST mesh. The median follow-up was 17 (interquartile range 9-24) months. Recurrent hernia was found in 2 of 62 (3.2%) patients followed for more than 6 months after surgery, but none required reoperation. The overall postoperative morbidity rate was 8.2%. No mesh-related complications occurred. Compared to baseline, there was a statistically significant improvement of all items of the SF-36 questionnaire (P < .001) and of the median GERD-HRQL score (P < .001). Conclusion: The use of Phasix ST mesh to reinforce crural repair for large hiatus hernias is safe, is effective in the short-term follow-up, and is associated to improved quality of life.
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Affiliation(s)
- Tommaso Panici Tonucci
- IRCCS Policlinico San Donato, Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, Milano, Italy
| | - Emanuele Asti
- IRCCS Policlinico San Donato, Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, Milano, Italy
| | - Andrea Sironi
- IRCCS Policlinico San Donato, Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, Milano, Italy
| | - Davide Ferrari
- IRCCS Policlinico San Donato, Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, Milano, Italy
| | - Luigi Bonavina
- IRCCS Policlinico San Donato, Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milano, Milano, Italy
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Hiatal hernia repair with Toupet fundoplication in surgical treatment of hiatal hernia, complicated by gastroesophageal reflux disease. КЛИНИЧЕСКАЯ ПРАКТИКА 2019. [DOI: 10.17816/clinpract1035-12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Introduction. Hiatal hernia occupies a third place in the structure of the gastrointestinal tract pathology. The association of hiatal hernia with gastroesophageal reflux disease can lead to severe complications and requires a surgical treatment.
Objective. To analyze short-term and long-term results of a surgical treatment of patients with hiatal hernia complicated by gastroesophageal reflux disease (GERD).
Methods. A retrospective analysis of the short-term and long-term treatment results of 62 patients suffering from hiatal hernia complicated by gastroesophageal reflux disease was performed. All the patients underwent a laparoscopic hiatal hernia repair supplemented by Toupet fundoplication.
Results. The hospital stay duration was 7.21.6 days. The postoperative complication rate was 6.5%. Mild functional dysphagia was noted in 8(12.9%). Persistent long-term dysphagia in the late postoperative period was observed in 2(3.2%) patients. The recurrences of hiatal hernia or GERD were noted in 15(24.2%) patients in 5 years after the surgery. The total GERD-HRQL questionnaire score 5 years after the surgery was 5.73.9.
Сonclusion. Laparoscopic interventions are safe, less traumatic, provide the possibility of early rehabilitation of patients, can achieve positive functional results in 85% of patients and should be used in the treatment of patients suffering from hiatal hernia complicated by GERD.
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Omura N, Tsuboi K, Yano F. Minimally invasive surgery for large hiatal hernia. Ann Gastroenterol Surg 2019; 3:487-495. [PMID: 31549008 PMCID: PMC6749952 DOI: 10.1002/ags3.12278] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 06/26/2019] [Accepted: 06/28/2019] [Indexed: 12/19/2022] Open
Abstract
The majority of large hiatal hernias are paraesophageal hiatal hernias (PEH). Once prolapse of the stomach to the chest cavity reaches a high degree, it is called an intrathoracic stomach. More than 25 years have elapsed since laparoscopic surgery was carried out as minimally invasive surgery for PEH. The feasibility and safety thereof has nearly been established. PEH may cause serious complications such as strangulation and perforation. The outcome of elective repair of PEH is better than emergent repair, so we should carry out elective repair as much as possible. Although not a major clinical problem, following PEH repair the rate of anatomical recurrence increases with age. In order to reduce the recurrence rate, mesh reinforcement by crural repair has been widely performed. Although this improves the short-term outcomes, the long-term outcomes are unclear. For PEH repair, fundoplication and gastropexy are believed desirable. We should select the procedure associated with a lower incidence of dysphagia and so on following surgery. While relaxing incision is useful for primary tension-free closure, it has not contributed to improvement in the recurrence rate.
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Affiliation(s)
- Nobuo Omura
- Department of SurgeryNational Hospital Organization Nishisaitama‐Chuo National HospitalTokyoJapan
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Kazuto Tsuboi
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
| | - Fumiaki Yano
- Department of SurgeryThe Jikei University School of MedicineTokyoJapan
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Schlosser KA, Maloney SR, Prasad T, Augenstein VA, Heniford BT, Colavita PD. Mesh reinforcement of paraesophageal hernia repair: Trends and outcomes from a national database. Surgery 2019; 166:879-885. [PMID: 31288936 DOI: 10.1016/j.surg.2019.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/09/2019] [Accepted: 05/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Placement of paraesophageal type of "mesh" in paraesophageal hernia repair is controversial. This study examines the trends and outcomes of mesh placement in paraesophageal hernia repair. METHODS The American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent paraesophageal hernia repair with or without mesh (2010-2017). Demographics, operative approach, and outcomes were compared over time. RESULTS Of 25,801, most paraesophageal hernia repair cases were elective (89.3%), without mesh (61.9%), and performed laparoscopically (91.3%).When compared with open paraesophageal hernia repair patients, the patients undergoing laparoscopic paraesophageal hernia repair had lesser rates of reoperation, readmission, mortality, overall complications and major complications (2.7% vs 4.8%, 6.2% vs 9.6%, 0.6% vs 2.9%, 7.1% vs 21.3%, 3.8% vs 11.1%, respectively; all P < .0001). Mesh placement was more common in laparoscopic paraesophageal hernia repair (38.9 vs 29.7, P < .0001) than opern paraesophageal hernia repair. During 2010-2017, mesh placement decreased from 46.2% to 35.2% of laparoscopic paraesophageal hernia repair (P < .0001). Operative times for laparoscopic paraesophageal hernia repair decreased over time, and laparoscpic paraesophageal hernia repair without mesh was consistently less (with mesh: 176.0 ± 71.0 to 149.9 ± 72.5 min, without mesh: 148.6 ± 71.4 to 134.6 ± 70.4). We observed no changes in comorbidities or adverse outcomes over time. Using multivariate analysis to control for potential confounding factors, chronic obstructive pulmonary disease was associated most strongly with adverse outcomes, including mortality (OR 2.53, CI 1.55-4.14), any complications (OR 1.80, CI 1.51-2.16), major complications (OR 1.80, CI 1.51-2.16), readmission (OR 1.63, CI 1.33-1.99) and reoperation (OR 1.49, CI 1.10-2.02). Mesh placement was not associated with adverse outcomes. CONCLUSION The placement of mesh during laparoscopic paraesophageal hernia repair is not associated with adverse outcomes. Use of mesh with laparoscopic paraesophageal hernia repair is decreasing with no apparent adverse impact on short-term patient outcomes. Further research is needed to investigate patient factors not captured by this national database, such as characteristics of the hernia, patient symptoms, and hernia recurrence.
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Siboni S, Sozzi M, Bonavina L. What Is the Value of Preoperative Esophageal Manometry in Patients with Giant Paraesophageal Hernia? J Am Coll Surg 2019; 228:211-212. [DOI: 10.1016/j.jamcollsurg.2018.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 11/27/2018] [Indexed: 11/30/2022]
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Sathasivam R, Bussa G, Viswanath Y, Obuobi RB, Gill T, Reddy A, Shanmugam V, Gilliam A, Thambi P. ‘Mesh hiatal hernioplasty’ versus ‘suture cruroplasty’ in laparoscopic para-oesophageal hernia surgery; a systematic review and meta-analysis. Asian J Surg 2019; 42:53-60. [PMID: 29887394 DOI: 10.1016/j.asjsur.2018.05.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 04/27/2018] [Accepted: 05/01/2018] [Indexed: 11/24/2022] Open
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Lazar DJ, Birkett DH, Brams DM, Ford HA, Williamson C, Nepomnayshy D. Long-Term Patient-Reported Outcomes of Paraesophageal Hernia Repair. JSLS 2018; 21:JSLS.2017.00052. [PMID: 29162971 PMCID: PMC5683814 DOI: 10.4293/jsls.2017.00052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background and Objectives: There is a lack of consensus on the optimal repair technique and the definition of good outcomes in paraesophageal hernia (PEH) repair. We reviewed long-term patient-reported outcomes of open and laparoscopic PEH repair to assist with our future surgical consent process. Methods: This was a retrospective case–control study including all patients with PEH repair performed from 2000 through 2012 at a single center without the use of mesh. We mailed questionnaires to patients to assess reoperation, symptom control, and satisfaction. Results: Chart review identified 217 patients who underwent PEH repair. Nineteen died during the follow-up period. Of the 106 returning the questionnaire, 87 underwent laparoscopic repair, and 19 had open repair, with follow-up of 6.6 (SD 3.9) years and 7.0 (SD 4.1) years, respectively. Reoperation rates were 9.9% and 5.3%, respectively (P = .720). Dysphagia, heartburn, and regurgitation improved in 95.4% of patients after laparoscopic repair and 89.5% after open repair (P = .318). Medication for symptom control was necessary in 54.0% of patients after laparoscopic repair and 26.3% after open repair (P = .029). In each group, 90% stated that they would still choose to have the operation (P = .713). Conclusions: Long-term patient-specific outcomes showed comparable, encouraging results between open and laparoscopic repair of PEH without mesh reinforcement. However, half of those undergoing laparoscopic repair required the use of medication for symptom control. This study adds to the literature describing long-term patient-specific outcomes and can be useful when counseling patients about PEH repair.
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Affiliation(s)
- Damien J Lazar
- Tufts University School of Medicine, Boston, Massachusetts
| | | | | | | | - Christina Williamson
- Department of Cardiovascular and Thoracic Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
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Abu Saleh WK, Morris LM, Tariq N, Kim MP, Chan EY, Meisenbach LM, Dunkin BJ, Sherman V, Rosenberg W, Bass BL, Graviss EA, Nguyen DT, Reardon P, Khaitan PG. Routine use of mesh during hiatal closure is safe with no increase in adverse sequelae. Surg Endosc 2017; 32:879-888. [PMID: 28917000 DOI: 10.1007/s00464-017-5758-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 07/14/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Primary laparoscopic hiatal repair with fundoplication is associated with a high recurrence rate. We wanted to evaluate the potential risks posed by routine use of onlay-mesh during hiatal closure, when compared to primary repair. METHODS Utilizing single-institutional database, we identified patients who underwent primary laparoscopic hiatal repair from January 2005 through December 2014. Retrospective chart review was performed to determine perioperative morbidity and mortality. Long-term results were assessed by sending out a questionnaire. Results were tabulated and patients were divided into 2 groups: fundoplication with hiatal closure + absorbable or non-absorbable mesh and fundoplication with hiatal closure alone. RESULTS A total of 505 patients underwent primary laparoscopic fundoplication. Mesh reinforcement was used in 270 patients (53.5%). There was no significant difference in the 30-day perioperative outcomes between the 2 groups. No clinically apparent erosions were noted and no mesh required removal. Standard questionnaire was sent to 475 patients; 174 (36.6%) patients responded with a median follow-up of 4.29 years. Once again, no difference was noted between the 2 groups in terms of dysphagia, heartburn, long-term antacid use, or patient satisfaction. Of these, 15 patients (16.9%, 15/89) in the 'Mesh' cohort had symptomatic recurrence as compared to 19 patients (22.4%, 19/85) in the 'No Mesh' cohort (p = 0.362). A reoperation was necessary in 6 patients (6.7%) in the 'Mesh' cohort as compared to 3 patients (3.5%) in the 'No Mesh' cohort (p = 0.543). CONCLUSIONS Onlay-mesh use in laparoscopic hiatal repair with fundoplication is safe and has similar short and long-term results as primary repair.
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Affiliation(s)
- Walid K Abu Saleh
- Department of General Surgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - Lee M Morris
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Nabil Tariq
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Min P Kim
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
- Division of Thoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Edward Y Chan
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
- Division of Thoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Leonora M Meisenbach
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
- Division of Thoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Brian J Dunkin
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Vadim Sherman
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Wade Rosenberg
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Barbara L Bass
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Patrick Reardon
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Puja G Khaitan
- Department of General Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA.
- Division of Thoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA.
- Department of Surgery, Division of Thoracic Surgery, Houston Methodist Hospital, 6550 Fannin St., Smith Tower, Suite 1601, Houston, 77030, TX, USA.
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Systematic review and meta-analysis of laparoscopic mesh versus suture repair of hiatus hernia: objective and subjective outcomes. Surg Endosc 2017; 31:4913-4922. [PMID: 28523363 PMCID: PMC5715047 DOI: 10.1007/s00464-017-5586-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 05/02/2017] [Indexed: 12/16/2022]
Abstract
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.
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Prusa AM, Kristo I, Rieder E, Ringhofer C, Asari R, Miholic J, Schoppmann SF. Tension-Free Inlay Repair of Large Hiatal Hernias Using Dual-Sided Composite PTFE/ePTFE Meshes in Laparoscopic Surgery for Gastroesophageal Reflux Disease. J Laparoendosc Adv Surg Tech A 2017; 27:710-714. [PMID: 28445106 DOI: 10.1089/lap.2016.0371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with gastroesophageal reflux disease (GERD) also frequently suffer from concomitant hiatal hernia. It has been described that a preoperative hiatal hernia of ≥3 cm is associated with a more than threefold relative risk for reflux symptom recurrence after fundoplication without mesh reinforcement. In this report, we describe our experience with the implantation of dual-sided composite PTFE/ePTFE meshes in a tension-free fashion during laparoscopic antireflux surgery (LARS). METHODS A prospective database containing data of all patients undergoing LARS and hiatal hernia repair with mesh implantation from January 2009 until December 2014 was interrogated. Ten patients with preoperative esophageal high resolution manometry and 24-hour pH impedance monitoring because of symptoms suggestive of GERD who received hiatal repair using dual-sided meshes in inlay technique were identified and included in this analysis. RESULTS There were no conversions to open surgery in the study group. Median operative time was 138 minutes (interquartile range Q1-Q3: 119-151 minutes) and average length of postoperative stay was 3.5 days (interquartile range Q1-Q3: 2.3-4.0 days). During a median follow-up period of 43.3 months (interquartile range Q1-Q3: 18.9-47.1 months), no redo operations had to be performed. Noteworthy, 2 patients complained about dysphagia (20%) during follow-up, but symptoms resolved after endoscopic interventions. CONCLUSIONS Tension-free inlay repair of large hiatal hernias using dual-sided composite PTFE/ePTFE meshes during LARS provides promising results. It provides satisfactory symptom relief and prolonged control of GERD. Further studies to validate its efficiency in a larger collective are needed.
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Affiliation(s)
- Alexander M Prusa
- 1 Department of Surgery, Upper GI Service and Research, Medical University of Vienna , Vienna, Austria
| | - Ivan Kristo
- 1 Department of Surgery, Upper GI Service and Research, Medical University of Vienna , Vienna, Austria .,2 Manometry Laboratory, Department of Surgery, Medical University of Vienna , Vienna, Austria
| | - Erwin Rieder
- 1 Department of Surgery, Upper GI Service and Research, Medical University of Vienna , Vienna, Austria
| | - Claudia Ringhofer
- 1 Department of Surgery, Upper GI Service and Research, Medical University of Vienna , Vienna, Austria .,2 Manometry Laboratory, Department of Surgery, Medical University of Vienna , Vienna, Austria
| | - Reza Asari
- 1 Department of Surgery, Upper GI Service and Research, Medical University of Vienna , Vienna, Austria
| | - Johannes Miholic
- 3 Department of Surgery, Medical University of Vienna , Vienna, Austria
| | - Sebastian F Schoppmann
- 1 Department of Surgery, Upper GI Service and Research, Medical University of Vienna , Vienna, Austria .,2 Manometry Laboratory, Department of Surgery, Medical University of Vienna , Vienna, Austria
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26
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Asti E, Sironi A, Bonitta G, Lovece A, Milito P, Bonavina L. Crura augmentation with Bio-A ® mesh for laparoscopic repair of hiatal hernia: single-institution experience with 100 consecutive patients. Hernia 2017; 21:623-628. [PMID: 28396955 DOI: 10.1007/s10029-017-1603-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 04/04/2017] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- E Asti
- Division of General Surgery, IRCCS Policlinico San Donato, Department of Biomedical Sciences for Health, University of Milano Medical School, Piazza Malan 1, San Donato Milanese, 20097, Milano, Italy
| | - A Sironi
- Division of General Surgery, IRCCS Policlinico San Donato, Department of Biomedical Sciences for Health, University of Milano Medical School, Piazza Malan 1, San Donato Milanese, 20097, Milano, Italy
| | - G Bonitta
- Division of General Surgery, IRCCS Policlinico San Donato, Department of Biomedical Sciences for Health, University of Milano Medical School, Piazza Malan 1, San Donato Milanese, 20097, Milano, Italy
| | - A Lovece
- Division of General Surgery, IRCCS Policlinico San Donato, Department of Biomedical Sciences for Health, University of Milano Medical School, Piazza Malan 1, San Donato Milanese, 20097, Milano, Italy
| | - P Milito
- Division of General Surgery, IRCCS Policlinico San Donato, Department of Biomedical Sciences for Health, University of Milano Medical School, Piazza Malan 1, San Donato Milanese, 20097, Milano, Italy
| | - L Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, Department of Biomedical Sciences for Health, University of Milano Medical School, Piazza Malan 1, San Donato Milanese, 20097, Milano, Italy.
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