Paraesophageal hernia repair with biomesh does not increase postoperative dysphagia

Laparoscopic large hiatus hernia repair with mesh reinforcement versus suture cruroplasty alone: a systematic review and meta-analysis

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.

A Narrative Review on Treatment of Giant Hiatal Hernia

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.

Outcomes of Laparoscopic Redo Fundoplication in Patients With Failed Antireflux Surgery: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of this meta-analysis was to summarize the current available evidence regarding the surgical outcomes of laparoscopic redo fundoplication (LRF).

SUMMARY OF BACKGROUND DATA

Although antireflux surgery is highly effective, a minority of patients will require a LRF due to recurrent symptoms, mechanical failure, or intolerable side-effects of the primary repair.

METHODS

A systematic electronic search on LRF was conducted in the Medline database and Cochrane Central Register of Controlled Trials. Conversion and postoperative morbidity were used as primary endpoints to determine feasibility and safety. Symptom improvement, QoL improvement, and recurrence rates were used as secondary endpoints to assess efficacy. Heterogeneity across studies was tested with the Chi-square and the proportion of total variation attributable to heterogeneity was estimated by the inconsistency (I2) statistic. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) across all studies.

RESULTS

A total of 30 studies and 2,095 LRF were included. The mean age at reoperation was 53.3 years. The weighted pooled proportion of conversion was 6.02% (95% CI, 4.16%-8.91%) and the meta-analytic prevalence of major morbidity was 4.98% (95% CI, 3.31%-6.95%). The mean follow-up period was 25 (6-58) months. The weighted pooled proportion of symptom and QoL improvement was 78.50% (95% CI, 74.71%-82.03%) and 80.65% (95% CI, 75.80%-85.08%), respectively. The meta-analytic prevalence estimate of recurrence across the studies was 10.71% (95% CI, 7.74%-14.10%).

CONCLUSIONS

LRF is a feasible and safe procedure that provides symptom relief and improved QoL to the vast majority of patients. Although heterogeneously assessed, recurrence rates seem to be low. LRF should be considered a valuable treatment modality for patients with failed antireflux surgery.

Mesh reinforcement of paraesophageal hernia repair: Trends and outcomes from a national database

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.

Management of the Difficult Hiatal Hernia

The ideal operative solution to giant paraesophageal hernias involves a complex evaluation of the functional anatomy and the intraoperative assessment of both esophageal length and crural closure tension. The addition of surgical adjuncts such as extended transmediastinal dissection, Collis gastroplasty, and mesh reinforcement are all necessary, on an individualized basis, to address these 2 primary causes of hernia recurrence. We discuss the options available.

Biologic Keyhole Mesh in Hiatal Hernia Repair

Background and Objectives

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

Methods

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

Results

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

Conclusion

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

Laparoscopic surgical treatment of esophageal hiatal hernia

Types II, III and IV esophageal hiatal hernia (EHH) which presents obvious symptoms or leads to potentially fatal complications requires surgical treatment. Laparoscopy has been used to repair EHH in the last two decades globally and proved to be minimally invasive compared to conventional open surgery. This review summarizes current status and prospectives of laparoscopic application in EHH treatment. The published articles on minimally invasive laparoscopic surgical treatment of EHH in PubMed, Cochrane Library and EMBASE databases were retrieved and analyzed. From 1992 to 2015, 86 English articles involving a total of 4771 patients receiving laparoscopic treatment for EHH were retrieved. Perioperative information including safety and feasibility of procedure, postoperative complications, and short/long-term outcome after laparoscopic repair was retrospectively analyzed. Laparoscopic surgical treatment of EHH is a safe, feasible and minimally invasive procedure with fast recovery after repair, low postoperative morbidity and recurrence.

Functional Results after Repair of Large Hiatal Hernia by Use of a Biologic Mesh

BACKGROUND

The aim of this observational study is to analyze the results of patients with large hiatal hernia and upside-down stomach after surgical closure with a biological mesh (Permacol(®), Covidien, Neustadt an der Donau, Germany). Biological mesh is used to prevent long-term detrimental effects of artificial meshes and to reduce recurrence rates.

METHODS

A total of 13 patients with a large hiatal hernia and endothoracic stomach, who underwent surgery between 2010 and 2014, were included. Interviews and upper endoscopy were conducted to determine recurrences, lifestyle restrictions, and current complaints.

RESULTS

After a mean follow-up of 26 ± 18 months (range: 3-58 months), 10 patients (3 men, mean age 73 ± 13, range: 26-81 years) were evaluated. A small recurrent axial hernia was found in one patient postoperatively. Dysphagia was the most common complaint (four cases); while in one case, the problem was solved after endoscopic dilatation. In three cases, bloat and postprandial pain were documented. In one case, an explantation of the mesh was necessary due to mesh migration and painful adhesions. In one further case with gastroparesis, pyloroplasty was performed without success. The data are compared to the available literature. It was found that dysphagia and recurrence rates are unrelated both in biological and in synthetic meshes if the esophagus is encircled. In series preserving the esophagus at least partially uncoated, recurrences after the use of biological meshes relieve dysphagia. After the application of synthetic meshes, dysphagia is aggravated by recurrences.

CONCLUSION

Recurrence is rare after encircling hiatal hernia repair with the biological mesh Permacol(®). Dysphagia, gas bloat, and intra-abdominal pain are frequent complaints. Despite the small number of patients, it can be concluded that a biological mesh may be an alternative to synthetic meshes to reduce recurrences at least for up to 2 years. Our study demonstrates that local fibrosis and thickening of the mesh can affect the outcome being associated with abdominal discomfort despite a successful repair. The review of the literature indicates comparable results after 2 years with both biologic and synthetic meshes embracing the esophagus. At the same point in time, reconstruction with synthetic and biologic materials differs when the esophagus is not or only partially encircled in the repair. This is important since encircling artificial meshes can erode the esophagus after 5-10 years.

The Use of Biological Meshes in Diaphragmatic Defects - An Evidence-Based Review of the Literature

The widespread use of meshes for hiatal hernia repair has emerged in the era of laparoscopic surgery, although sporadic cases of mesh augmentation of traumatic diaphragmatic rupture have been reported. The indications for biologic meshes in diaphragmatic repair are ill defined. This systematic review aims to investigate the available evidence on the role of biologic meshes in diaphragmatic rupture and hiatal hernia repair. Limited data from sporadic case reports and case series have demonstrated that repair of traumatic diaphragmatic rupture with biologic mesh is safe technique in both the acute or chronic setting. High level evidence demonstrates short-term benefits of biologic mesh augmentation in hiatal hernia repair over primary repair, although adequate long-term data are not currently available. Long-term follow-up data suggest no benefit of hiatal hernia repair using porcine small intestine submucosa over suture repair. The effectiveness of different biologic mesh materials on hernia recurrence requires further investigation.

A systematic review and meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair

BACKGROUND

Equipoise exists regarding whether mesh cruroplasty during laparoscopic large hiatal hernia repair improves symptomatic outcomes compared with suture repair.

DATA SOURCE

Systematic literature review (MEDLINE and EMBASE) identified 13 studies (1,194 patients; 521 suture and 673 mesh) comparing mesh versus suture cruroplasty during laparoscopic repair of large hiatal hernia. We abstracted data regarding symptom assessment, objective recurrence, and reoperation and performed meta-analysis.

CONCLUSIONS

The majority of studies reported significant symptom improvement. Data were insufficient to evaluate symptomatic versus asymptomatic recurrence. Time to evaluation was skewed toward longer follow-up after suture cruroplasty. Odds of recurrence (odds ratio .51, 95% confidence interval .30 to .87; overall P = .014) but not need for reoperation (odds ratio .42, 95% confidence interval .13 to 1.37; overall P = .149) were less after mesh cruroplasty. Quality of evidence supporting routine use of mesh cruroplasty is low. Mesh should be used at surgeon discretion until additional studies evaluating symptomatic outcomes, quality of life, and long-term recurrence are available.

Effect of acellular human dermis buttress on laparoscopic hiatal hernia repair

PURPOSE

The objective of this study was to evaluate the performance of acellular human dermis reinforcement during laparoscopic hiatal hernia repair.

METHODS

A prospective non-randomized, single institution study enrolled patients undergoing laparoscopic hiatal hernia repair. Acellular human dermis, FlexHD (Musculoskeletal Transplant Foundation, Edison, NJ) or AlloDerm (LifeCell Inc., Branchburg, NJ) were used to buttress the repair after primary closure. A protocol barium swallow (BAS) was performed at 6 months and then as needed due to clinical indications. Primary outcome measure was recurrence. Patients completed preoperative and postoperative GERD symptom questionnaires and quality of life surveys (SF-36). Kruskal-Wallis ANOVA, Student's t test, Fisher's exact test, or Wilcoxon signed-rank test were utilized as appropriate (p < 0.05 considered statistically significant).

RESULTS

Fifty-four patients (10 men and 44 women) with a mean age of 62 ± 10 years underwent laparoscopic hiatal hernia repair using Flex HD (n = 37) or AlloDerm (n = 17). Both groups were similar with respect to gender, age, hiatus size, hernia type [sliding/Type I (n = 14) or paraesophageal/Type III/IV (n = 40)], esophageal motor function (manometry), preoperative SF-36 quality of life surveys, and GERD symptom questionnaires. Forty-seven patients (87 %) completed the BAS at 6 months; each group had two recurrences (p = 0.597). At median follow-up of 33 months, there were 3 recurrences (18 %) in the AlloDerm group and 5 recurrences (14 %) in the Flex HD group (p = 0.365). Minimal differences in GERD symptoms or SF-36 scores were detected between groups. However, anti-reflux medication usage, GERD symptoms, and quality of life significantly improved for both groups after laparoscopic hiatal hernia repair.

CONCLUSIONS

Laparoscopic hiatal hernia repair with acellular human dermis reinforcement results in improvement of GERD-related symptoms and quality of life without mesh-associated complications. The type of acellular human dermis did not influence recurrence rate.

Hiatal hernia repair with biologic mesh reinforcement reduces recurrence rate in small hiatal hernias

The utility of mesh reinforcement for small hiatal hernia found especially during antireflux surgery is unknown. Initial reports for the use of biological mesh for crural reinforcement during repair for defects greater than 5 cm have been shown to decrease recurrence rates. This study compares patients with small hiatal hernias who underwent onlay biologic mesh buttress repair versus those with suture cruroplasty alone. This is a single-institution retrospective review of all patients undergoing repair of hiatal hernia measuring 1-5 cm between 2002 and 2009. The patients were evaluated based on surgical repair: one group undergoing crural reinforcement with onlay biologic mesh and other group with suture cruroplasty only. Seventy patients with hiatal hernia measuring 1-5 cm were identified. Thirty-eight patients had hernia repair with biologic mesh, and 32 patients had repair with suture cruroplasty only. Recurrence rate at 1 year was 16% (5/32) in patients who had suture cruroplasty only and 0% (0/38) in the group with crural reinforcement with absorbable mesh (statistically significant, P = 0.017). Suture cruroplasty alone appears to be inadequate for hiatal hernias measuring 1-5 cm with significant recurrence rate and failure of antireflux surgery. Crural reinforcement with absorbable mesh may reduce hiatal hernia recurrence rate in small hiatal hernias.

Mesh in laparoscopic large hiatal hernia repair: a systematic review of the literature

BACKGROUND

The use of mesh is becoming more popular for large hiatal hernia (type II-IV) repair to reduce the recurrence rate. The aim of this study was to outline the currently available literature on the use of mesh in laparoscopic large hiatal hernia repair, emphasizing objective outcome.

METHODS

A structured search of the literature was performed in the Medline, Embase, and Cochrane Central Register of Controlled Trials databases.

RESULTS

A total of 26 studies met the inclusion criteria. There were three randomized controlled trials, seven prospective and five retrospective cohort studies, and five prospective and one retrospective case-control study. The study design was not reported in the remaining studies. In the included studies, laparoscopic hiatal hernia repair was performed with mesh in 924 patients (mesh group) and without mesh in 340 patients (nonmesh group). The type of mesh used was very different: polypropylene in six, biomesh in nine, polytetrafluoroethylene (PTFE) in two, expanded PTFE (ePTFE) in two, and composite polypropylene-PTFE in another two. At least two different kinds of mesh were used in five studies. Radiological and/or endoscopic follow-up was performed after a mean (± SEM) period of 25.2 ± 4.0 months. There was no or only a small recurrence (recurrent hiatal hernia <2 cm) in 385 of the 451 available patients (85.4 %) in the mesh group and in 182 of 247 (73.7 %) in the nonmesh group.

CONCLUSIONS

The use of mesh in the repair of large hiatal hernias is promising with respect to the reduction of anatomical recurrences. However, many different kinds and configurations of mesh are available. This systematic review of the literature is a basis for high-quality randomized controlled trials to obtain the most effective and safe mesh in the long term.

Allograft dermal matrix hiatoplasty during laparoscopic primary fundoplication, paraesophageal hernia repair, and reoperation for failed hiatal hernia repair

BACKGROUND

Hiatal repair failure is the nemesis of laparoscopic paraesophageal hernia repair as well as the major cause of failure of primary fundoplication and reoperation on the hiatus. Biologic prosthetics offer the promise of reinforcing the repair without risks associated with permanent prosthetics.

DESIGN

Retrospective evaluation of safety and relative efficacy of laparoscopic hiatal hernia repair using an allograft (acellular dermal matrix) onlay. Patients with symptomatic failures underwent endoscopic or radiographic assessment of hiatal status.

RESULTS

Greater than 6-month follow-up was available for 252 of 450 consecutive patients undergoing laparoscopic allograft-reinforced hiatal hernia repair between January 2007 and March 2011. No erosions, strictures, or persisting dysphagia were encountered. Adhesions were minimal in cases where reoperation was required. Failure of the hiatal repair at median 18 months (6-51 months) was significantly (p < 0.005) different between groups: group A (primary fundoplication with axial hernia ≤ 2 cm), 3.7 %; group B (primary fundoplication with axial hernia 2-5 cm), 7.1 %; group G (giant/paraesophageal), 8.8 %; group R (reoperative), 23.4 %. Additionally, mean time to failure was significantly shorter in group R (247 days) compared with the other groups (462-489 days).

CONCLUSIONS

Use of allograft reinforcement to the hiatus is safe at 18 months median follow-up. Reoperations had a significantly higher failure rate and shorter time to failure than the other groups despite allograft, suggesting that primary repairs require utmost attention and that additional techniques may be needed in reoperations. Patients with hiatal hernias >2 cm axially had a recurrence rate equal to that of patients undergoing paraesophageal hiatal hernia repair, and should be treated similarly.