Clinical evaluation of laparoscopic repair of large hiatal hernias with TiMesh

Quality of life after giant hiatus hernia repair: A systematic review

BACKGROUND

Elective surgery is the treatment of choice for symptomatic giant hiatus hernia (GHH), and quality of life (QoL) has become an important outcome measure following surgery. The aim of this study is to review the literature assessing QoL following repair of GHH.

METHODOLOGY

A systematic literature search was performed by two reviewers independently to identify original studies evaluating QoL outcomes after GHH surgery. MeSH terms such as paraoesophageal; hiatus hernia; giant hiatus hernia and quality of life were used in the initial search. Original studies in English language using validated questionnaires on humans were included. Review articles, conference abstracts and case reports and studies with duplicate data were excluded.

RESULTS

Two hundred and eight articles were identified on initial search, of which 38 studies (4404 patients) were included. Studies showed a significant heterogeneity in QoL assessment tools, surgical techniques and follow-up methods. All studies assessing both pre-operative and post-operative QoL (n = 31) reported improved QoL on follow-up after surgical repair of GHH. Improvement in QoL following GHH repair was not affected by patient age, surgical technique or the use of mesh. Recurrence of GHH after surgery may, however, adversely impact QoL.

CONCLUSION

Surgical repair of GHH improved QoL scores in all the 38 studies. The impact of recurrence on QoL needs further assessment. The authors also recommend uniform reporting of surgical outcomes in future studies.

Critical appraisal of the impact of surgical repair of type II-IV paraoesophageal hernia (POH) on pulmonary improvement: A systematic review and meta-analysis

BACKGROUND

Paraoesophageal hernia (POH) comprising type II-IV hiatal hernia often presents with pulmonary symptoms such as shortness of breath. However, impact of surgical repair on improvement in pulmonary symptoms is unclear.

OBJECTIVE

This systematic review and meta-analysis aimed at characterising impact of POH repair on patient reported improvement in pulmonary symptoms.

METHODS

This systematic review identified studies reported pulmonary symptoms in patients with undergoing surgical repair for Type II-IV POH from 1st January 2001 to 1st December 2018. Primary outcome was improvement in pulmonary symptoms. Secondary outcomes were improvement in other patient-reported outcomes such as heartburn, regurgitation, chest pain, and dysphagia and intraoperative and postoperative outcomes.

RESULTS

This systematic review identified 27 studies (n = 4428 patients) reporting assessment of pulmonary symptoms. However, only 21 studies (n = 2902 patients) reported preoperative and postoperative pulmonary symptoms and hence these were included in the final meta-analysis. There was significant improvement in pulmonary symptoms following POH repair (OR: 8.40, CI_95%: 4.91-14.35, p < 0.001), with improvement in all types of POH. Rates of overall and major complications were 16% and 5%, respectively. Rates of conversion, 30-day mortality, reoperation and recurrence were 2%, 1% 4% and 12% respectively.

CONCLUSION

This review demonstrates that POH repair is associated with improvement in pulmonary symptoms with acceptable low laparoscopic conversion rates, morbidity, mortality and recurrence rates.

Assessment of short-term outcome with TiO2 mesh in laparoscopic repair of large paraesophageal hiatal hernias

Background

Laparoscopic large para-oesophageal hiatal hernia (LPHH) repair using mesh reinforcement significantly reduces postoperative recurrence rates compared to conventional suture repair, especially within short follow-up times. However, the ideal strategy for repairing LPHH remains disputable because no clear guidelines are given regarding indications, mesh type, shape or position. The aim of this study was to survey our short-term results of LPHH management with a biosynthetic monofilament polypropylene mesh coated with titanium dioxide to enhance biocompatibility (TiO₂Mesh™).

Methods

A retrospective study was performed at Ramon y Cajal University Hospital, Spain from December 2014 to October 2018. Data were collected on 27 consecutive patients with extensive hiatal hernia defects greater than 5 cm for which a laparoscopic repair was performed by primary suture and additional reinforcement with a TiO₂Mesh™. Study outcomes were investigated, including clinical and radiological recurrences, dysphagia and mesh-related drawbacks.

Results

Twenty-seven patients were included in our analysis; 10 patients were male, and 17 were female. The mean age was 73 years (range, 63–79 years). All operations were performed laparoscopically. The median postoperative hospital stay was 3 days. After a mean follow-up of 18 months (range, 8-29 months), only 3 patients developed clinical recurrence of reflux symptoms (11%), and 2 had radiological recurrences (7%). No mesh-related complications occurred.

Conclusions

TiO₂Mesh™ was found to be safe for laparoscopic repair of LPHH with a fairly low recurrence rate in this short-term study. Long-term studies conducted over a period of years with large sample sizes will be essential for confirming whether this mesh is suitable as a standard method of care with few drawbacks.

[Hiatus hernia : Standards and controversies in diagnostics and treatment]

A hiatus hernia is defined as a transdiaphragmatic protrusion/migration of the intrabdominal contents through the esophageal hiatus of the diaphragm. The classification of hiatus hernias is based on anatomical morphological differentiation (types I-IV). The leading symptoms and psychological stress vary with respect to the symptoms, e. g. reflux and compression symptoms. Gastroscopy and multichannel intraluminal impedance pH measurement are obligatory preoperative functional diagnostics. A distinction is made between frequent type I hernia (antireflux surgery), symptomatic paraesophageal, thoracic and mixed hernia types (II-IV). Surgical indications exist in symptomatic type II-IV hernias. Hiatal mesh augmentation reduces recurrences. The complication potential of synthetic meshes must be taken into account. Biological implants show no advantages.

[Operative treatment of hiatus hernia : Evidence on mesh inlay]

High rates of recurrence in hiatus hernia and antireflux surgery led to the introduction of different methods for diaphragm closure. Prosthetic diaphragm closure with meshes remains a controversial issue in the literature. Available data show lower recurrence rates after prosthetic diaphragm closure; however, there is no clear standard for the indications and technique. Despite the availability of a few prospective randomized trials, a clear recommendation regarding this issue cannot currently be given.

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.

The choice of primary repair or mesh repair for paraesophageal hernia: a decision analysis based on utility scores

BACKGROUND

Controversy exists on the use of mesh in the repair of paraesophageal hernias (PEH). This debate centers around the type of mesh used, its value in preventing recurrence, its short- and long-term complications, and the consequences of those complications compared with primary repair. Decision analysis is a method to account for the important aspects of a clinical decision. The purpose of this study was to determine whether or not the addition of mesh would be superior in PEH repair.

METHODS

A decision analysis model of the choice between primary repair and mesh repair of a PEH was constructed. The essential features of the decision were the rate of perioperative complications, PEH recurrence rate, reoperation rate after recurrence, rate of symptomatic recurrence, and type of outcome after reoperation. The literature was reviewed to obtain data for the decision analysis and the average rates used in the baseline analysis. A utility score was used as the outcome measure, with a perfect outcome receiving a score of 100 and death 0. Sensitivity analysis was used to determine if changing the rates of recurrence or reoperation changed the dominant treatment.

RESULTS

Using the baseline analysis, mesh repair was slightly superior to primary repair (utility score 99.59 vs 99.12, respectively). However, if recurrence rates were similar, primary repair would be slightly superior; whereas if reoperation rates were similar, mesh repair would be superior. Using sensitivity analysis, there are combinations of recurrence rates and reoperation rates that would make one repair superior to the other. However, these differences are relatively small.

CONCLUSIONS

Depending on what the decision-maker accepts as the recurrence and reoperation rates for these types of repair, either mesh or primary repair may be the treatment of choice. However, the differences between the two are small, and, perhaps, clinically inconsequential.

Laparoscopic upper gut surgery

Australian surgeons have been prominent in the introduction, development, and consolidation of laparoscopic surgery of the upper gut. In doing this, some of the very best principles of surgical innovation have been in evidence: preliminary animal work in which to test hypotheses and techniques, followed by careful application and documentation in the clinical setting, randomized clinical trials and finally academic reporting and ongoing development. This review documents the introduction of laparoscopic surgery for gastroesophageal reflux, hiatus hernia, achalasia, gastroesophageal malignancy, obesity, and a range of emergency conditions in Australia. Those involved are regarded as world leaders in their field. A vital component of this success has been the close cooperation between surgeons and gastroenterologists within the Gastroenterological Society of Australia.

Fibrin sealant (Tisseel) for hiatal mesh fixation in an experimental model in pigs

BACKGROUND

This study was designed to assess the efficacy of the fibrin sealant fixation of titanized polypropylene mesh in experimental hiatal mesh closure in pigs. Prosthetic hiatal closure is recommended for the repair of large hiatal/paraesophageal hernias as well as for antireflux surgery. However, only limited data exist on the favorable choice of meshes and fixation devices. Migration of the implant and trauma to neighboring organs due to perforating devices, such as sutures or tacks, present potentially lethal complications. In this study, we propose the fixation of titanized polypropylene meshes (TS) specifically developed for hiatal closure (TISure; GfE Medizintechnik GmbH, Nuremberg, Germany) with human fibrin sealant (FS, Tisseel; Baxter Biosciences, Vienna, Austria).

MATERIALS AND METHODS

A laparotomy was carried out in 7 mini-pigs (27-30 kg bodyweight) under general anaesthesia, and a TS was implanted after precise dissection of the right and left crura and the crural commissure. The key hole of the TS was placed around the esophagus at the gastroesophageal junction. One mL of FS was applied with the Easy Spray system (Baxter Biosciences, Vienna, Austria) for circular and three dimensional mesh fixation onto the diaphragm. Due to the lack of accepted gold standards of hiatal mesh reinforcement, no control group was used. Animals were sacrificed after 4 wk, and meshes were explanted after macroscopical assessment of the correct position and tissue integration. Histology was performed.

RESULTS

All meshes showed excellent tissue integration and no signs of migration or dislocation. FS was completely degraded and replaced by well vascularized fibroblastic tissue.

CONCLUSIONS

Titanized polypropylene mesh with FS fixation was found to be a safe and efficient combination for reinforcement of the hiatal closure in this preliminary experimental model.