Laparoscopic augmentation of the diaphragmatic hiatus with biologic mesh versus suture repair: a systematic review and meta-analysis

Medium term (> 12 months) outcomes after laparoscopic hiatal hernia repair without conventional fundoplication using PH4B-mesh implant (Phasix™) in 176 reflux patients: experience and technique

BACKGROUND

Hiatal mesh repair remains a controversial topic among anti-reflux surgeons. Biosynthetic mesh cruroplasty may prevent early recurrence while avoiding late esophageal erosion and strictures associated with non-resorbable materials. So far, medium-term results on hiatal PH4B (Poly-4-Hydroxybutyrate) mesh repair from high-volume centers are lacking.

METHODS

We analyzed the medium-term efficacy and safety of PH4B mesh cruroplasty in 176 consecutive patients (≥ 18 years) with symptomatic hiatal hernias. Treatment failure was defined as the clinical recurrence of reflux symptoms. Patients could choose between mesh augmented hiatal repair (combined with a modified anterior hemifundoplication and fundophrenicopexy), Nissen fundoplication, and magnetic sphincter augmentation at their discretion. We also describe the surgical approach to mesh augmented hiatal repair used at our center.

RESULTS

On average, patients were 55 (± 14) years old and followed up for 22 (± 7; sum: 3931) months. Treatment failed in 6/176 (3%, 95% CI: 2-7%) patients. The 24-month Kaplan-Meier failure estimate was 2.8% (95% CI: 0.4-5%). Each centimeter in hernia size increased the risk of failure by 52% (p = 0.02). Heavier patients (BMI > 27) had an 11% higher probability of clinical symptom recurrence (p = 0.03). The dysphagia and bloating/gas rate were 13/176 (7%), each. 8 (5%) patients required endoscopy due to dysphagia but without intervention. No serious complications, including mesh infection and erosion, or fatalities, occurred.

CONCLUSION

Augmented PH4B mesh cruroplasty without conventional fundoplication shows excellent intermediate-term results in patients with reflux disease due to hiatal hernia. Around one in thirty patients experience treatment failure within 2 years of surgery. Hernia size and overweight are key determinants of treatment failure.

Evidence mapping on how to perform an optimal surgical repair of large hiatal hernias

BACKGROUND

Symptomatic and large hiatal hernia (HH) is a common disorder requiring surgical management. However, there is a lack of systematic, evidence-based recommendations summarizing recent reviews on surgical treatment of symptomatic HH. Therefore, this systematic review aimed to create evidence mapping on the key technical issues of HH repair based on the highest available evidence.

METHODS

A systematic review identified studies on eight key issues of large symptomatic HH repair. The literature was screened for the highest level of evidence (LE from level 1 to 5) according to the Oxford Center for evidence-based medicine's scale. For each topic, only studies of the highest available level of evidence were considered.

RESULTS

Out of the 28.783 studies matching the keyword algorithm, 47 were considered. The following recommendations could be deduced: minimally invasive surgery is the recommended approach (LE 1a); a complete hernia sac dissection should be considered (LE 3b); extensive division of short gastric vessels cannot be recommended; however, limited dissection of the most upper vessels may be helpful for a floppy fundoplication (LE 1a); vagus nerve should be preserved (LE 3b); a dorso-ventral cruroplasty is recommended (LE 1b); routine fundoplication should be considered to prevent postoperative gastroesophageal reflux (LE 2b); posterior partial fundoplication should be favored over other forms of fundoplication (LE 1a); mesh augmentation is indicated in large HH with paraesophageal involvement (LE 1a).

CONCLUSION

The current evidence mapping is a reasonable instrument based on the best evidence available to guide surgeons in determining optimal symptomatic and large HH repair.

Mesh Versus No Mesh for Cruroplasty

This review describes the evolution of hiatal hernia repair for the past several decades: From the use of a primary tissue repair only, the subsequent inclusion of synthetic mesh and its complications, to current day indications for mesh use. We will highlight the recent research in biologic and composite meshes as well as the ongoing limitations in studying their efficacy. Finally, we will describe our institutional indications and surgical technique practices in the utilization of biologic mesh.

A Systematic Review Examining the Experimental Methodology Behind In Vivo Testing of Hiatus Hernia and Diaphragmatic Hernia Mesh

INTRODUCTION

Mesh implants are regularly used to help repair both hiatus hernias (HH) and diaphragmatic hernias (DH). In vivo studies are used to test not only mesh safety, but increasingly comparative efficacy. Our work examines the field of in vivo mesh testing for HH and DH models to establish current practices and standards.

METHOD

This systematic review was registered with PROSPERO. Medline and Embase databases were searched for relevant in vivo studies. Forty-four articles were identified and underwent abstract review, where 22 were excluded. Four further studies were excluded after full-text review-leaving 18 to undergo data extraction.

RESULTS

Of 18 studies identified, 9 used an in vivo HH model and 9 a DH model. Five studies undertook mechanical testing on tissue samples-all uniaxial in nature. Testing strip widths ranged from 1-20 mm (median 3 mm). Testing speeds varied from 1.5-60 mm/minute. Upon histology, the most commonly assessed structural and cellular factors were neovascularisation and macrophages respectively (n = 9 each). Structural analysis was mostly qualitative, where cellular analysis was equally likely to be quantitative. Eleven studies assessed adhesion formation, of which 8 used one of four scoring systems. Eight studies measured mesh shrinkage.

DISCUSSION

In vivo studies assessing mesh for HH and DH repair are uncommon. Within this relatively young field, we encourage surgical and materials testing institutions to discuss its standardisation.

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.

When should we use mesh in laparoscopic hiatal hernia repair? A systematic review

The use of mesh in laparoscopic hiatal hernia repair (LHHR) remains controversial. The aim of this systematic review was to determine the usefulness of mesh in patients with large hiatal hernia (HH), obesity, recurrent HH, and complicated HH. We performed a systematic review of the current literature regarding the outcomes of LHHR with mesh reinforcement. All articles between 2000 and 2020 describing LHHR with primary suturing, mesh reinforcement, or those comparing both techniques were included. Symptom improvement, quality of life (QoL) improvement, and recurrence rates were evaluated in patients with large HH, obesity, recurrent HH, and complicated HH. Reported outcomes of the use of mesh in patients with large HH had wide variability and heterogeneity. Morbidly obese patients with HH should undergo a weight-loss procedure. However, the benefits of HH repair with mesh are unclear in these patients. Mesh reinforcement during redo LHHR may be beneficial in terms of QoL improvement and hernia recurrence. There is scarce evidence supporting the use of mesh in patients undergoing LHHR for complicated HH. Current data are heterogeneous and have failed to find significant differences when comparing primary suturing with mesh reinforcement. Further research is needed to determine in which patients undergoing LHHR mesh placement would be beneficial.

[Use of Mesh in Hiatal Hernia Repair and Gastroesophageal Reflux Disease - Pro]

Net augmentation in surgical care of hiatus hernias has many advantages, but is still controversial. Optimal surgical treatment of symptomatic hiatus hernia is to provide long-term correction of the malposition of the stomach and other organs that have been displaced in the thorax, as well as reducing the necessity of risky reoperations. In order to assess the role of net augmentation in repair of the hiatus here, the benefit in the form of the avoidance of symptomatic recurrence and reoperations must be balanced against the risk of net-associated complications. In the present review article, we present a detailed evaluation of current evidence on net augmentation. We conclude that net augmentation in large hernias (> 5 cm), with or without paraesophageal involvement, should be routinely employed, as this reduces the risk of recurrence and the need for complex reoperations with a high risk of complications. Net-associated complications are rare and can largely be avoided with the correct implantation technique and proper net materials. The level of evidence could be improved if more validated register and randomised controlled studies were performed.

Biologic Mesh in Surgery: A Comprehensive Review and Meta-Analysis of Selected Outcomes in 51 Studies and 6079 Patients

BACKGROUND

In recent decades, biologic mesh (BM) has become an important adjunct to surgical practice. Recent evidence-based clinical applications of BM include but are not limited to: reconstruction of abdominal wall defects; breast reconstruction; face, head and neck surgery; periodontal surgery; other hernia repairs (diaphragmatic, hiatal/paraesophageal, inguinal and perineal); hand surgery; and shoulder arthroplasty. Prior systematic reviews of BM in complex abdominal wall hernia repair had several shortcomings that our comprehensive review seeks to address, including exclusion of laparoscopic repair, assessment of risk of bias, use of an acceptable meta-analytic method and review of risk factors identified in multivariable regression analyses.

MATERIALS AND METHODS

We sought articles of BM for open ventral hernia repair reporting on early complications, late complications or recurrences and included minimum of 50. We used the quality in prognostic studies risk of bias assessment tool. Random effects meta-analysis was applied.

RESULTS

This comprehensive review selected 62 articles from 51 studies that included 6,079 patients. Meta-analytic pooling found that early complications are present in about 50%, surgical site occurrences (SSOs) in 37%, surgical site infections (SSIs) in 18%, reoperation in 7%, readmission in 20% and mortality in 3%. Meta-analytic estimates of late outcomes included overall complications (42%), SSOs (40%) and SSIs (22%). Specific SSOs included seroma (14%), hematoma (4%), abscess (10%), necrosis (5%), dehiscence (8%) and fistula formation (5%). Reoperation occurred in about 17%, mesh explantation in 9% and recurrence in 36%.

CONCLUSION

Estimates of nearly all outcomes from individual studies were highly heterogeneous and sensitivity analyses and meta-regressions generally failed to explain this heterogeneity. Recurrence is the only outcome for which there are consistent findings for risk factors. Bridge placement of BM is associated with higher risk of recurrence. Prior hernia repair, history of reintervention and history of mesh removal were also risk factors for increased recurrence.

What Is the Reality of Hiatal Hernia Management?-A Registry Analysis

Introduction: To date, the guidelines for surgical repair of hiatal hernias do not contain any clear recommendations on the hiatoplasty technique with regard to the use of a mesh or to the type of fundoplication (Nissen vs. Toupet). This present 10-years analysis of data from the Herniamed Registry aims to investigate these questions.

Methods: Data on 17,328 elective hiatal hernia repairs were entered into the Herniamed Registry between 01.01.2010 and 31.12.2019. 96.4% of all repairs were completed by laparoscopic technique. One-year follow-up was available for 11,280 of 13,859 (81.4%) patients operated during the years 2010–2018. The explorative Fisher's exact test was used for statistical calculation of significant differences with an alpha = 5%. Since the annual number of cases in the Herniamed Registry in the years 2010–2012 was still relatively low, to identify significant differences the years 2013 and 2019 were compared.

Results: The use of mesh hiatoplasty for axial and recurrent hiatal hernias remained stable over the years from 2013 to 2019 at 20 and 45%, respectively. In the same period the use of mesh hiatoplasty for paraesophageal hiatal hernia slightly, but significantly, increased from 33.0 to 38.9%. The proportion of Nissen and Toupet fundoplications for axial hiatal hernia repair dropped from 90.2% in 2013 to 74.0% in 2019 in favor of “other techniques” at 20.9%. For the paraesophageal hiatal hernias (types II–IV) the proportion of Nissen and Toupet fundoplications was 68.1% in 2013 and 66.0% in 2019. The paraesophageal hiatal hernia repairs included a proportion of gastropexy procedures of 21.7% in 2013 and 18.7% in 2019. The recurrent hiatal hernia repairs also included a proportion of gastropexies 12.8% in 2013 and 15.1% in 2019, Nissen and Toupet fundoplications of 72.7 and 62.7%, respectively, and “other techniques” of 14.5 and 22.2%, respectively. No changes were seen in the postoperative complication and recurrence rates.

Conclusion: Clear trends are seen in hiatal hernia repair. The use of meshes has only slightly increased in paraesophageal hiatal hernia repairs. The use of alternative techniques has resulted in a reduction in the use of the “classic” Nissen and Toupet fundoplication surgical techniques.

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.

Short-Term Outcomes in Patients Undergoing Paraesophageal Hiatal Hernia Repair

Many patients with hiatal hernias (HH) are asymptomatic; however, symptoms may include heartburn, regurgitation, dysphagia, nausea, or vague epigastric pain depending on the hernia type and severity. The ideal technique and timing of repair remains controversial. This report describes short-term outcomes and readmissions of patients undergoing HH repair at our institution. All patients who underwent HH repair from January 2012 through April 2017 were reviewed. Patients undergoing concomitant bariatric surgery were excluded. 239 patients were identified and 128 were included. Eighty-eight were female (69%) and 40 were male (31%) with a mean age of 59 years (range 20–91 years) and a mean BMI of 29.2 kg/m² (17–42). Worsening GERD was the most common presenting symptom in 79 (61.7%) patients. Eighty-four laparoscopic cases (65.6%) and 44 robotic assisted (34.4%) procedures were performed. Mesh was used in 59 operations (3 polytetrafluoroethylene; 56 biologic). All hiatal hernia types (I-IV) were collected. Majority were initial operations (89%). Techniques included: Toupet fundoplication in 68 cases (63.0%), Nissen fundoplication in 36 (33.3%), Dor fundoplication in 4 (3.7%), concomitant Collis gastroplasty in 4 (3.1%), and primary suture repair in 20 (15.6%). Outcomes between robotic and laparoscopic procedures were compared. Length of stay was reported as median and interquartile range for laparoscopic and robotic: 1.0 day (1.0–3.0) and 2.0 days (1.0–2.5); p = 0.483. Thirty-day readmission occurred in 9 patients, 7 (8.3%) laparoscopic and 2 (4.6%) robotic; p = 0.718. Two 30-day reoperations occurred, both laparoscopic; p = 0.545. Total of 16 complications occurred; 18.6% had a complication with the use of mesh compared to 8.7% without the use of mesh, p = 0.063. There were no conversion to open modality and no mortalities were reported. Hiatal hernia repair can be performed safely with a low incidence of complications.

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.

Minimally invasive surgery for large hiatal hernia

The majority of large hiatal hernias are paraesophageal hiatal hernias (PEH). Once prolapse of the stomach to the chest cavity reaches a high degree, it is called an intrathoracic stomach. More than 25 years have elapsed since laparoscopic surgery was carried out as minimally invasive surgery for PEH. The feasibility and safety thereof has nearly been established. PEH may cause serious complications such as strangulation and perforation. The outcome of elective repair of PEH is better than emergent repair, so we should carry out elective repair as much as possible. Although not a major clinical problem, following PEH repair the rate of anatomical recurrence increases with age. In order to reduce the recurrence rate, mesh reinforcement by crural repair has been widely performed. Although this improves the short-term outcomes, the long-term outcomes are unclear. For PEH repair, fundoplication and gastropexy are believed desirable. We should select the procedure associated with a lower incidence of dysphagia and so on following surgery. While relaxing incision is useful for primary tension-free closure, it has not contributed to improvement in the recurrence rate.

Large Hiatal Hernia Repair with Urinary Bladder Matrix Graft Reinforcement and Concomitant Sleeve Gastrectomy

Background:

There is no current consensus on the management of large hiatal hernias concomitant with performance of a sleeve gastrectomy procedure. Proposed solutions have included performing a modified Nissen fundoplication, performing cruroplasty alone, utilizing the Linx device, performing cruroplasty with reinforcement material, and avoiding the sleeve procedure altogether in favor of a bypass procedure in order to minimize gastroesophageal reflux. Urinary bladder matrix (UBM) represents a biologically derived material for use in hiatal hernia repair reinforcement with the potential to improve durability of repair without incurring the risks of other reinforcement materials.

Methods:

This study reports the results of a retrospective chart review of 32 cases of large hiatal hernia repair utilizing both primary crural repair and UBM reinforcement concomitant with laparoscopic sleeve gastrectomy by a single surgeon. Hernia diameter averaged 6 cm (range 4–9 cm). After an average of 1 year followup, 30 patients were assessed for subjective symptoms of gastroesophageal reflux (GERD) using the Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) score. Twenty patients were evaluated with either upper gastrointestinal (GI) series, endoscopy, or both.

Results:

Each repair was successful and completed laparoscopically concomitant with sleeve gastrectomy. Anterior and posterior cruroplasty was performed using interrupted 0-Ethibond suture using the Endostitch device. The UBM graft exhibited favorable handling characteristics placed as a keyhole geometry sutured to the crura with absorbable suture. A careful chart review was undertaken to assess for complications. There have been no reoperations. After a median of 12 months (range, 4–27 months) of followup, an assessment of recurrences or long-term complications was completed. Median GERD-HRQL score was 6, with a range of 0 to 64 (of possible 75), indicating very low-level reflux symptomatology. Follow-up upper GI radiographs or endoscopy were obtained in 20 cases and show intact repairs.

Conclusion:

In this series of 32 cases, laparoscopic cruroplasty with UBM graft reinforcement has been effective and durable at 12 months of followup. This technique may offer one satisfactory solution for large hiatal hernia repair concomitant with laparoscopic sleeve gastrectomy that may achieve a durable repair with low GERD symptoms.

[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.

'Mesh hiatal hernioplasty' versus 'suture cruroplasty' in laparoscopic para-oesophageal hernia surgery; a systematic review and meta-analysis

In laparoscopic 'paraoesophageal hernia' (POH) repair, non-absorbable suture materials have been used to close the crural defects. More recently, various types of prosthetic mesh have been utilized to repair the defect. We conducted a systematic review with meta-analysis of the recent and up to-date studies incorporating 942 POH repairs. We examined the rates of recurrence, reoperation, and complication rates alongside operative time of these two techniques in the management POH. Randomized controlled trials (RCT) and observational studies comparing mesh hiatal hernioplasty versus Suture cruroplasty for Paraoesophageal hernia were selected by searching Medline, Embase, and Cochrane Central database published between January 1995 and December 2016. Predefined inclusion and exclusion criteria were applied to select the studies. The outcome variables analysed are recurrence of hiatal hernia, reoperation, operative time and complications. Nine studies (RCTs = 4 and Observational studies = 5) were analysed totalling 942 patients (Mesh = 517, Suture cruroplasty = 425). The pooled effect size for recurrence favoured mesh repair over suture cruroplasty (OR 0.48, 95% CI 0.32, 0.73, P < 0.05). But the operation time is significantly less in suture cruroplasty (SMD 15.40, 95% CI 7.92, 22.88, P < 0.0001). Comparable effect sizes were noted for both groups which included reoperation (OR 0.35, 95%CI 0.09, 1.31, P = 0.12) and complication rates (OR 1.30, 95%CI 0.74, 2.29, P = 0.36). Our systematic review and meta-analysis demonstrates that mesh hiatoplasty and suture cruroplasty produce comparable results with regards to reoperation rate and complications following the repair of paraoesophageal hernias (POH). Moreover, the study showed significant reduction of recurrence following mesh hiatoplasty.

Case of complete mesh migration into the stomach after mesh hiatoplasty for a hiatal hernia

Mesh migration is a rare complication of surgery for a hiatal hernia. Here, we present the case of a 72-year-old who complained of dysphasia and bodyweight loss. Upper gastrointestinal endoscopy revealed incarcerated mesh in the lumen of the esophagogastric junction. Surgery was performed under both endoscopy and laparoscopy, and the mesh was successfully removed via gastrostomy. To the best of our knowledge, our case is the first in which mesh that had migrated into the esophagogastric junction was removed by a combination of laparoscopic and endoscopic procedure, although the cases of 17 patients in which mesh migrated into the stomach after mesh hiatoplasty have previously been reported in the literature.

Emergency Laparoscopic Repair of Giant Left Diaphragmatic Hernia following Minimally Invasive Esophagectomy: Description of a Case and Review of the Literature

Postoperative diaphragmatic hernia (PDH) is an increasingly reported complication of esophageal cancer surgery. PDH occurs more frequently when minimally invasive techniques are employed, but very little is known about its pathogenesis. Currently, no consensus exists concerning preventive measures and its management. A 71-year-old man underwent minimally invasive esophagectomy for esophageal cancer. Three months later, he developed a giant PDH, which was repaired by direct suture via laparoscopic approach. A hypertensive pneumothorax occurred during surgery. This complication was managed by the anaesthesiologist through a high fraction of inspired O₂ and several recruitment manoeuvres. The patient remained free of hernia recurrence until he died of neoplastic cachexia 5 months later. Laparoscopic repair of PDH may be safe and effective even in the acute setting and in the case of massive herniation. However, surgeons and anaesthesiologists should be aware of the risk of intraoperative pneumothorax and be prepared to treat it promptly.

Treatment of paraesophageal hiatal hernia in octogenarians: a systematic review and retrospective cohort study

Over the coming years octogenarians will make up an increasingly large proportion of the population. With the rise in octogenarians more paraesophageal hiatal hernias may be identified. In research for the optimal treatment for paraesophageal hiatal hernias, octogenarians are often omitted and the optimal surgical strategy for this patient group remains unclear. A systematic search in PubMed, Embase, and The Cochrane Library was conducted, including articles compromising 'surgery,' 'paraesophageal hiatal hernia,' and 'octogenarians.' Selection of articles was based on independent review by two authors. Alongside, a retrospective cohort study was conducted including all type II-IV hiatal hernia repairs performed in the VU Medical Center in Amsterdam, The Netherlands, from 2005 to 2015. A total of 486 papers were eligible for selection. After careful selection, a total of eight articles were included. All articles were retrospective cohort studies describing different proportions of octogenarians. The populations and surgical techniques were very heterogeneous. Elective paraesophageal hiatal hernia repair was performed safely in symptomatic octogenarians in all studies. Additional analysis of 84 patients, of which 9.5% octogenarians, was performed at our tertiary referral center. A larger hernia type, more acute interventions and a higher morbidity and mortality rate was observed in octogenarians compared to patients aged <80 years. In conclusion, elective paraesophageal hiatal hernia repair can be performed in octogenarians, especially in patients without comorbidity. Findings suggest improvement in symptoms in short-term follow up, with minimal morbidity and mortality. With regard to surgical techniques, laparoscopy and fundoplication were performed safely. Octogenarians need to be included in future clinical trials to further evaluate the optimal surgical intervention. Preoperative risk assessment by clinical prediction rules should guide operative intervention, in order to evaluate risks and benefits in this challenging population.

Long-term outcomes of laparoscopic large hiatus hernia repair with nonabsorbable mesh

The use of mesh to augment suture repair of large hiatus hernias remains controversial. Repair with mesh may help reduce the recurrence rate of primary repair, but concerns about the potential for serious complications, such as mesh erosion or stricturing, continue to limit its use. We aim to evaluate the long-term outcome of primary hiatus hernia repair with lightweight polypropylene mesh (TiMesh) specifically looking at rates of clinical recurrence, dysphagia, and mesh-related complications. From a prospectively maintained database, 50 consecutive patients who underwent elective primary laparoscopic hiatal hernia repair with TiMesh between January 2005 and December 2007 were identified. Case notes and postoperative endoscopy reports were reviewed. Clinical outcomes were evaluated using a structured questionnaire, including a validated dysphagia score. Of the 50 patients identified, 36 (72%) were contactable for follow-up. At a median follow-up of 9 years, the majority of patients (97%) regarded their surgery as successful. Twelve patients (33%) reported a recurrence of their symptoms, but only 4 (11%) reported that their symptoms were as severe as prior to the surgery. There was no significant difference between pre- and postoperative dysphagia scores. Postoperative endoscopy reports were available for 32 patients at a median time point of 4 years postoperatively, none of which revealed any mesh-related complications. One patient had undergone a revision procedure for a recurrent hernia at another institution. In this series, primary repair of large hiatus hernia with nonabsorbable mesh was not associated with any adverse effects over time. Patient satisfaction with symptomatic outcome remained high in the long term.

What are the differences in the outcome of laparoscopic axial (I) versus paraesophageal (II-IV) hiatal hernia repair?

INTRODUCTION

Comparison of elective laparoscopic repair of axial vs paraesophageal hiatal hernias reveals relevant differences in both the patient collectives and the complexity of the procedures.

MATERIALS AND METHODS

The present uni- and multivariable analysis of data from the Herniamed Registry compares the outcome for 2047 (67.3%) (type I) axial with 996 (32.7%) (types II-IV) paraesophageal primary hiatal hernias following laparoscopic repair.

RESULTS

Compared with the patients with axial hiatal hernias, patients with paraesophageal hiatal hernia were nine years older, had a higher ASA score (ASA III/IV: 34.8 vs 13.7%; p < 0.001), and more often at least one risk factor (38.8 vs 21.4%; p < 0.001). This led in the univariable analysis to significantly more general postoperative complications (6.0 vs 3.0%; p < 0.001). Reflecting the greater complexity of the procedures used for laparoscopic repair of paraesophageal hiatal hernias, significantly higher intraoperative organ injury rates (3.7 vs 2.3%; p = 0.033) and higher postoperative complication-related reoperation rates (2.1 vs 1.1%; p = 0.032) were identified. Univariable analysis did not reveal any significant differences in the recurrence and pain rates on one-year follow-up. Multivariable analysis did not find any evidence that the use of a mesh had a significant influence on the recurrence rate.

CONCLUSION

Surgical repair of paraesophageal hiatal hernia calls for an experienced surgeon as well as for corresponding intensive medicine competence because of the higher risks of general and surgical postoperative complications.

Routine use of mesh during hiatal closure is safe with no increase in adverse sequelae

BACKGROUND

Primary laparoscopic hiatal repair with fundoplication is associated with a high recurrence rate. We wanted to evaluate the potential risks posed by routine use of onlay-mesh during hiatal closure, when compared to primary repair.

METHODS

Utilizing single-institutional database, we identified patients who underwent primary laparoscopic hiatal repair from January 2005 through December 2014. Retrospective chart review was performed to determine perioperative morbidity and mortality. Long-term results were assessed by sending out a questionnaire. Results were tabulated and patients were divided into 2 groups: fundoplication with hiatal closure + absorbable or non-absorbable mesh and fundoplication with hiatal closure alone.

RESULTS

A total of 505 patients underwent primary laparoscopic fundoplication. Mesh reinforcement was used in 270 patients (53.5%). There was no significant difference in the 30-day perioperative outcomes between the 2 groups. No clinically apparent erosions were noted and no mesh required removal. Standard questionnaire was sent to 475 patients; 174 (36.6%) patients responded with a median follow-up of 4.29 years. Once again, no difference was noted between the 2 groups in terms of dysphagia, heartburn, long-term antacid use, or patient satisfaction. Of these, 15 patients (16.9%, 15/89) in the 'Mesh' cohort had symptomatic recurrence as compared to 19 patients (22.4%, 19/85) in the 'No Mesh' cohort (p = 0.362). A reoperation was necessary in 6 patients (6.7%) in the 'Mesh' cohort as compared to 3 patients (3.5%) in the 'No Mesh' cohort (p = 0.543).

CONCLUSIONS

Onlay-mesh use in laparoscopic hiatal repair with fundoplication is safe and has similar short and long-term results as primary repair.

ANALYSIS OF EARLY POST-OPERATIONAL COMPLICATIONS IN PATIENTS UNDERGOING LAPAROSCOPIC SURGERY FOR HIATAL HERNIA

In order to identify the advantages of the original modification of Nissen fundoplication techniques and identify the safest mash material for prosthetic reinforcement of hiatal closure, was made analysis of early postoperative complications in 121 patients with hiatal hernia.The formation of the non tension fundoplication reduces the level of early postoperative complications. The usage of biological prosthesis has the advantage in comparison with synthetic ones. In general, the usage of mashes significantly increases the severity of the complaints of patients after the intervention, but most of them are within 3-14 days of the postoperative period.

Hiatal Hernia Repair with Novel Biological Graft Reinforcement

Background and Objectives:

Hiatal hernias are repaired laparoscopically with increasing use of reinforcement material. Both synthetic and biologically derived materials reduce the recurrence rate compared to primary crural repair. Synthetic mesh introduces complications, such as mesh erosion, fibrosis, and infection. Urinary bladder matrix (UBM) represents a biologically derived material for use in hiatal hernia repair reinforcement with the potential to improve durability of repair without incurring the risks of other reinforcement materials.

Methods:

The 15 cases presented involved hiatal hernia repair with primary crural repair with UBM reinforcement and fundoplication. Patients were followed for an average of 3 years, and were assessed with upper gastrointestinal (GI) series, endoscopy, and assessments of subjective symptoms of gastroesophageal reflux disease (GERD).

Results:

Hernia diameters averaged 6 cm. Each repair was successful and completed laparoscopically. UBM exhibited favorable handling characteristics when placed as a horseshoe-type graft sutured to the crura. One patient underwent endoscopic balloon dilatation of a mild postoperative stenosis that resolved. No other complications occurred. In more than 3 years of follow-up, there have been no recurrences or long-term complications. GERD-health-related quality of life (HRQL) scores averaged 6 (range, 0–12, of a possible 50), indicating little reflux symptomatology. Follow-up upper GI series were obtained in 9 cases and showed intact repairs. An upper endoscopy was performed in 8 patients and showed no recurrences.

Conclusion:

Surgeons may safely use laparoscopic fundoplication with UBM reinforcement for successful repair of hiatal hernias. In this series, repairs with UBM grafts have been durable at 3 years of follow-up and may serve as an alternative to synthetic mesh reinforcement of hiatal hernia repairs.

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.