Teflon pledget reinforced fundoplication causes symptomatic gastric and esophageal lumenal penetration

Mesh-related complications in paraoesophageal repair: a systematic review

BACKGROUND

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Laparoscopic gastric fundus tamponade: a novel adaptation of the Toupet fundoplication for large paraesophageal hernia repair

BACKGROUND

Laparoscopic repair of large paraesophageal hiatal hernia with defects too large to close primarily or greater than 8 cm is technically challenging. The ideal repair remains unclear and is often debated. Utilizing the gastric fundus as an autologous patch to obliterate and tamponade large hiatal defects may offer a new solution. The aim of this study was to evaluate the short-term outcomes following partial posterior fundoplication with gastric fundus tamponade.

METHODS

Retrospective chart review and prospective patient follow up was conducted on patients who underwent laparoscopic hiatal hernia repair between 2015 and 2019 by a single surgeon. Basic demographics, pre-operative diagnoses, operative technique, and clinical outcomes were recorded.

RESULTS

Fifteen patients underwent the described technique for repair of large paraesophageal hiatal hernia. All procedures were completed laparoscopically with a short post-operative length of stay (mean of 3 days) and no 30-day readmissions. The majority of patients reported resolution of their pre-operative symptoms. Only one patient required surgery for emergent indications and the same patient was the only mortality in the study, which was secondary to respiratory failure, necrotizing pneumonia, and sepsis as a result of gastric volvulus and obstruction.

CONCLUSION

Utilizing the gastric fundus as an autologous patch to repair large hiatal hernia may be a safe and efficacious solution with good short-term outcomes. However, further studies should be conducted to elucidate long-term results.

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

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

Intraoesophageal migration of Teflon pledgets used for hiatal hernia repair: a serious adverse event

11 months following an elective paraoesophageal hernia repair, a female patient presents to the emergency department with severe dysphagia. A CT showed a distention of the distal oesophagus caused by a foreign body and dense material inside and outside the oesophagus wall. A gastroscopy confirmed the presence of a bezoar and secondary oesophagitis due to the intraoesophageal migration of Teflon pledgets. Even when used appropriately, only for the crus repair, the use of Teflon pledgets may result in fistulisation through the oesophagus. This complication suggests that the use of Teflon pledgets to buttress a hiatal hernia repair should be used with caution and that an alternative technique (eg, resorbable pledgets) could be preferred.

Short-term results after laparoscopic repair of giant hiatal hernias with pledgeted sutures: a retrospective analysis

Purpose

This study investigates if pledgeted sutures for hiatal closure could be an alternative to mesh for the surgical treatment of large hiatal hernia.

Methods

Forty-one patients who underwent laparoscopic 270° Toupet fundoplication with pledgeted sutured crura between September 2014 and April 2017 were evaluated with regard to recurrence of hiatal hernia at 3 months and 1 year after surgery. Indication for pledgets was a hiatal surface area of at least 5.60 cm², or migration of more than 1/3 of the stomach into the thorax or preoperative hernia size > 5 cm. The integrity of repair was assessed using a barium swallow test 3 months and 1 year after surgery.

Results

All operations could be completed laparoscopically with no intraoperative complications. Until study end no complications related to the pledgets have occurred. Forty-four of 50 patients (88.0%) completed the follow-up radiographic examination 3 months (mean 12.7 weeks) after surgery, and 37 patients (74.0%; mean 55.1 weeks) 1 year after surgery. Postoperative recurrence was diagnosed in 3/44 patients (6.8%) at 3 months, and in 4/37 patients (10.8%) at 1 year follow-up. Only one patient was symptomatic, 1 year after surgery (2.7%). All other patients with reherniations were asymptomatic at time of the study.

Conclusions

Utilization of pledgets to reinforce hiatal sutures seems safe and shows a quite low early recurrence rate compared to other methods. Long-term data will allow firm conclusions as to whether pledgeted sutures are an appropriate solution for the treatment of giant hiatal hernias.

Gastro-oesophageal fistula in an achalasia patient following myotomy as an unusual cause of heartburn

We report a case of delayed presentation of a gastro-oesophageal fistula following a Heller myotomy and anterior fundoplication for achalasia in a 28-year-old man. After a period of symptom resolution following initial operation, dysphagia and severe heartburn commenced temporarily, related to non-steroidal anti-inflammatory drug (NSAID) use. Endoscopy demonstrated a secondary opening in the lower oesophagus and a barium swallow showed an oesophageal fistula to the stomach. Currently, reasonable symptom control has been obtained on double dose pantoprazole. Barium study best demonstrated the abnormality. NSAIDs should possibly be avoided in cases of severe dysmotility of the oesophagus.

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 Mesh-augmented Hiatoplasty With Cardiophrenicopexy Versus Laparoscopic Nissen Fundoplication for the Treatment of Gastroesophageal Reflux Disease: A Double-center Randomized Controlled Trial

OBJECTIVE

Laparoscopic mesh-augmented hiatoplasty with cardiophrenicopexy (LMAH-C) might represent an alternative treatment of gastroesophageal reflux disease (GERD) and may provide durable reflux control without fundoplication. The expected benefit is the prevention of fundoplication-related side effects. Aim of the present trial was to compare LMAH-C with laparoscopic Nissen fundoplication (LNF) in patients with GERD.

METHODS

In a double-center randomized controlled trial (RCT) patients with proven GERD were eligible and assigned by central randomization to either LMAH-C (n = 46) or LNF (n = 44). The indigestion subscore of the Gastrointestinal Symptom Rating Scale questionnaire (GSRS) indicating gas-related symptoms as possible side effects of LNF was the primary endpoint. Secondary endpoints comprised pH testing and endoscopy and other symptoms measured by the GSRS, dysphagia, and the Gastrointestinal Quality of Life Index. The follow-up period was 36 months.

RESULTS

Indigestion subscore (LMAH-C 2.9 ± 1.5 vs LNF 3.7 ± 1.6; P = 0.031) but not dysphagia (2.8 ± 1.9 vs 2.3 ± 1.7; P = 0.302) and quality of life (106.9 ± 25.5 vs 105.8 ± 24.9; P = 0.838) differed between the groups at 36 months postoperatively. Although the reflux subscore improved in both groups, it was worse in LMAH-C patients (2.5 ± 1.6 vs 1.6 ± 1.0; P = 0.004) corresponding to a treatment failure of 77.3% in LMAH-C patients and of 34.1% in LNF patients (P < 0.001).

CONCLUSIONS

LNF is more effective in the treatment of GERD than LMAH-C. Procedure-related side effects seem to exist but do not affect the quality of life. Laparoscopic fundoplication therefore remains the standard surgical treatment for GERD.

Use of Mesh in Laparoscopic Paraesophageal Hernia Repair: A Meta-Analysis and Risk-Benefit Analysis

Introduction

Mesh augmentation seems to reduce recurrences following laparoscopic paraesophageal hernia repair (LPHR). However, there is an uncertain risk of mesh-associated complications. Risk-benefit analysis might solve the dilemma.

Materials and Methods

A systematic literature search was performed to identify randomized controlled trials (RCTs) and observational clinical studies (OCSs) comparing laparoscopic mesh-augmented hiatoplasty (LMAH) with laparoscopic mesh-free hiatoplasty (LH) with regard to recurrences and complications. Random effects meta-analyses were performed to determine potential benefits of LMAH. All data regarding LMAH were used to estimate risk of mesh-associated complications. Risk-benefit analysis was performed using a Markov Monte Carlo decision-analytic model.

Results

Meta-analysis of 3 RCTs and 9 OCSs including 915 patients revealed a significantly lower recurrence rate for LMAH compared to LH (pooled proportions, 12.1% vs. 20.5%; odds ratio (OR), 0.55; 95% confidence interval (CI), 0.34 to 0.89; p = 0.04). Complication rates were comparable in both groups (pooled proportions, 15.3% vs. 14.2%; OR, 1.02; 95% CI, 0.63 to 1.65; p = 0.94). The systematic review of LMAH data yielded a mesh-associated complication rate of 1.9% (41/2121; 95% CI, 1.3% to 2.5%) for those series reporting at least one mesh-associated complication. The Markov Monte Carlo decision-analytic model revealed a procedure-related mortality rate of 1.6% for LMAH and 1.8% for LH.

Conclusions

Mesh application should be considered for LPHR because it reduces recurrences at least in the mid-term. Overall procedure-related complications and mortality seem to not be increased despite of potential mesh-associated complications.

Laparoscopic mesh-augmented hiatoplasty without fundoplication as a method to treat large hiatal hernias

Purpose

Laparoscopic hiatal hernia repair with additional fundoplication is a commonly recommended standard surgical treatment for symptomatic large hiatal hernias with paraesophageal involvement (PEH). However, due to the risk of persistent side effects, this method remains controversial. Laparoscopic mesh-augmented hiatoplasty without fundoplication (LMAH), which combines hiatal repair and mesh reinforcement, might therefore be an alternative.

Methods

In this retrospective study of 55 (25 male, 30 female) consecutive PEH patients, the perioperative course and symptomatic outcomes were analyzed after a mean follow-up of 72 months.

Results

The mean DeMeester symptom score decreased from 5.1 to 1.8 (P < 0.001) and the gas bloating value decreased from 1.2 to 0.5 (P = 0.001). The dysphagia value was 0.7 before surgery and 0.6 (P = 0.379) after surgery. The majority of the patients were able to belch and vomit (96 and 92 %, respectively). Acid-suppressive therapy on a regular basis was discontinued in 68 % of patients. In 4 % of patients, reoperation was necessary due to recurrent or persistent reflux. A mesh-related stenosis that required endoscopic dilatation occurred in 2 % of patients.

Conclusions

LMAH is feasible, safe and provides an anti-reflux effect, even without fundoplication. As operation-related side effects seem to be rare, LMAH is a potential treatment option for large hiatal hernias with paraesophageal involvement.

Modern treatment of paraesophageal hernia: preoperative evaluation and technique for laparoscopic repair

This article reviews the preoperative evaluation of patients with paraesophageal hernia (PEH) and details the principles and components of a laparoscopic PEH repair. Complete hernia sac dissection and excision, adequate esophageal mobilization, reapproximation of the crura, and creation of an antireflux barrier make up the key steps in any repair and are described. Although the preferred operative approach to PEH has undergone significant modification, especially since the introduction of minimally invasive laparoscopic techniques, many controversies still exist. The decision of whether to use mesh to reinforce the crural closure remains an unresolved issue in the surgical literature, and further evolution in this and other areas of PEH surgery is sure to occur in the near future.

Paraoesophageal herniation: a review

BACKGROUND

Paraoesophageal hiatus herniae repair can represent a formidable challenge. Afflicted patients tend to be elderly with multiple infirmities often with cardio-pulmonary dysfunction. They may present acutely with protracted vomiting and concurrent biochemical imbalances and it is a technically demanding procedure. There are several debated issues regarding operative technique. This paper will attempt to explain the nature of paraoesophageal hiatus herniae and reviews the recommended pre-operative investigations and operative strategies available.

METHODS

A literature search was performed from Pubmed and suitable clinical papers were selected for review. When attempting to address whether meshes should be included routinely, electronic searches were performed in PubMed, Embase and the Cochrane library. A systematic search was done with the following medical subject heading (MeSH) terms: 'paraoesophageal hernia repair' AND 'mesh'. In PubMed and Embase the search was carried out with the limits 'humans', 'English language', 'all adult: 19+ years' and 'published between 1990 and 2010'. A manual cross-reference search of the bibliographies of included papers was carried out to identify additional potentially relevant studies.

RESULTS

Firm conclusions are difficult to draw due to the diverse nature of both the disorder and the presentation however principals of management can be suggested. Similarly, there is no conclusive proof of the most effective operative technique and therefore the options are described.

CONCLUSION

Due to the relative lack of cases encountered at smaller institutions, there is a good argument for centralisation of these cases into regional centres to allow research and facilitate improvements in care.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pledgeted mattress sutures reduce recurrent reflux after laparoscopic Nissen fundoplication

INTRODUCTION

In response to a perceived increase in the incidence of recurrent reflux after adopting the laparoscopic Nissen fundoplication, we adjusted our technique to include the use of pledgeted, horizontal mattress sutures for crural closure and wrap construction.

METHODS

We assessed the impact of this technical modification in children who underwent laparoscopic fundoplication between 1997 and 2007 at a large children's hospital. The medical history, indications, technical details, and outcomes were reviewed. Differences between groups were assessed with chi(2), logistic regression, and Kaplan-Meier analysis.

RESULTS

A total of 384 subjects were identified. Neurologic deficits were present in 77%. The crural closure and wrap were constructed with simple sutures in 226 and with pledgeted, horizontal mattress sutures in 158. The cumulative incidences of recurrent reflux, gagging/retching, wrap failure on imaging studies, and reoperation were significantly greater with the use of simple sutures (P < .01, .03, < .01, and < .01, respectively). Kaplan-Meier analysis confirmed a significant difference in the probability of recurrent reflux with simple sutures despite a significant difference in postoperative follow-up. Operative time was the same with both methods.

CONCLUSIONS

The use of pledgeted, horizontal mattress sutures for crural closure and wrap construction in laparoscopic Nissen fundoplication may reduce the incidence of recurrent reflux.

Initial experience with laparoscopic crural closure in the management of hiatal hernia in obese patients undergoing sleeve gastrectomy

BACKGROUND

The prevalence of gastroesophageal reflux disease (GERD) and/or hiatal hernia (HH) is significantly increased in morbidly obese patients. Laparoscopic bariatric procedures such as gastric banding (LGB) and Roux-en-Y gastric bypass have been shown to improve both obesity and reflux symptoms. The aim of this paper is to evaluate the effectiveness of laparoscopic sleeve gastrectomy (LSG) and hiatal hernia repair (HHR) for the treatment of obesity complicated by HH.

METHODS

From October 2008, six patients underwent HHR in addition to LSG. Clinical outcomes have been evaluated in terms of GERD symptoms improvement or resolution, interruption of antireflux medication, and X-ray evidence of HH recurrence.

RESULTS

Symptomatic HH was diagnosed preoperatively in four patients. In two additional patients, HH was asymptomatic and it was diagnosed intraoperatively. Prosthetic reinforcement of crural closure was performed in two symptomatic cases with a HH >5 cm. Mortality was nil and no complications occurred. After a mean follow-up of 4 months, GERD symptoms resolution occurred in three patients, while the other patient reported an improvement of reflux. Body mass index had fallen from 43.4 to 36.2 kg/m(2). A small recurrence in the patient with persistence of reflux symptoms has been radiologically reported.

CONCLUSIONS

Laparoscopic crural closure in addition to LSG could represent a valuable option for the synchronous management of morbid obesity and HH, providing good outcomes in terms of weight loss and GERD symptoms control.

Severe complication of laparoscopic mesh hiatoplasty for paraesophageal hernia

BACKGROUND

Several studies have shown that laparoscopic hernia repair for large paraesophageal hiatal hernia is associated with a high recurrence rate. Therefore, some authors recommend the use of prosthetic meshes. Considering the dynamic area between the esophagus and the diaphragmatic crura with its constant motion, it is astonishing that only a minor number of surgeons describe mesh-associated complications.

METHODS

Between January 2000 and August 2008, 26 patients of the Centre Hospitalier Emile Mayrisch (CHEM, Luxembourg) underwent laparoscopic repair for large paraesophageal hiatal hernia (median age, 70 (range, 39-90) years). In nine patients, prosthetic mesh reinforcement was performed (7 composite/2 mono-phase mesh). Crural repair without tension was performed only with sutures. There were no conversions. Follow-up assessment was prospective with the GIQL (Gastro-Intestinal Quality of Life) Index.

RESULTS

Responses to the GIQLI questionnaires were obtained from 20 patients (6 died of unrelated causes). Nineteen patients were satisfied with their symptom control 1 year after the operation (GIQLI 127). Sixteen patients had radiological follow-up (median, 24 months). Three patients treated without mesh (3/10) showed a radiological recurrence. All of them (3/10) had symptoms. None of the controlled patients with mesh (0/6) showed a recurrence. One patient developed a severe aortal bleeding 1, 2, and 3 weeks after the laparoscopic mono-phase mesh repair. During conventional operation, the bleeding stopped. Three years later, the follow-up showed a satisfied patient (GIQLI 127).

CONCLUSIONS

In view of the described complication, there is still considerable controversy regarding the routine use of mesh. To increase safety, a composite mesh should be preferred.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Current controversies in paraesophageal hernia repair

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Collagen metabolism and recurrent hiatal hernia: cause and effect?

Hiatus hernia (HH) is a condition characterized by herniation of the intra-abdominal organs into the thorax. Of the several types that have been identified, the most common is type I (sliding) HH. Congenital predisposition and acquired factors, for example trauma and iatrogeny, have been identified as causative factors. There is a strong association between gastroesophageal reflux disease and HH-the prevalence of reflux in HH may reach 94%. Many methods have been used to treat reflux disease and HH, among which are laparoscopic techniques, which gained popularity as a safe method of treatment. Primary crural repair without mesh application was found to have a recurrence rate of up to 42%. This led to the introduction of mesh in HH repair, which was associated with a significant decrease in recurrence rate. Collagen and its relation to hernia have been investigated for several decades. Collagen has mechanical properties sufficient to enable it to support healed scars and other tissues. Nineteen distinct types of collagen have been recognized, the most common of which are types I and III. Type III collagen is the major constituent of early granulation tissue whereas type I predominates as healing proceeds. Collagen fibers are imbedded in extracellular matrix (ECM), which is in continuous process of synthesis and degradation under the action of matrix metalloproteinases. Many authors have studied the role of collagen in ventral hernia and have even defined hernia as a disease of the ECM. The relationship between collagen and HH, and its recurrence, is not fully understood and needs further investigation.

Late gastric perforations after laparoscopic fundoplication

BACKGROUND

Late complications are rarely encountered after laparoscopic Nissen fundoplication. These complications include acute gastric herniation through the esophageal hiatus, port-site herniation, recurrent reflux, and anatomic failure of the fundoplication. Only three cases of late gastric perforation after laparoscopic Nissen fundoplication have been reported, all associated with intrathoracic wrap herniation.

METHODS

We retrospectively reviewed all cases of gastric perforation after laparoscopic antireflux procedures performed between July 1991 and March 2002 by a single surgeon.

RESULTS

In this series of 1,600 laparoscopic antireflux procedures, we found six delayed gastric fundal perforations occurring in three patients at 1, 41, 48, 51, 68, and 72 months after surgery. All the perforations were on the anterior wall of the fundus of the stomach and were distant from the stitches of the fundoplication. None of the perforations was associated with severe peritoneal contamination.

CONCLUSIONS

This series of late gastric fundal perforations in 0.2% of our patients after laparoscopic fundoplication may have been caused by medications, gastric stasis, ischemia, or a foreign body such as a stitch or Teflon pledget.

Laparoscopic hiatal hernia repair with human acellular dermal matrix patch: our initial experience

BACKGROUND

The laparoscopic repair of large hiatal hernia followed by an antireflux procedure is currently the gold standard therapy for gastroesophgeal reflux disease. However, it is recognized that recurrent hiatal herniation and wrap migration are major sources of operative failures in these patients. Some have described a reduction of such events with the placement of nonbiodegradable prosthetic patches over the primary cruroplasty. This prosthetic material may be associated with transesophageal and gastric erosions and a higher rate of postoperative dysphagia and chest pain when compared with simple suture cruroplasty alone. The aim of this study is to compare hiatal closure with a biodegradable patch (acellular dermal matrix) and simple suture curaplasty in patients undergoing laparoscopic antireflux surgery.

METHODS

A total of 44 patients were prospectively enrolled in this study. Twenty-two consecutive patients undergoing large hiatal hernia repair (>5 cm) and fundoplication with primary suture cruroplasty only (group 1) were compared with 22 consecutive patients undergoing the same procedure with suture cruroplasty reinforced with an onlay acellular dermal matrix patch (group 2). The 2 groups were compared with regards to demographics, size of the hiatal hernia, pre- and postoperative symptom scores, pH studies, operative times, and hiatal hernia recurrence.

RESULTS

Patients in both groups were well matched by age, weight, height, and size of hiatal hernia. There were similar preoperative values in esophageal manometry, 24-hour pH monitoring, and symptom scoring in both groups. Average operative time was 108 minutes in group 1 and 121 minutes in group 2. There were no major complications in either group. The median period of hospitalization was 1 day in both groups. Postoperative pH studies and symptoms score data were significantly improved in both groups. There was no significant difference in postoperative symptoms scores for dysphagia between the 2 groups. Two patients (one in each group) underwent esophageal dilatation for mild dysphagia postoperatively. In group 1, 2 patients (9%) had Nissen failure with hiatal hernia recurrences 6 months after surgery. There were no recurrences for the follow-up period in group 2.

CONCLUSIONS

Our early results suggest that hiatal hernia repair reinforced with an acellular dermal matrix patch may reduce the incidence of recurrent herniation and wrap migration. In addition, the increase in postoperative dysphagia, chest pain, and esophageal erosions associated with nondegradable mesh has not been observed in those with an acellular dermal matrix patch to this point in our follow up. However, future investigation of the material for this particular application as well as longer follow-up is necessary.

Laparoscopic mesh hiatoplasty for paraesophageal hernias and fundoplications: a critical analysis of the available literature

BACKGROUND

Little grade A medical evidence exists to support the use of prosthetic material for hiatal closure. Therefore, the authors compiled and analyzed all the available literature to determine whether the use of prosthetic mesh in hiatoplasty for routine laparoscopic fundoplications (LF) or for the repair of large (>5 cm) paraesophageal hernias (PEH) would decrease recurrence.

METHODS

A literature search was performed using an inclusive list of relevant search terms via Medline/PubMed to identify papers (n = 19) describing the use of prosthetic material to repair the crura of patients undergoing laparoscopic PEH reduction, LF, or both.

RESULTS

Case series (n = 5), retrospective reviews (n = 6), and prospective randomized (n = 4) and nonrandomized (n = 4) trials were identified. Laparoscopic procedures (n = 1,368) were performed for PEH, gastroesophageal reflux disease (GERD), hiatal hernia, or a combination of the three. Group A (n = 729) had primary suture repair of the crura, and group B (n = 639) had repair with either interposition of mesh to close the hiatus or onlay of prosthetic material after hiatal or crural closure. The use of mesh was associated with fewer recurrences than primary suture repair in both the LF and PEH groups. The mean follow-up period did not differ between the groups (20.7 months for group A vs. 19.2 months for group B). None of the papers cited any instance of prosthetic erosion into the gastrointestinal tract.

CONCLUSIONS

The current data tend to support the use of prosthetic materials for hiatal repair in both routine LF and the repair of large PEHs. Longer and more stringent follow-up evaluation is necessary to delineate better the safety profile of mesh hiatoplasty. Future randomized trials are needed to confirm that mesh repair is superior to simple crural closure.

Prosthetic closure of the esophageal hiatus in large hiatal hernia repair and laparoscopic antireflux surgery

BACKGROUND

Laparoscopy has become the standard surgical approach to both surgery for gastroesophageal reflux disease and large/paraesophageal hiatal hernia repair with excellent long-term results and high patient satisfaction. However, several studies have shown that laparoscopic hiatal hernia repair is associated with high recurrence rates. Therefore, some authors recommend the use of prosthetic meshes for either laparoscopic large hiatal hernia repair or laparoscopic antireflux surgery. The aim of this article was to review available studies regarding the evolution, different techniques, results, and future perspectives concerning the use of prosthetic materials for closure of the esophageal hiatus.

METHODS

A search of electronic databases, including Medline and Embase, was performed to identify available articles regarding prosthetic hiatal closure for large hiatal or paraesophageal hernia repair and/or laparoscopic antireflux surgery. Techniques and results as well as recurrence rates and complications related to the use of prosthetics for hiatal closure were reviewed and compared. Additionally, recent experiences and recommendations of experienced experts in this field were collected.

RESULTS

The results of 42 studies were analyzed in this review. Some techniques of mesh hiatal closure were evaluated; however, most authors prefer posterior mesh cruroplasty. The type and shape of hiatal meshes vary from small angular meshes to A-shaped, V-shaped, or complete circular meshes. The most frequently utilized materials are polypropylene, polytetrafluoroethylene, or dual meshes. All studies show a low rate of postoperative hernia recurrence, with no mortality and low morbidity. In particular, comparative studies including two prospective randomized trials comparing simple sutured hiatal closure to prosthetic hiatal closure show a significantly lower rate of postoperative hiatal hernia recurrence and/or intrathoracic wrap migration in patients who underwent prosthetic hiatal closure.

CONCLUSIONS

Laparoscopic large hiatal/paraesophageal hernia repair with prosthetic meshes as well as laparoscopic antireflux surgery with prosthetic hiatal closure are safe and effective procedures to prevent hiatal hernia recurrence and/or postoperative intrathoracic wrap migration, with low complication rates. The type of mesh, particularly the size and shape, is still controversial and is a matter for future research in this field.

Technical Controversies in Fundoplication Surgery

Gastroesophageal reflux disease (GERD) is a common health problem affecting more than 50% of the population. For those who experience more than occasional symptoms, GERD has a profound effect on their quality of life. With the advent of laparoscopic surgery, fundoplication has been used to treat GERD. Fundoplication also is used in the surgical management of paraesophageal hernias. Technical controversies are addressed in this article, including open versus laparoscopic approaches, the choice of complete (360 degres) or partial fundoplication, whether or not a gastroplasty is required, and the use of prosthetic materials in crural repair.