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

Hiatal hernia repair with biosynthetic mesh reinforcement: a qualitative systematic review

INTRODUCTION

Reinforcement of crural closure with synthetic resorbable mesh has been proposed to decrease recurrence rates after hiatal hernia repair, but continues to be controversial. This systematic review aims to evaluate the safety, efficacy, and intermediate-term results of using biosynthetic mesh to augment the hiatus.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed throughout this systematic review. The Risk of Bias in Non-Randomized Studies of Interventions and Risk of Bias in Randomized Trials tools were used to perform qualitative assessment of all studies included in this review. Recommendations were then summarized for the following pre-defined key items: protocol, research question, search strategy, study eligibility, data extraction, study design, risk of bias, publication bias, and statistical analysis.

RESULTS

The systematic literature search found 520 articles, 101 of which were duplicates and 355 articles were determined to be unrelated to our study and excluded. The full text of the remaining 64 articles was thoroughly assessed. A total of 18 articles (1846 patients) were ultimately included for this review, describing hiatal hernia repair using three different biosynthetic meshes-BIO-A, Phasix ST, and polyglactin mesh. Mean operative time varied from 127 to 223 min. Mean follow up varied from 12 to 54 months. There were no mesh erosions or explants. One mesh-related complication of stenosis requiring reoperation was reported with BIO-A. Studies showed significant improvement in symptom and quality-of-life scores, as well as satisfaction with surgery. Recurrence was reported as radiologic or clinical recurrence. Overall, recurrence rate varied from 0.9 to 25%.

CONCLUSION

The use of biosynthetic mesh is safe and effective for hiatal hernia repair with low complications rates and high symptom resolution. The reported recurrence rates are highly variable due to significant heterogeneity in defining and evaluating recurrences. Further randomized controlled trials with larger samples and long-term follow-up should be performed to better analyze outcomes and recurrence rates.

Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper

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.

Does bioabsorbable mesh reduce hiatal hernia recurrence rates? A meta-analysis

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.

Surgical treatment of large and complicated hiatal hernias with the new resorbable mesh with hydrogel barrier (Phasix™ ST): a preliminary study

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 360^o 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.

Medium-term safety and efficacy profile of paraesophageal hernia repair with Phasix-ST® mesh: a single-institution experience

BACKGROUND

Hernia recurrence after laparoscopic repair is a perplexing problem. In an effort to reduce anatomical and clinical recurrences, different type of meshes have been used to bolster the esophageal hiatus.

OBJECTIVE

The aim of this study was to assess safety, medium-term efficacy, and quality of life improvement after laparoscopic repair of hiatal hernia reinforced with a biosynthetic absorbable mesh (Phasix-ST^®).

METHODS

Observational single-center retrospective single-arm cohort study (November 2015-February 2021). We included all adult patients (> 18 years old) who underwent laparoscopic paraesophageal hernia repair with Phasix-ST^® mesh and Toupet fundoplication.

RESULTS

Sixty-eight patients were included. The median postoperative stay was 3.2 days (range 2-9) and the postoperative complication rate was 11.7%. The median follow-up time was 27 months (range 1-53). No mesh-related complications were detected. Hernia recurrence was diagnosed in six patients (8.8%). The recurrence-free probability at 34 months was 0.89 (95% CI 0.807-0.988) while at 60 months was 0.86 (95% CI 0.76-0.97). Hernia recurrences were mostly observed between 21 and 36 months after the operation. None of the patients required surgical revision and all were managed with PPI. Postoperative dysphagia requiring endoscopic balloon dilatation occurred in 2.9% of patients. Compared to baseline, both the GERD-HRQL (15.2 ± 6.2 vs. 3.2 ± 3.1; p = 0.026) and all SF-36 items were significantly improved (p < 0.001).

CONCLUSIONS

Laparoscopic crura augmentation with Phasix-ST^® mesh combined with a Toupet fundoplication is safe and seems effective in the medium-term follow-up. Phasix-ST^® crural reinforcement resulted in low hernia recurrence rate with a sustained symptoms and quality of life improvement.

Characteristics and outcomes of patients undergoing paraesophageal hernia repair with selective use of biologic mesh

BACKGROUND

The use of biologic mesh in paraesophageal hernia repair (PEHR) has been associated with decreased short-term recurrence but no statistically significant difference in long-term recurrence. Because of this, we transitioned from routine to selective use of mesh for PEHR. The aim of this study was to examine our indications for selective mesh use and to evaluate patient outcomes in this population.

METHODS

We queried a prospectively maintained database for patients who underwent laparoscopic PEHR with biologic mesh from October 2015 to October 2018, then performed a retrospective chart review. The decision to use mesh was made intraoperatively by the surgeon. Recurrence was defined as the presence of > 2 cm intrathoracic stomach on postoperative upper gastrointestinal (UGI) series.

RESULTS

Mesh was used in 61/169 (36%) of first-time PEHRs, and in 47/82 (57%) of redo PEHRs. Among first-time PEHRs, the indications for mesh included hiatal tension (85%), poor crural tissue quality (11%), or both (5%). Radiographic recurrence occurred in 15% of first-time patients (symptomatic N = 2, asymptomatic N = 3). There were no reoperations for recurrence. Among redo PEHRs, the indication for mesh was most commonly the redo nature of the repair itself (55%), but also hiatal tension (51%), poor crural tissue quality (13%), or both (4%). Radiographic recurrence occurred in 21% of patients (symptomatic N = 4, asymptomatic N = 1). There was 1 reoperation for recurrence in the redo-repair group.

CONCLUSIONS

We selectively use biologic mesh in a third of our first-time repair patients and in over half of our redo-repair patients when there is a perceived high risk of recurrence based on hiatal tension, poor tissue quality, or prior recurrence. Despite the high risk for radiologic recurrence, there was only 1 reoperation for recurrence in the entire cohort.

Paraesophageal hernia: to fundoplicate or not?

The need for an antireflux procedure during repair of a paraesophageal hernia (PEH) has been the subject of a long-standing controversy. With most centers now performing routine fundoplication during PEH repair, high-quality data on whether crural repair alone or using a mesh may provide adequate anti-reflux effect is still scarce. We sought to answer to the question: "Is fundoplication routinely needed during PEH repair?". Our endpoints were (I) rates of postoperative gastroesophageal reflux disease (GERD) (either symptomatic or objectively assessed), (II) rates of recurrence, and (III) rates of postoperative dysphagia. We searched the MEDLINE, Cochrane, PubMed, and Embase databases for papers published between 1995 and 2019, selecting comparative cohort studies and only including papers reporting the rationale for performing or not performing fundoplication. Overall, nine papers were included for review. While four of the included studies recommended selective or no fundoplication, most of these data come from earlier retrospective studies. Higher-quality data from recent prospective studies including two randomized controlled trials recommended routine fundoplication, mostly due to a significantly lower incidence of postoperative GERD. However, only a relatively short follow-up of 12 months was presented, which we recognize as an important limitation. Fundoplication did not seem to result in reduced recurrence rates when compared to primary repair alone.

Concomitant hiatal hernia repair during bariatric surgery: does the reinforcement make the difference?

BACKGROUND

Hiatal hernia repair (HHR) is still controversial during bariatric procedures, especially in case of laparoscopic sleeve gastrectomy (LSG).

AIMS

to report the long-term results of concomitant HHR, evaluating the safety and efficacy of posterior cruroplasty (PC), simple or reinforced with biosynthetic, absorbable Bio-A^® mesh (Gore, Flagstaff, AZ, USA). Primary endpoint: PC's failure, defined as symptomatic HH recurrence, nonresponding to medical treatment and requiring revisional surgery.

METHODS

The prospective database of 1876 bariatric operations performed in a center of excellence between 2011-2019 was searched for concomitant HHR. Intraoperative measurement of the hiatal surface area (HSA) was performed routinely.

RESULTS

A total of 250 patients undergone bariatric surgery and concomitant HHR (13%). Simple PC (group A, 151 patients) was performed during 130 LSG, 5 re-sleeves and 16 gastric bypasses; mean BMI 43.4±5.8 kg/m², HSA mean size 3.4±2 cm². Reinforced PC (group B) was performed in 99 cases: 62 primary LSG, 22 LGB and 15 revisions of LSG; mean BMI 44.6±7.7 kg/m2, HSA mean size 6.7±2 cm². PC's failure, with intrathoracic migration (ITM) of the LSG was encountered in 12 cases (8%) of simple vs. only 4 cases (4%) of reinforced PC (P=0.23); hence, a repeat, reinforced PC and R-en-Y gastric bypass (LRYGB) was performed laparoscopically in all cases. No mesh-related complications were registered perioperatively or after long-term follow-up (mean 50 months). One case of cardiac metaplasia without goblet cells was detected 4 years postoperatively; conversion to LRYGB, with reinforced redo of the PC was performed. The Cox hazard analysis showed that the use of more than four stitches for cruroplasty represents a negative factor on recurrence (HR=8; P<0.05).

CONCLUSIONS

An aggressive search for and repair of HH during any bariatric procedure seems advisable, allowing a low HH recurrence rates. Additional measures, like mesh reinforcement of crural closure with biosynthetic, absorbable mesh, seem to improve results on long term follow-up, especially in case of larger hiatal defects. In our experience, reinforcement of even smaller defects seems advisable in obese population.

A Collective Review of Gore Bio-A Absorbable Synthetic Mesh in Cruroplasty Reinforcement

Background: Laparoscopic repair of hiatal hernia (HH) is associated with a considerable failure rate. Compared to suture repair alone, mesh-reinforced cruroplasty may be associated with fewer short-term recurrences, yet its use remains controversial. The aim of this study was to analyze the current literature assessing the use of Bio-A absorbable synthetic mesh in the reinforcement of primary crural closure after laparoscopic HH repair. Methods: A systematic review of primary literature in the MEDLINE and PubMed databases was conducted. We searched for investigations reporting patient outcomes in laparoscopic HH repair with onlay Gore Bio-A tissue reinforcement (W. L. Gore & Associates, Inc.) published between January 2008 and December 2019. The primary outcome was anatomical recurrence rate. Secondary outcomes were complication rate, symptomatic outcomes, and mortality. Results: Eight studies met inclusion criteria. There were two prospective and six retrospective cohort studies. In the included studies, laparoscopic HH repair was performed with Bio-A absorbable synthetic mesh in 734 patients. The anatomical recurrence data were extracted across all studies, and an objective recurrence was identified in 21/280 (7.5%) patients. There was only 1 (0.17%) mesh-related complication in the included studies. Conclusions: The use of Bio-A absorbable synthetic mesh in the repair of HHs may be promising, as it offers low rates of anatomical recurrence and mesh-related complications, but more data are still necessary to validate these findings. This collective review of literature is a basis for future randomized controlled trials to identify the most effective and safe mesh in the long term.

Five Year Follow-up of a Randomized Controlled Trial of Laparoscopic Repair of Very Large Hiatus Hernia With Sutures Versus Absorbable Versus Nonabsorbable Mesh

OBJECTIVE

To determine whether absorbable or nonabsorbable mesh repair of large hiatus hernias is followed by less recurrences at late follow-up compared to sutured repair.

SUMMARY OF BACKGROUND DATA

Radiological recurrences have been reported in up to 30% of patients after repair of large hiatus hernias, and mesh repair has been proposed as a solution. Earlier trials have revealed mixed outcomes and early outcomes from a trial reported previously revealed no short-term advantages for mesh repair.

METHODS

Multicentre prospective double-blind randomized controlled trial of 3 methods of hiatus hernia repair; sutures versus absorbable mesh versus nonabsorbable mesh. Primary outcome - hernia recurrence assessed by barium meal X-ray and endoscopy at 3-4 years. Secondary outcomes - clinical symptom scores at 2, 3, and 5 years.

RESULTS

126 patients were enrolled - 43 sutures, 41 absorbable mesh, and 42 nonabsorbable mesh. Clinical outcomes were obtained at 5 years in 89.9%, and objective follow-up was obtained in 72.3%. A recurrent hernia (any size) was identified in 39.3% after suture repair, 56.7% - absorbable mesh, and 42.9% - nonabsorbable mesh (P = 0.371). Clinical outcomes were similar at 5 years, except chest pain, diarrhea, and bloat symptoms which were more common after repair with absorbable mesh.

CONCLUSIONS

No advantages were demonstrated for mesh repair at up to 5 years follow-up, and symptom outcomes were worse after repair with absorbable mesh. The longer-term results from this trial do not support mesh repair for large hiatus hernias.

The use of biosynthetic mesh in giant hiatal hernia repair: is there a rationale? A 3-year single-center experience

PURPOSE

Reinforced prosthetic crural repair is particularly indicated for giant hiatal hernias. The rationale is to reduce the recurrence rate in the long term. The aim of our study is to evaluate the outcomes of laparoscopic giant hiatal hernia repair using a biosynthetic mesh.

METHODS

We retrospectively analyzed 44 patients who underwent laparoscopic mesh-reinforced hiatal closure and fundoplication using a biosynthetic material. Inclusion criterion was large hiatal defects (> 5 cm). Follow-up was scheduled at 6, 12 and 36 months after surgery.

RESULTS

44 patients (29F) with a mean age of 62 years (range 14-85) and mean of BMI 24.5 kg/m² (range 21-29) underwent successful laparoscopic repair. Twenty-six (59.1%) patients had Nissen-Rossetti fundoplication, whereas 18 (40.9%) had Toupet fundoplication. Six-month questionnaire for the evaluation of symptoms was available for 43 patients (97.7%) and for 40 (90.9%) patients at 12 and 36 months. Mean preoperative symptoms score analysis was 1.68 ± 0.73. Mean scores at each follow-up time were significantly improved compared to baseline (p > 0.05). Barium swallow was available in 37 patients (84.1%) at 1 year after surgery. Radiologic recurrence was observed in two patients (4.5%). No patient had symptoms attributable to recurrence or required revisional surgery. There were no mesh-related complications at 3 years follow-up.

CONCLUSIONS

The use of biosynthetic mesh for crural reinforcement is associated with a low incidence of mesh-related complications and with a reasonably low recurrence rate (4.5%) at 36 months. However, additional data with longer follow-up are needed to determine long-term safety and efficacy.

Platelet-rich plasma PRP vs. absorbable mesh as cruroplasty reinforcement: a study on an animal model

BACKGROUND

Reinforcement of posterior cruroplasty has been proposed to minimize the failure of hiatal hernia repair (HHR). The applications of autologous platelet-rich plasma (PRP) and absorbable mesh are barely reported in this area.

AIMS

To analyze local macroscopic and microscopic changes induced by mesh vs. PRP as reinforcement of HHR, using a reliable laparoscopic experimental porcine model.

MATERIAL AND METHODS

This prospective, comparative pilot study was conducted on 14 female pigs, aged four to six months. An iatrogenic hiatal defect was laparoscopically simulated and repaired, reinforced with Bio-A® mesh (group A) or PRP (group B). Specimen retrieval was performed after seven months for histopathological (HP) examination.

RESULTS

No local or general complications were registered, with complete resorption of reinforcements, that determined inflammatory infiltrates with local collagen production and tissue neo-vascularization. Group A had an increased mean chronic inflammation score (p = .3061), showing significant sclerotic collagenizing process. PRP enhanced angiogenesis, collagenizing, myofibroblast recruitment and tissue ingrowth.

CONCLUSIONS

No residual materials or evidence of anatomical distortion were found. Animal model was safe and reliable. This is the first report of complete absorption of Bio-A^® positioned on crural area. HP results suggest the clinical application of PRP in HHR as a promising co-adjuvant to local remodeling and healing.Abbreviations: ASA: American Society of Anesthesiologists; AB: Alcian Blue; PAS: Periodic Acid-Schiff; CP: platelet concentrate; fPC: filtered plasma concentrate; GERD: gastro-esophageal reflux disease; HSA: hiatal surface area; HHR: hiatal hernia repair; HP: histopathological; HH: hiatal hernia; HE: hematoxylin and eosin; HR: hiatus repair alone; HRM: hiatus repair and acellular dermal matrix; NM: Nicolae Manolesccu; LNF: laparoscopic Nissen fundoplication; PC: posterior cruroplasty; PPP: platelet-poor plasma; RP: platelet-rich plasma.

Laparoscopic repair of a giant hiatal hernia after minimally invasive oesophagectomy

Minimally invasive oesophagectomy has become popular, but studies showed a higher rate of postoperative hiatus hernia compared with open oesophagectomy. Our video presents the laparoscopic biosynthetic mesh repair of a symptomatic giant hiatus hernia in a 71-year-old man who had undergone minimally invasive oesophagectomy one year earlier for distal adenocarcinoma of the oesophagus. The operative time was 120 minutes. The patient started oral intake on postoperative day one and was discharged on postoperative day three. Postoperative computed tomography at six months showed no signs of recurrence. In the setting of a symptomatic hiatus hernia post-minimally invasive oesophagectomy, we suggest an initial laparoscopic approach, because of its countless advantages.

Anatomic Observation of Recurrent Hiatal Hernia: Recurrence or Disease Progression?

BACKGROUND

Recurrence after hiatal hernia repair is common. The causes are uncertain. Our observation is the site of recurrence is primarily the nonsutured or nonreinforced anterior-left lateral portion of the hiatus. Our aim was to assess the distribution of hiatal hernia recurrence location as a basis for developing a theory of recurrence.

METHODS

Consecutive patients who underwent repair of recurrent hiatal hernias from March 2012 to December 2019 were reviewed. Data collected included age, sex, date of operation, location of hiatal hernia recurrence, operative approach, method of hiatal hernia repair, fundoplication performed, need for gastrectomy, and additional procedures.

RESULTS

One hundred and eight consecutive patients were studied. The distribution of recurrence locations was as follows: anterior 67%, posterior 12%, and circumferential 21%. Foreshortened esophagus was a contributing factor in 12%. Median time from the original repair to recurrence was 1.5 years (interquartile range 0.9 to 3.75 years) for posterior recurrences, 2.75 years (interquartile range 1.15 to 8.5 years) for circumferential recurrences, and 3.25 years (interquartile range 1.38 to 10 years) for anterior recurrences. Recurrences were repaired in a variety of techniques, depending on the clinical circumstances.

CONCLUSIONS

Hiatal hernia recurrences due to failure of the crural closure were less common, but early, recurrences. The majority of recurrences were due to stretching of the hiatus anterior and to the left of the esophagus. We theorize that the pathophysiology of late hiatal hernia recurrence is widening of the anterior and left lateral portion of the hiatus secondary to repeated stress from differential pressures that eventually overcomes the tensile strength of the hiatus.

Safety and Efficacy of Crura Augmentation with Phasix ST Mesh for Large Hiatal Hernia: 3-Year Single-Center Experience

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.

Repair of Adult Benign Tracheoesophageal Fistulae With Absorbable Patches: Single-Center Experience

BACKGROUND

This group previously reported on the repair of a wide tracheoesophageal fistula with a bioabsorbable patch. The current study describes a consecutive series of patients operated on using the same technique.

METHODS

Data of patients undergoing surgical closure of tracheoesophageal fistula at a single center from 2011 to 2018 were extracted and analyzed.

RESULTS

An absorbable patch was used in 8 of 23 patients (34.8%) operated on for tracheoesophageal fistula during the study period. Causes of the fistulae included postintubation injury (n = 6), mediastinal radiotherapy (n = 1), and a complication of lung resection (n = 1). The median fistula size was 27.5 mm (range, 15 to 45 mm). In 3 patients, the surgical approach was through cervicotomy and in 5 it was through right thoracotomy. Prosthetic materials consisted of Gore Bio-A (W.L. Gore & Associates, Inc, Newark, DE) tissue reinforcement in 6 patients and polyglactin 910 knitted mesh in 2 patients. In every case, the prosthesis was covered with a pedicled muscle flap. The esophageal defect was treated by primary closure in 7 patients and by esophageal exclusion in 1. Fistula recurrence and postoperative death occurred in 1 patient (12.5%), whereas 7 patients experienced postoperative complications (87.5%). Five patients resumed oral intake, and 3 breathed without a tracheal appliance. Compared with the other patients, in those who underwent repair of their fistula using a prosthesis, the median size of the airway defect was larger, morbidity was greater, and the rate of resumption of oral intake was lower.

CONCLUSIONS

Repair of tracheoesophageal fistulae with synthetic prostheses is feasible and may be effective in complex cases. Further research is needed to identify the ideal prosthetic material.

Retrospective Review and Prospective Follow-up of 85 Consecutive Patients Treated With a Novel Hepatic-derived Surgical Mesh for Hiatal Hernia Repair: Outcomes, Surgical Complications, and Revisions

This study examined outcomes, surgical complications, and revisions in patients treated with laparoscopic Nissen fundoplication for hiatal hernia and substantial gastroesophageal reflux disease. In total, 85 consecutive patients who underwent hernia repair with MIROMESH Biologic Matrix, a novel hepatic-derived surgical mesh served as subjects. Subjects were contacted by phone, consented, and participated in an Institutional Review Board-approved structured phone interview. Responses were acquired from 73 of the 85 patients. The gastroesophageal reflux disease health-related quality of life showed significant improvement postoperatively. Subjects reported high satisfaction with the procedure. The use of proton pump inhibitors was significantly reduced. Three minor complications were reported; these were quickly resolved without further sequelae. There were no mesh-related complications. No subjects reported further surgery. Placement of the surgical mesh, during surgery, to reinforce the hiatal repair was easy and safe. Excellent outcomes and no revisions a mean of 1.3 years after surgery suggest that a durable repair had been achieved.

Use of absorbable meshes in laparoscopic paraesophageal hernia repair

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

Mid-term safety profile evaluation of Bio-A absorbable synthetic mesh as cruroplasty reinforcement

PURPOSE

The aim of the present paper is to report the results of a single institution series of hiatal hernia repair (HHR) with augmented mesh hiatoplasty focusing on safety and efficacy profile of Bio-A absorbable synthetic mesh.

MATERIALS AND METHODS

A retrospective evaluation of prospectively maintained database showed 120 consecutive patients submitted to HHR reinforced with bio-absorbable synthetic mesh. The study populations included two groups: (A) 92 obese patients-reinforced hiatoplasty concurrent with bariatric procedure; (B) 28 non-obese patients-reinforced hiatoplasty concurrent with antireflux surgery. Symptoms assessment was made with GERD-HRQL and Rome III. The X-ray with barium swallow, the CT scan, in selected cases, and the endoscopy were used as recurrence evaluation and as endoscopic complications assessment. Only patients with a mean follow-up of 12 months were included in this study. A Cox hazard was made to evaluate factors affecting the recurrence.

RESULTS

No case of intra-peri and post-operative (mean follow-up of 41 months) complications mesh related were registered. The dysphagia-rate was 8.7% for Group A and 11% for Group B. 74% of Group A and 61% of Group B patients are actually PPIs free with median GERD-HRQL score of 4 (from 16) and 6 (from 23), respectively (difference pre-post-operative < 0.05). Recurrence rate was 5.4% in Group A and 7.1% in Group B. The Cox hazard analysis showed that the use of more than four stitches for cruroplasty represents a negative factor on recurrence (HR = 8; p < 0.05).

CONCLUSIONS

This is, in our knowledge, the largest report (120 consecutive patients) with mid-term follow-up (41 months of mean FU) on bio-absorbable mesh on the hiatus in obese and non-obese patients. These results supports the use of absorbable mesh for HHR (safe profile-0% of complications rate), showing excellent recurrence rate results and good GERD symptoms control.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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