Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series

Effectiveness of anterior gastropexy with mesh reinforcement in reducing the recurrence of giant hiatal hernia

BACKGROUND

The number of patients with giant hiatal hernias requiring surgery is increasing. However, there have been some concerns regarding the possible high recurrence rates. Additional gastropexy has been suggested to reduce recurrence rates. This study aimed to examine whether additional gastropexy is effective in patients with giant hiatal hernias.

METHODS

We enrolled 77 patients with giant hiatal hernias who underwent laparoscopic hiatal hernia repair between June 2011 and December 2022. The patients were divided into two groups according to the presence or absence of gastropexy, the surgical outcomes and recurrence of hiatal hernia between the groups were compared.

RESULTS

The gastropexy group included 52 patients (68%). Although the operating time was longer in the gastropexy than in the non- gastropexy group (P < 0.01), there were no differences in the pre- and post- operative complications between the two groups. Surgery with gastropexy significantly improved symptoms, such as heartburn, reflux, chest pain, and vomiting, as well as the pathology of hiatal hernia, cardiac loosening, and esophagitis. The rates of recurrence of hiatal hernia and esophagitis were significantly lower in the gastropexy than in the non- gastropexy group (P < 0.01 and P = 0.04, respectively).

CONCLUSIONS

Laparoscopic anterior gastropexy is safe and effective for preventing the recurrence of giant hiatal hernias.

Long-term durability and temporal pattern of revisional surgery of laparoscopic large hiatal hernia repair

Laparoscopic repair is the preferred surgical treatment for symptomatic Large Hiatal Hernia (LHH). However, data on long-term outcomes are limited. This study aims to evaluate the 20-year follow-up results of laparoscopic LHH repair in a high-volume experienced tertiary center. Retrospective analysis of patients who underwent elective laparoscopic LHH repair between 1992 and 2008. Preoperative and perioperative data were collected. The primary endpoint was the long-term reoperation rate. Survival analyses were calculated according to the Kaplan-Meier method and compared with the log-rank test. A Cox proportional hazard model was used to investigate predictive factors of the need for revisional surgery. A total of 176 patients were included. All the procedures were performed laparoscopically, and in 5 cases (3.0%) with a robot-assisted approach. Mesh-augmented cruroplasty was performed in 26 patients (15.8%). A fundoplication was added in all patients: Nissen in 158 (89.8%), Toupet in 5 (2.8%), and Collis-Nissen in 13 (7.4%). Postoperative mean follow-up was 224.6 ± 83.3 months. Clinically significant hiatal hernia recurrence occurred in 27 (16.2%), and 18 patients (10.2%) underwent surgical revision. The median time-to-redo was 12 months (IQR 6-42 months). Overall durability without revisional surgery at 20-year follow-up was 90%. The rate of revisional surgery after LHH repair is low and is generally required within 12 months from primary surgery. Our results highlight the long-lasting effects of LHH repair at 20-year follow-up.

Global trends and research hotspots in esophageal strictures: A bibliometric study

BACKGROUND

Esophageal stricture is a prevalent condition affecting the digestive system, primarily marked by dysphagia and the obstruction of food passage through the esophagus. This narrowing of the esophageal lumen can significantly impact a person's ability to eat and drink comfortably, often leading to a decrease in nutritional intake and quality of life.

AIM

To explore the current research status and future trends of esophageal stricture through bibliometric analysis.

METHODS

Literature on esophageal stricture from 2004 to 2023 was retrieved from the Web of Science Core Collection. Statistical analysis was performed using Excel, VOSviewer, CiteSpace, and RStudio. This study provides data on annual production trends, countries/regions, influential authors, institutions, journals, references, and keywords.

RESULTS

The study included 1485 publications written by 7469 authors from 1692 institutions across 66 countries/regions, published in 417 journals. The United States, China, and Japan are the major contributors to this field, with many quality papers. Song Ho-young, Diseases of the Esophagus, Gastrointestinal Endoscopy, and Mayo Clinic are the top authors, journals, co-cited journals, and institutions, respectively. The most frequent keywords are stent, endoscopy, management, etiology, and prevention; regenerative medicine, endoscopic injection, and autologous tissue transplantation are the latest research frontiers. These keywords reflect continuous advancements in technical innovation, treatment strategies, preventive measures in the esophageal stricture research field, and a sustained focus on improving patient prognosis. In contrast, the basic sciences were underrepresented.

CONCLUSION

This study provides an insightful analysis of the developments in the field of esophageal stricture over the past twenty years, with stent placement is currently a hot research topic.

One-year outcomes of biological mesh in hiatal hernia repair: a real-world study

PURPOSE

The placement of synthetic mesh during laparoscopic hiatal hernia repair has been verified to reduce postoperative recurrence, but mesh erosion and other related complications may occur to synthetic mesh, and our aim was to verify the safety and efficacy of biological mesh in hiatal hernia repair.

METHODS

Patients with hiatal hernia who were treated at a tertiary teaching university hospital from December 2020 to May 2023 were prospectively included in this study. General clinical data, hernia-related data, and intraoperative data were collected, and the patients were followed up at 1, 3, 6, and 12 months after surgery, after 12 months, follow-up as needed for primary outcome until September 2024. The following parameters were recorded during follow-up visit: gastroesophageal reflux symptoms, Gastroesophageal reflux disease-Health related quality of life (GERD-HRQL) questionnaire, postoperative recurrence, mesh-related complications and patients' overall satisfaction.

RESULTS

A total of 82 patients with hiatal hernia were included in this study. The mean age of the patients was 62.68 ± 15.93 years, mean BMI 24.81 ± 4.05 kg/m2, the average operation time was 128.21 ± 39.20 min. There was statistically significant improvement of GERD symptom postoperative (p<0.05). 72 cases (93.5%) were rated as "Great" on the GERD-HRQL at the 12 months after surgery; 65 cases (84.4%) were rated as "very satisfactory" on the overall satisfaction scale at the 12 months after surgery. 6 patients (7.3%) experienced recurrences, with no mesh-related complications reported during the follow-up.

CONCLUSION

At a mean follow-up of 25.43 ± 10.38 months, the present study showed that laparoscopic hiatal hernia repair with biologic mesh results in low rates of 1-year recurrence and complications and increased patient satisfaction.

Case Report: Total intragastric mesh migration six years after diaphragmatic rupture and hiatal hernia surgery

Background

Mesh implementation to repair the hiatal space is already justified. Nevertheless, the use of this procedure is debated in regard of complications that may occur. Mesh erosion and migration are considered the most serious complications of mesh repairs.

Case presentation

It has not yet been well described in the literature. We describe a case of mesh erosion of stomach, many years later after a prosthetic repair of a diaphragmatic rupture associated to hiatal hernia, is presented here because of its rarity.

Conclusion

Few explanations have been put forward to explain this incident. Could it be due to inflammatory processes, or to the composition of the Meshes? As yet, there is no definitive explanation.

Novel Posterior Rectus Sheath Flap for Paraesophageal Hernia Repairs

This Surgical Intervention describes a new method to repair large or recurrent paraesophageal hernias.

[Mesh suture in the treatment of diaphragmatic hernias]

The paper studies the results of surgical treatment of the first 25 patients with diaphragmatic hernias who underwent laparoscopic surgeries for hiatal hernias using polypropylene mesh sutures using the proprietary method.

MATERIAL AND METHODS

Polypropylene mesh strips were used instead of traditional sutures to seal the crura of the diaphragm in 25 patients. The intervention technique and treatment outcomes are described. The study included 25 patients, 5 males and 20 females, operated on between 2019 and 2024 with a diagnosis of hiatal hernia (HH), aged 38 to 79 years.

RESULTS

The mean surgery duration was 83.4 minutes (50 to 120 minutes), and intraoperative and postoperative complications were not observed. The mean hospital stay was 1.5 days (1 to 4 days). Four patients (16%) had a recurrence of hernia diagnosed using imaging studies, but there were no clinically significant recurrences in all 25 patients. Twenty (80%) patients permanently discontinued proton pump inhibitors (PPIs), and 2 (8%) significantly reduced their dose. Eighteen (72%) patients had complete resolution of their HH-related symptoms; in 4 (16%) patients, these symptoms significantly reduced. All patients were satisfied with the treatment outcomes.

CONCLUSIONS

The use of mesh sutures to seal the crura of the diaphragm supports the concept of pressure distribution and muscle resistance to incision, which is often seen with traditional suture material. In addition, the mesh material stimulates scar tissue growth through the pores of the prosthesis, strengthening the suture line.

ENDOSCOPIC MANAGEMENT OF MESH MIGRATION FOLLOWING HIATAL HERNIA REPAIR

BACKGROUND

The use of mesh in the repair of large hiatal hernias is still controversial. One of the most feared adverse events related to the use of mesh is erosion into the esophageal and gastric walls.

AIMS

To record the endoscopic treatment of mesh that has migrated into the gastric lumen after surgical treatment of hiatal hernia.

METHODS

The technical option was to wait for the progressive migration of the mesh into the gastric lumen, monitoring with upper digestive endoscopy, with removal by traction at the best time, with the aid of foreign body forceps.

RESULTS

The mesh was completely removed, and the evolution was satisfactory, without complications.

CONCLUSIONS

In patients with mesh migration into the stomach who are oligosymptomatic and do not show signs of complications, endoscopic surveillance and subsequent removal of the foreign body can be successfully performed when the mesh is not adhered to the gastric wall, avoiding surgical procedures with high morbidity and mortality.

Complications After Paraesophageal Hernia Repair

Paraesophageal hernia repair (PEHR) is a challenging operation both technically and because the affected patient population is typically older with more comorbidities. As a result, PEHR is associated with substantial morbidity. Morbidity and mortality following PEHR vary significantly depending on the acuity of the operation and size of the hernia. In addition to a higher risk for general peri- and postoperative complications there are a variety of other foregut specific complications to consider including, acute perioperative, early, and late reherniation, mesh-related complications, perforation, gastroparesis, pulmonary and insufflation-related complications, among others. This review focuses on the complication-specific data on incidence, recognition etiology and management.

Mesh vs. non-mesh repair of type I hiatal hernias: a propensity-score matching analysis of 6533 patients from the Herniamed registry

INTRODUCTION

Surgical treatment of type I hiatal sliding hernias aims to control the gastroesophageal reflux symptoms and prevention of hernia recurrence. Usually, a cruroplasty is performed to narrow the hiatal orifice. Here, it remains controversial if a mesh reinforcement of the cruroplasty should be performed, since benefits as well as mesh-associated complications have been described.

METHODS

We performed a propensity-score matching analysis with data derived from the Herniamed registry comparing patients undergoing laparoscopic type I hiatal hernia repair with and without synthetic mesh. We analyzed perioperative, intraoperative, and postoperative data including data derived from the 1-year follow-up in the registry.

RESULTS

6.533 patients with an axial, type I hiatal hernia and gastroesophageal reflux are included in this analysis. Mesh augmentation of the hiatoplasty was performed in n = 1.252/6.533 (19.2%) of patients. The defect size in the subgroup of patients with mesh augmentation was with mean 16.3 cm2 [14.5; 18.2] significantly larger as in the subgroups without mesh augmentation with 10.8 cm2 [8.7; 12.9]; (p < 0.001). In patients with mesh hiatoplasty n = 479 (38.3%) Nissen and n = 773 (61.7%) Toupet fundoplications are performed. 1.207 matched pairs could be analyzed. The mean defect size after matching was with 15.9 cm2 comparable in both groups. A significant association was seen regarding recurrence (4.72% mesh vs. 7.29% non-mesh hiatoplasty, p = 0.012). The same relation can be seen for pain on exertion (8.78% vs 12.10%; p = 0.014) and pain requiring treatment (6.13% vs 9.11%; p = 0.010). All other outcome parameter showed no significant correlation.

CONCLUSIONS

Our data demonstrate that mesh-reinforced laparoscopic type I hiatal hernia repair in larger defects is associated with significantly lower rates for recurrence, pain on exertion and pain requiring treatment.

Five-Year Outcomes from a Prospective Study on Safety and Efficacy of Phasix ST Mesh Use at the Hiatus During Paraesophageal Hernia Repair

BACKGROUND

Laparoscopic paraesophageal hernia (PEH) repair has a high hernia recurrence rate. The aim of this study was to assess the 5-year hernia recurrence rate after PEH repair using a combination of bioresorbable mesh and advanced surgical techniques to address tension as needed in a prospective group of patients.

STUDY DESIGN

In 2016, a prospective database was established for 50 patients undergoing primary, elective PEH repair with a new bioresorbable mesh (Phasix ST). Intraoperatively, tension was addressed with Collis gastroplasty and diaphragm relaxing incisions as needed. All 50 patients from the initial study were tracked and asked to return for objective follow-up. Recurrence was considered present for any hernia more than 2 cm in size.

RESULTS

Objective follow-up was conducted in 27 of the original 50 (54%) patients at a median of 5.25 years after their PEH repair. Before the 5-year follow-up, 5 patients had a known recurrent hernia. Objective evaluation at 5 years identified an additional 3 recurrences, for a total recurrence rate of 25% (8 of 32 patients). The hernia recurrence rate in patients with a Collis gastroplasty was significantly lower than in those without a Collis (7% vs 54%, p = 0.008). Two patients underwent reoperation for hernia recurrence. No patient had a mesh infection or mesh erosion.

CONCLUSIONS

The combination of Phasix ST Mesh and tension-reducing techniques during PEH repair led to a 25% hernia recurrence rate at 5 years. The addition of a Collis gastroplasty led to significantly fewer hernia recurrences and is indicative of the potential for esophageal shortening in many patients with a PEH. The long-term safety and efficacy of Phasix ST Mesh in combination with surgical technique for PEH repair is confirmed.

Does crural repair with biosynthetic mesh improve outcomes of revisional surgery for recurrent hiatal hernia?

BACKGROUND

Laparoscopic revisional surgery for recurrent hiatal hernia (HH) is technically demanding. Re-recurrences are common and esophageal hiatus mesh reinforcement might improve durability of the repair, thus minimizing the risk of re-herniation.

PURPOSE

Assess safety and effectiveness of simple suture repair (no mesh group) vs. crural augmentation with a biosynthetic absorbable mesh (mesh group) in patients with recurrent HH.

METHODS

Observational retrospective study from September 2012 to December 2022. Only patients undergoing redo surgery for previous failures of hiatal hernia repair were enrolled. Surgical failure was defined as symptomatic recurrent HH with > 2 cm of gastric tissue above the diaphragmatic impression at upper gastrointestinal endoscopy and/or swallow study. Gastro-Esophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) and Short Form-36 (SF-36) questionnaires were used to assess and preoperative and postoperative symptoms and quality of life.

RESULTS

One hundred four patients were included. Overall, 60 patients (57.7%) underwent mesh-reinforced cruroplasty, whereas 44 (42.3%) underwent simple suture cruroplasty. Mesh and no mesh groups had similar baseline demographics, symptoms, prevalence of esophagitis and Barrett's esophagus, and HH size. A composite crural repair was most commonly performed in the mesh group (38.3% vs. 20.5%; p = 0.07). In addition to cruroplasty, most patients (91%) underwent a Toupet fundoplication. The 90-day postoperative complication rate was 8.6%, and there was no mortality. Recurrent HH was diagnosed in 21 patients (20.2%) with a clinical trend toward reduced incidence in the mesh group (16.7% vs. 25%; p = 0.06). Compared to baseline, there was a statistically significant improvement of median GERD-HRQL score (p < 0.01) and all SF-36 items (p < 0.01).

CONCLUSIONS

Laparoscopic revisional surgery for recurrent HH is safe and effective. Selective use of biosynthetic mesh may protect from early recurrence and has the potential to reduce re-herniation in the long-term.

Foregut Erosion Related to Biomedical Implants: A Scoping Review

Introduction: Biomedical devices implanted transabdominally have gained popularity over the past 50 years in the treatment of gastroesophageal reflux disease, paraesophageal hiatal hernia, and morbid obesity. Device-related foregut erosions (FEs) represent a challenging event that demands special attention owing to the potential of severe postoperative complications and death. Purpose: The aim was to provide an overview of full-thickness foregut injury leading to erosion associated with four types of biomedical devices. Methods: The study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). PubMed, EMBASE, and Web of Science databases were queried until December 31, 2023. Eligible studies included all articles reporting data, management, and outcomes on device-related FE. Results: Overall, 132 articless were included for a total of 1292 patients suffering from device-related FE. Four different devices were included: the Angelchik antireflux prosthesis (AAP) (n = 25), nonabsorbable mesh for crural repair (n = 60), adjustable gastric banding (n = 1156), and magnetic sphincter augmentation device (n = 51). The elapsed time from device implant to erosion ranged from 1 to 480 months. Most commonly reported symptoms were dysphagia and epigastric pain, while acute presentation was reported rarely and mainly for gastric banding. The technique for device removal evolved from more invasive open approaches toward minimally invasive and endoscopic techniques. Esophagectomy and gastrectomy were mostly reported for nonabsorbable mesh FE. Overall mortality was .17%. Conclusions: Device-related FE is rare but may occur many years after AAP, nonabsorbable mesh, adjustable gastric banding, and magnetic sphincter augmentation implant. FE-related mortality is infrequent, however, increased postoperative morbidity and the need for esophagogastric resection were observed for nonabsorbable mesh-reinforced cruroplasty.

IDEAL Phase 2a Results: Posterior Rectus Sheath Flap for Hiatal Augmentation in Complex Paraesophageal Hernias

OBJECTIVE

To report the developmental phase results of posterior rectus sheath hiatal flap augmentation (PoRSHA), a promising surgical innovation for large and recurrent paraesophageal hernias.

BACKGROUND

Durable hernia repair for large paraesophageal hernias continues to be a surgical challenge. PoRSHA addresses the challenges of current and historical approaches to complex paraesophageal hernias and demonstrates significant promise as a successful alternative approach.

METHODS

Using the IDEAL framework, we outline the technical modifications made over the first 27 consecutive cases using PoRSHA. Outcomes measured included hernia recurrence on routine imaging at 6 months and 2 years, development of a postoperative abdominal wall eventration and incidence of solid food dysphagia.

RESULTS

Twenty-seven patients at our single institution with type III (n=12), type IV (n=7), or recurrent (n=8) paraesophageal hernias underwent PoRSHA. Surgery was safely and successfully carried out in all cases. Stability of the technique was reached after 16 cases, resulting in 4 main repair types. At an average follow-up of 11 months, we observed no radiologic recurrences, no abdominal eventrations or hernias at the donor site, and 1 patient with occasional solid food dysphagia that resolved with dilation.

CONCLUSIONS

PoRSHA can not only be safely added to conventional hiatal hernia repair with appropriate training but also demonstrates excellent short-term outcomes. While the long-term durability with 5-year follow-up is still needed, here we provide cautious optimism that PoRSHA may represent a novel solution to the long-standing high recurrence rates observed with current complex PEH repair.

Cruroplasty with or without mesh? A systematic literature review with a novel time-organized proportion meta-analysis

BACKGROUND

Improved outcomes with the use of non-absorbable mesh (NAM) for inguinal hernia repairs led to its rapid adoption for hiatal hernia (HH) repairs; however, feared complications occurred, and the trend shifted toward using absorbable mesh (AM). We aimed to analyze the literature assessing objective HH recurrence rates after primary laparoscopic cruroplasty with or without the use of different mesh types.

METHODS

A systematic literature review with both pairwise and time-organized proportion meta-analyses of articles published between January 1993 and September 2022 was performed using the MEDLINE, EMBASE, and Taylor & Francis databases to identify relevant studies comparing groups undergoing cruroplasty with suture repair (SR) alone, AM, NAM, or partially absorbable mesh (PAM). Studies documenting an objective follow-up ≥ 6 months were included. The primary outcome was the HH recurrence rate confirmed by barium esophagram or upper GI endoscopy.

RESULTS

A total of 34 studies met the inclusion criteria, including 6 randomized clinical trials, 25 retrospectives studies, and 3 prospective cohort studies. A total of 2170 subjects underwent laparoscopic HH repair and completed an objective follow-up ≥ 6 months after surgery; the objective recurrence rate was 20.8% (99/477) at a mean follow-up of 25.8 ± 16.4 months for the SR group, 20.6% (244/1187) at 28.1 ± 13.8 months for the AM group, 13.7% (65/475) at 30.8 ± 15.3 months for the NAM group, and 0% (0/31) at 32.5 ± 13.5 months for the PAM group. However, the pairwise meta-analysis revealed that overall mesh use was not superior to SR in preventing long-term HH recurrence.

CONCLUSION

The use of AM does not appear to reduce HH recurrence compared to SR alone. Although the data favors NAM to decrease objective HH recurrence in the mid-term, the long-term (≥ 48 months) recurrence rate was similar with or without any type of mesh.

[Surgical strategy for hiatal hernias]

The indications for surgical treatment of hiatus hernias differentiate between type I and types II, III and IV hernias. The indications for a type I hernia should include a proven reflux disease but the indications for surgical treatment of types II, III and IV hernias are mandatory due to the symptoms with problems in the passage of food and due to the sometimes very severe possible complications. The primary aims of surgery are the repositioning of the herniated contents and a hiatoplasty, which includes a surgical narrowing of the esophageal hiatus by suture implantation. In addition, depending on the clinical situation other procedures, such as hernia sac removal, mesh implantation, gastropexy and fundoplication can be considered. There are various approaches to the repair, all of which have individual advantages and disadvantages. An adaptation to the specific needs situation of the patient and the expertise of the surgeon is therefore essential.

Unusual Presentation of Incarcerated True Parahiatal Hernia: Management of a Rare Clinical Entity

True parahiatal hernia is a type of diaphragmatic hernia in which herniation occurs through a defect in the diaphragm, adjacent to the normal oesophageal hiatus. Its reported incidence is very rare, and it is commonly misdiagnosed as paraoesophageal hernia. Although the clinical distinction between paraoesophageal and parahiatal hernia is difficult, it is essential to recognise these two separate entities clinically as their management differs. Clinical presentation of parahiatal hernia includes symptoms related to gastro-oesophageal reflux disease (GERD). Patients may also present emergently with symptoms of respiratory distress and chest symptoms. With that in mind, we describe a compelling case of a young lady who initially presented with symptoms suggestive of acute coronary syndrome. However, she was found to have an incarcerated parahiatal hernia.

BRAZILIAN HERNIA AND ABDOMINAL WALL SOCIETY STATEMENT ON LARGE HIATAL HERNIAS MANAGEMENT

Large hiatal hernias, besides being more prevalent in the elderly, have a different clinical presentation: less reflux, more mechanical symptoms, and a greater possibility of acute, life-threatening complications such as gastric volvulus, ischemia, and visceral mediastinal perforation. Thus, surgical indications are distinct from gastroesophageal reflux disease-related sliding hiatal hernias. Heartburn tends to be less intense, while symptoms of chest pain, cough, discomfort, and tiredness are reported more frequently. Complaints of vomiting and dysphagia may suggest the presence of associated gastric volvulus. Signs of iron deficiency and anemia are found. Surgical indication is still controversial and was previously based on high mortality reported in emergency surgeries for gastric volvulus. Postoperative mortality is especially related to three factors: body mass index above 35, age over 70 years, and the presence of comorbidities. Minimally invasive elective surgery should be offered to symptomatic individuals with good or reasonable performance status, regardless of age group. In asymptomatic and oligosymptomatic patients, besides obviously identifying the patient's desire, a case-by-case analysis of surgical risk factors such as age, obesity, and comorbidities should be taken into consideration. Attention should also be paid to situations with greater technical difficulty and risks of acute migration due to increased abdominal pressure (abdominoplasty, manual labor, spastic diseases). Technical alternatives such as partial fundoplication and anterior gastropexy can be considered. We emphasize the importance of performing surgical procedures in cases of large hiatal hernias in high-volume centers, with experienced surgeons.

Is it meaningful to add mesh reinforcement to laparoscopic fundoplication for esophageal hiatal hernias in the patients with high risk of hiatal hernia recurrence?

BACKGROUND

While laparoscopic fundoplication is a standard surgical procedure for patients with esophageal hiatal hernias, the postoperative recurrence of esophageal hiatal hernias is a problem for patients with giant hernias, elderly patients, or obese patients. Although there are some reports indicating that reinforcement with mesh is effective, there are differing opinions regarding the use thereof. The aim of this study is to investigate whether mesh reinforcement is effective for laparoscopic fundoplication in patients with esophageal hiatus hernias.

METHODS

The subjects included 280 patients who underwent laparoscopic fundoplication as the initial surgery for giant esophageal hiatal hernias, elderly patients aged 75 years or older, and obese patients with a BMI of 28 or higher, who were considered at risk of recurrent hiatal hernias based on the previous reports. Of the subject patients, 91 cases without mesh and 86 cases following the stabilization of mesh use were extracted to compare the postoperative course including the pathology, symptom scores, surgical outcome, and recurrence of esophageal hiatus hernias.

RESULTS

The preoperative conditions indicated that the degree of esophageal hiatal hernias was high in the mesh group (p = 0.0001), while the preoperative symptoms indicated that the score of heartburn was high in the non-mesh group (p = 0.0287). Although the surgical results indicated that the mesh group underwent a longer operation time (p < 0.0001) and a higher frequency of intraoperative complications (p = 0.037), the rate of recurrence of esophageal hiatal hernia was significantly low (p = 0.049), with the rate of postoperative reflux esophagitis also tending to be low (p = 0.083).

CONCLUSIONS

Mesh reinforcement in laparoscopic fundoplication for esophageal hiatal hernias contributes to preventing the recurrence of esophageal hiatal hernias when it comes to patient options based on these criteria.

Hiatal Hernia Repair With Tension-Free Mesh or Crural Sutures Alone in Antireflux Surgery: A 13-Year Follow-Up of a Randomized Clinical Trial

Importance

Antireflux surgery is an effective treatment of gastroesophageal reflux disease (GERD), but the durability of concomitant hiatal hernia repair remains challenging. Previous research reported that the use of a mesh-reinforced, tension-free technique was associated with more dysphagia for solid foods after 3 years without reducing hiatal hernia recurrence rates compared with crural sutures alone, but the long-term effects of this technique have not been assessed.

Objective

To assess the long-term anatomical and functional outcomes of using a mesh for hiatal hernia repair in patients with GERD.

Design, Setting, and Participants

A double-blind, randomized clinical trial was performed at a single center (Ersta Hospital, Stockholm, Sweden) from January 11, 2006, to December 1, 2010. A total of 159 patients were recruited and randomly assigned. Data for the current analysis were collected from September 1, 2021, to March 31, 2022. All analyses were conducted with the intention-to-treat population.

Interventions

Closure of the diaphragmatic hiatus with crural sutures alone vs a tension-free technique using a nonabsorbable polytetrafluoroethylene mesh (Bard CruraSoft).

Main Outcomes and Measures

The primary outcome was radiologically verified recurrent hiatal hernia after more than 10 years. Secondary outcomes were dysphagia scores (ranging from 1 to 4, with 1 indicating no episodes of dysphagia and 4 indicating more than 3 episodes of dysphagia per day) for solid and liquid foods, generic 36-Item Short Form Health Survey and disease-specific Gastrointestinal Symptom Rating Scale symptom assessment scores, proton pump inhibitor consumption, and reoperation rates. Intergroup comparisons of parametric data were performed using t tests; for nonparametric data, Mann-Whitney U, χ2, or Fisher exact tests were used. For intragroup comparisons vs the baseline at follow-up times, the Friedman test was used, and post hoc analysis was performed using Wilcoxon matched pairs.

Results

Of 145 available patients, follow-up data were obtained from 103 (response rate 71%; mean [SD] age at follow-up, 65 [11.3] years; 55 [53%] female), with 53 initially randomly assigned to mesh reinforcement, and 50 to crural suture alone. The mean (SD) follow-up time was 13 (1.1) years. The verified radiologic hiatal hernia recurrence rates were 11 of 29 (38%) in the mesh group vs 11 of 35 (31%) in the suture group (P = .61). However, 13 years postoperatively, mean (SD) dysphagia scores for solids remained significantly higher in the mesh group (mean [SD], 1.9 [0.7] vs 1.6 [0.9]; P = .01).

Conclusions and Relevance

Findings from this long-term follow-up of a randomized clinical trial suggest that tension-free crural repair with nonabsorbable mesh does not reduce the incidence of hiatal hernia recurrence 13 years postoperatively. This finding combined with maintained higher dysphagia scores does not support the routine use of tension-free polytetrafluoroethylene mesh closure in laparoscopic hiatal hernia repair for treatment of GERD.

Trial Registration

ClinicalTrials.gov Identifier: NCT05069493.

Trends in outcomes of 862 giant hiatus hernia repairs over 30 years

PURPOSE

Laparoscopic giant hiatus hernia repair is technically difficult with ongoing debate regarding the most effective surgical technique. Repair of small hernia has been well described but data for giant hernia is variable. This study evaluated trends in outcomes of laparoscopic non-mesh repair of giant paraesophageal hernia (PEH) over 30 years.

METHODS

Retrospective analysis of a single-surgeon prospective database. Laparoscopic non-mesh repairs for giant PEH between 1991 and 2021 included. Three-hundred-sixty-degree fundoplication was performed routinely, evolving into "composite repair" (esophagopexy and cardiopexy to the right crus). Cases were chronologically divided into tertiles based on operation date (Group 1, 1991-2002; Group 2, 2003-2012; Group 3, 2012-2021) with trends in casemix, operative factors and outcomes evaluated. Hernia recurrence was plotted using weighted moving average and cumulative sum (CUSUM) analysis.

RESULTS

862 giant PEH repairs met selection criteria. There was an increasing proportion of "composite repair" after the first decade (Group 1, 2.7%; Group 2, 81.9%; Group 3, 100%; p < 0.001). There were less anatomical hernia recurrence (Group 1, 36.6%; Group 2, 22.9%; Group 3, 22.7%; p < 0.001) and symptomatic recurrence (Group 1, 34.2%; Group 2, 21.9%; Group 3, 7%; p < 0.001) over time. The incidence of anatomical recurrence declined over time, decreasing from 30.8% and plateauing below 17.6% near the study's end. Median followup (months) in the first decade was higher but followup between the latter two decades comparable (Group 1, 49 [IQR 20, 81]; Group 2, 30 [IQR 15, 65]; Group 3, 24 [14, 56]; p < 0.001). There were 10 (1.2%) Clavien-Dindo grade ≥ III complications including two perioperative deaths (0.2%).

CONCLUSION

Hernia recurrence rates decreased with increasing case volume. This coincided with the increasing adoption of "composite repair", supporting the possible improvement in recurrence rates with this approach.

Diaphragmatic relaxing incisions for complex hiatal reconstruction: longer-term follow-up confirms safety, efficacy and rare complications

BACKGROUND

Tension is an important factor in hernia repairs. Relaxing incisions to reduce tension are common with ventral hernia repairs, and techniques for relaxing incisions also exist for the hiatus. The aim of this study was to update our original experience with a diaphragm relaxing incision (DRI) in a larger group of patients with longer follow-up.

METHODS

A retrospective chart review was performed to identify all patients who had a DRI between August 2016 and September 2021 during hiatal hernia repair. All DRI defects were repaired with permanent mesh remote from the esophagus. Objective follow-up was with chest x-ray, upper GI series (UGI) or both.

RESULTS

Seventy-three patients had a total of 79 DRI (right in 63, left in 4, and bilateral in 6 patients), during a primary (n = 52) or redo (n = 21) hiatal hernia repair. Concomitant Collis gastroplasty was used in 38 patients (52%). A single intra-operative complication occurred where the right crus tore during a right DRI. At a median of 15 months, 78% of patients had objective follow-up. There was one hernia through a repaired right DRI (1.2%). No patient had evidence of diaphragm paralysis and there were no mesh infections. The 1-year hernia recurrence rate in these patients was 3.9%.

CONCLUSIONS

A DRI can be done safely with minimal risk of intra- or post-operative complications. There was a low rate of herniation through the defect when repaired with permanent mesh. No patient developed a mesh infection despite concomitant Collis gastroplasty in 52% of patients, and there was no evidence of diaphragm paralysis on imaging studies. Further, the low rate of hiatal hernia recurrence suggests efficacy of a DRI to reduce crural closure tension. These excellent outcomes should encourage use of a DRI in patients with a difficult hiatus during hernia repair.

Laparoscopic Posterior Cruroplasty and Anterior Gastropexy for Type IV Hiatal Hernia Repair in an Elderly Patient: A Case Report and Review of the Literature

A hiatal hernia describes a defect of the portion of the esophageal hiatus of the diaphragm, which leads to herniation of the abdominal contents into the chest cavity. Type IV paraesophageal hernias (PEH) have been associated with relatively large defects and are usually symptomatic. Surgical intervention is indicated in patients with symptoms or complicated paraesophageal hernias. The elderly age group represents a challenge in terms of management approach. Our purpose is to emphasize the safety and efficacy of early laparoscopic posterior cruroplasty and anterior gastropexy during PEH repair in the elderly age group. A 90-year-old male without significant past medical or surgical history was admitted for a five-day history of left upper quadrant abdominal pain associated with multiple episodes of vomiting. The physical exam revealed left upper quadrant pain and rebound tenderness. Abdominal CT with IV contrast showed a large hiatal hernia containing the entire stomach and part of the duodenum with an abrupt transition zone at the duodenum. The patient underwent laparoscopic hiatal hernia repair, posterior cruroplasty, and anterior gastropexy. Postoperatively, the patient tolerated the procedure, and further follow-up in the clinic showed resolution of his symptoms without complications. Prompt identification and proper management represent a crucial step in the management of PEH, especially in elderly comorbid patients. Laparoscopic anterior gastropexy is a safe and effective method for type III/IV hiatal hernias in elderly patients.

Pre-existing hiatal mesh increases morbidity during and after revisional antireflux surgery: A retrospective multicenter study

BACKGROUND

Revisional antireflux surgery, including hiatus hernia repair, is increasingly common. Mesh-augmented hiatal closure at the time of index operation is controversial but commonly performed. Although a meta-analysis of randomized data has demonstrated no additional benefit of routine mesh placement, it is unclear whether this practice results in harm, particularly at the time of revisional antireflux surgery. We determined whether pre-existing mesh at the hiatus increases morbidity during and after revisional antireflux surgery.

METHODS

Analysis of prospectively-maintained databases of all elective revisional antireflux surgery cases in 36 hospitals across Australia took place over 10 years. Intraoperative and postoperative outcomes of patients with and without prior hiatal mesh were compared. Propensity score-matched analysis was used to validate primary findings.

RESULTS

A total of 346 revisional cases (35 with pre-existing mesh) were analyzed. The 2 groups had comparable baseline characteristics. In total, 77 (22.2%) patients had 148 intraoperative adverse events. Pre-existing mesh was associated with a higher risk of intraoperative complications (48.6% vs 22.5%, odds ratio 3.25, 95% confidence interval 1.63-6.38, P = .002), secondary to bleeding, and lacerations to pleura, lung, and liver. Overall, 63 (18.2%) patients developed postoperative complications. Pre-existing mesh was associated with increased postoperative morbidity (37.1% vs 16.1%, odds ratio 3.09, 95% confidence interval 1.50-6.43, P = .005), particularly due to bleeding and respiratory complications. Importantly, pre-existing mesh independently predicted the occurrence of intraoperative and postoperative complications.

CONCLUSION

Prior hiatal mesh significantly increases morbidity during and after revisional antireflux surgery. Given that revisional surgery is increasingly being performed, our findings discourage routine mesh use during primary antireflux surgery.

Anterior reconstruction of the esophageal hiatus: a novel approach for the repair of large diaphragmatic hernias

Introduction: Paraesophageal hernias (PEH) often require surgical repair. The standard approach, primary posterior hiatal repair, has been associated with a high recurrence rate. Over the past few years, we have developed a new approach for repairing these hernias, which we believe restores the original anatomy and physiology of the esophageal hiatus. Our technique includes anterior crural reconstruction with routine anterior mesh reinforcement and fundoplication. Objective: To determine the safety and the clinical success of anterior crural reconstruction with routine mesh reinforcement. Material and methods: Data were collected retrospectively on 178 consecutive patients who had a laparoscopic repair of a symptomatic primary or recurrent PEH between 2011 and 2021 using the above technique. The primary outcome was clinical success, and the secondary outcome was 30 days of major complications and patient satisfaction. This was assessed by imaging tests, gastroscopies, and clinical follow-up. Results: Mean follow-up was 65 (SD 37.1) months. No intraoperative or 30 days postoperative mortality or major complications were recorded. Recurrence rate requiring a re-operation was 8.4% (15/178). Radiological and gastroenterological evidence of minor type 1 recurrence was 8.9%. Conclusion: This novel technique is safe with satisfactory long-term results. The outcome of our study will hopefully motivate future randomized control trials.

Invasive acupuncture for gastroparesis after thoracic or abdominal surgery: a systematic review and meta-analysis

OBJECTIVES

This meta-analysis aimed to systematically evaluate the efficacy of acupuncture in treating postsurgical gastroparesis syndrome (PGS) after thoracic or abdominal surgery.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Twelve databases (PubMed, Embase, Cochrane Library Cochrane Central Register of Controlled Trials (CENTRAL), Medline (Ovid) (from 1946), Web of Science, EBSCO, Scopus, Open Grey, China National Knowledge Infrastructure (CNKI), Wanfang Database, Chinese Scientific Journals Database (VIP) and China Biology Medicine disc (CBM)) and three registration websites (WHO International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, and Chinese Clinical Trial Registry (ChiCTR)) were searched from the inception to September 2022, and citations of the included literature were screened.

ELIGIBILITY CRITERIA

All randomised controlled trials addressing invasive acupuncture for PGS.

DATA EXTRACTION AND SYNTHESIS

Key information on the included studies was extracted by two reviewers independently. Risk ratio (RR) with 95% CI was used for categorical data, and mean difference with 95% CI for continuous data. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. Outcomes were conducted with trial sequential analysis (TSA).

RESULTS

Fifteen studies with 759 patients met the inclusion criteria. Subgroup analyses revealed that compared with the drug group, the drug and acupuncture group had a greater positive effect on the total effective rate (TER) (nine trials, n=427; RR=1.20; 95% CI 1.08 to 1.32; P-heterogeneity=0.20, I2=28%, p=0.0004) and the recovery rate (RCR) (six trials, n = 294; RR = 1.61; 95% CI 1.30 to 1.98; P-heterogeneity=0.29, I2=19%, p<0.0001) of PGS after abdominal surgery. However, acupuncture showed no significant advantages in terms of the TER after thoracic surgery (one trial, p=0.13) or thoracic/abdominal surgery-related PGS (two trials, n = 115; RR=1.18; 95% CI 0.89 to 1.57; P-heterogeneity=0.08, I2=67%, p=0.24) and the RCR after thoracic/abdominal surgery (two trials, n=115; RR=1.40; 95% CI 0.97 to 2.01; P-heterogeneity=0.96, I2=0%, p=0.07). The quality of evidence for TER and RCR was moderate certainty. Only one study reported an acupuncture-related adverse event, in the form of mild local subcutaneous haemorrhage and pain that recovered spontaneously. TSA indicated that outcomes reached a necessary effect size except for clinical symptom score.

CONCLUSION

Based on subgroup analysis, compared with the drug treatment, acupuncture combined drug has significant advantages in the treatment of PGS associated with abdominal surgery, but not with thoracic surgery.

PROSPERO REGISTRATION NUMBER

CRD42022299189.

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

BACKGROUND

To compare the difference in outcomes in laparoscopic large hiatus hernia (LHH) repair using suture-based and mesh-based repair techniques.

METHODS

A systematic search of articles was conducted in PubMed, Medline and Embase using the PRISMA guidelines. Studies comparing recurrences and reoperations in those patients with large hiatal hernia repair (> 30% stomach in the chest, > 5 cm hiatal defect, hiatal surface area > 10 cm²) who had mesh vs no mesh were assessed quantitatively. The impact of mesh on significant intraoperative/postoperative surgical complications was qualitatively assessed.

RESULTS

Pooled data included six randomized controlled trials and thirteen observational studies with 1670 patients (824 with no mesh, 846 with mesh). There was a significant reduction in the total recurrence rate with mesh (OR 0.44, 95% CI 0.25-0.80, p = 0.007). Mesh use did not cause significant reduction in recurrences > 2 cm (OR 0.94, 95% CI 0.52-1.67, p = 0.83) or in reoperation rates (OR 0.64, 95% CI 0.39-1.07, p = 0.09). None of the specific meshes assessed were found to be superior in the reduction of recurrence or reoperation rates. Cases of mesh erosion with eventual foregut resection were noted and were associated with synthetic meshes only.

CONCLUSION

Mesh reinforcement seemed protective against total recurrence in LHH although this has to be interpreted with caution given the level of heterogeneity introduced by the inclusion of observational studies in the analysis. There was no significant reduction in large recurrences (> 2 cm) or reoperation rate. If the synthetic mesh is to be used patients need to be informed of the risk of mesh erosion.

Novel "starburst" mesh configuration for paraesophageal and recurrent hiatal hernia repair: comparison with keyhole mesh configuration

BACKGROUND

Controversy exists over the use of mesh, its type and configuration in repair of hiatal hernia. We have used biological mesh for large or recurrent hiatal hernias. We have developed a mesh configuration to better enhance the tensile strength of the hiatus by folding the mesh over the edge of the hiatus-entitled the "starburst" configuration. We report our experience with the starburst configuration, comparing it to our results with the keyhole configuration.

METHODS

Medical records of all patients undergoing either the keyhole or starburst mesh configuration hiatal hernia repair were reviewed between 2017 and 2021. Data gathered included age, sex, type of hernia (sliding, paraesophageal, or recurrent), fundoplication type (none, Nissen, Toupet, Dor, Collis-Nissen, Collis-Toupet, or magnetic sphincter augmentation [MSA]), 30-day complications, and long-term outcomes (hiatal hernia recurrence, reflux-symptom recurrence, dysphagia, dilations, reoperations).

RESULTS

From 7/2017 to 8/2019, 51 cases using the keyhole mesh were completed. Sliding hiatal hernia comprised 4%, paraesophageal hernia (PEH) 64% and recurrent hiatal hernia (RHH) 34% of cases. Distribution of fundoplication type: 2% none, 41% Nissen, 41% Toupet, 8% Dor, 2% Collis-Nissen, and 6% Collis-Toupet. 30-day complication rate 31%. Long-term outcomes: recurrent hiatal hernia 16%, dysphagia 12%, dysphagia requiring dilation(s) 10%, recurrent GERD symptoms 4%, and reoperation 14%. From 10/2020 to 8/2021, 58 cases using the starburst configuration were completed. PEH comprised 60% and RHH 40%. Distribution of fundoplication type: 10% none, 40% Nissen, 43% Toupet, 5% MSA, 2% Collis-Toupet. 30-day complication rate 16%. Long-term outcomes: recurrent hiatal hernia 19%, dysphagia 14%, dilations 5%, recurrent GERD symptoms 9%, and reoperations 3%.

CONCLUSION

The starburst mesh configuration compares favorably with the keyhole configuration with respect to postoperative dysphagia, need for esophageal dilation, and GERD symptom recurrence, with similar recurrence rates. We are continuing to further refine this technique and study the long-term outcomes.

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

INTRODUCTION

The use of bioabsorbable mesh at the hiatus is controversial. Long-term data are scant. We evaluated the world literature and performed a meta-analysis to determine if these meshes were effective in reducing recurrence.

METHODS

A literature search was performed using PubMed, MEDLINE, and ClinicalKey. We evaluated articles reporting on both Bio-A™ (polyglycolic acid:trimethylene carbonate-PGA:TMC) and Phasix™ (poly-4-hydroxybutyrate-P4HB) used at the hiatus. The DerSimonian-Laird random effects model was used to estimate the overall pooled treatment effect along with a 95% confidence interval (CI). Similar analysis was conducted to compare the clinical outcomes, i.e., recurrence rate, mean surgical time, mean hospital stays and mean follow-up duration between non-Mesh and Mesh group. The I2 statistic was computed to assess the heterogeneity in effect sizes across the studies.

RESULTS

A total of 21 studies (12 mesh studies with 963 subjects and 9 non-mesh studies with 617 subjects) were included to conduct the meta-analysis. There was one article reporting outcomes on P4HB mesh (73 subjects) and 11 on PGA:TMC mesh (890 subjects). The bioabsorbable mesh group had a significantly lower recurrence rate compared to the non-mesh group (8% vs. 18%; 95%CI 0.08-0.17), pooled p-value < 0.0001. Surgery time was shorter in the mesh group compared to the non-mesh group (136.4 min vs. 150 min) but not statistically significant (p = 0.54). There tended to be a more extended follow-up period after surgery in the non-mesh group compared to the mesh group (27 vs. 25.8 months, range 10.8-54 months); but not statistically significant (ES: 27.4; 95%CI 21.6-33.3; p = 0.92).

CONCLUSIONS

Hiatal hernia repair with bioabsorbable mesh is more effective at reducing hernia recurrence rate in the mid-term than simple suture cruroplasty. Further studies investigating the long-term outcomes and P4HB mesh are needed.

Hiatal hernia recurrences after laparoscopic surgery: exploring the optimal technique

INTRODUCTION

The recurrence rate of hiatal hernia (HH) after laparoscopic surgery with crural repair and Nissen or Toupet fundoplication is high (< 25-42%). HH repair can be reinforced with additional anterior sutures, vertical mesh strips (VMS) or mesh placement but the effect in the long-term (> 1 year) is still unclear. We determined the recurrence rate of HH after surgery and established whether the use of reinforcement techniques could reduce long-term recurrence rates.

METHODS

In this retrospective cohort study patients were included if they underwent a laparoscopic fundoplication in this hospital between 2012 and 2019. HH was measured with computed tomography and baseline patient characteristics and surgical details were collected. Primary outcomes were recurrence of symptoms and re-intervention, secondary outcome was effect of surgical reinforcement techniques. Statistical analyses comprised chi-square tests, Mann-Whitney U tests and uni- and multivariable logistic regression analyses.

RESULTS

In total, 307 patients were included, 206 women and 101 men. During primary surgery, 208 patients underwent a Toupet fundoplication and 97 patients underwent a Nissen fundoplication. Reinforcements consisted of anterior sutures in 132 patients, VMS in 89 patients and mesh in 17 patients. After primary surgery, recurrence of HH was diagnostically confirmed in 64 patients (20.8%). Use of VMS during primary surgery was significantly associated with fewer recurrences (OR = 0.34, p = 0.048), corrected for confounding factors. Secondary surgery was performed in 54 patients (17.6%) and tertiary surgery in five patients (1.6%). Mesh and VMS were used more during secondary and tertiary surgery.

CONCLUSION

The recurrence rate among HH patients in this cohort study was 20.8% with a mean follow-up time of 6 years. Secondary surgery was performed in 17.6% of the patients. In future, the use of VMS might lead to fewer recurrences after primary laparoscopic repair of HH.

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

Evaluation of the efficacy and safety of the new monofilament fully resorbable mesh with hydrogel barrier (Phasix™ ST), for large and complex hiatal hernia repair. Between December 2017 and December 2020, 60 patients with large or complicated hiatal hernia were treated (40 robotic and 20 laparoscopic procedures). The mesh was placed after primary closure of the hiatal defect, in an onlay fashion around the esophagus, followed by 360^o fundoplication. Follow-up at 3, 6, 12, 18, 24 months from intervention included clinical evaluation and upper GI endoscopy. In cases of recurrence, radiologic survey and manometry were utilized. There were no conversions to open repair or significant postoperative incidents. Over a median follow-up of 21 months (range 3-36), no recurrences or mesh related complications were observed. From our early experience, Phasix™ ST mesh seems to be safe and effective for the reinforcement of crural defects in large and complex hiatal hernia.

Complications, caused by application of the net implants in the hiatal hernias plasty

Objective. Studying of complications, connected with application of the net implants in patients with large hiatal hernias. Materials and methods. Retrospective investigation was conducted with objective to study complications, connected with application of the net implants in patients with large hiatal hernias, operated in the clinic during period from 2008 to 2018 yr. Of 1168 patients operated on and suffering gastro-esophageal reflux disease as well as hiatal hernias, 817 have had large hernias. In 353 patients with large hernias for strengthening of cruroraphy sutures the net implants were applied. There were used low-weighted implant-net Ultrapro, the composite net Parietex, self-fixating surgical net ProGrip, absorbable net Vicryl, polytetrafluoroethylene net with nitinol carcass, biological net Bio-A. All the patients symptoms were registered, and the quality of life studied. Results. Complications, caused by the net implants impact, were revealed in 17 (1.5%) patients. In all 17 patients the esophageal structuring have occurred due to pronounced cicatrization in region of the net implant installation. In 6 patients dysphagia due to the net ingrowth into esophageal tissue was observed, and in 2 – chronic inflammatory process in place of the net installation. One patient have had small esophageal perforation with restricted mediastinitis. In 3 patients, in whom the polytetrafluoroethylene nets were installed, their migration into esophageal lumen was revealed. Reoperations were done in all 17 patients. In 7 patients the net was removed completely. In 1 patient the net was removed and mediastinum drained. In 3 patients, in whom polytetrafluoroethylene nets have migrated into esophageal lumen, they were removed endoscopically with further installation of special stents. Results of reoperations were estimated as good in 15 patients. In 2 patients after reoperations dysphagia was observed, which needed a second time balloon dilatation and installation of stent in 1 of them. Conclusion. Nonabsorbable nets ought to be applied with high technical accuracy, it is necessary to prevent their contact with the esophagus. Application of the polytetrafluoroethylene nets with nitinol carcass for plasty of large hiatal hernias must be forbidden.

Poor Gastric Emptying in Patients with Paraesophageal Hernias: Pyloroplasty, Per-Oral Pyloromyotomy, BoTox, or Wait and See?

Gastric emptying delay may be caused with both functional and anatomic derangements. Gastroparesis is suspected in patients presenting with certain foregut symptoms without anatomic obstruction. Data are still emerging regarding the best treatment of this condition. In cases where large paraesophageal hernias alter the upper gastrointestinal anatomy, it is difficult to know if gastroparesis also exists. Management of hiatal hernias is also still evolving, with various strategies to reduce recurrence being actively investigated. In this article, we present a systematic review of the existing literature around the management of gastroparesis and the management of paraesophageal hernias when they occur separately. In addition, since there are limited data to guide diagnosis and management of these conditions when they are suspected to coexist, we provide a rational strategy based on our own experience in patients with paraesophageal hernias who have symptoms or studies that raise suspicion for a coexisting functional disorder.

Large hiatus hernia: time for a paradigm shift?

Background

Laparoscopic large hiatal hernia (LHH) repair remains a challenge despite three decades of ongoing attempts at improving surgical outcome. Its rarity and complexity, coupled with suboptimal initial approach that is usually best suited for small symptomatic herniae have contributed to unacceptable higher failure rates.

Results

We have therefore undertaken a systematic appraisal of LHH with a view to clear out our misunderstandings of this entity and to address dogmatic practices that may have contributed to poor outcomes.

Conclusions

First, we propose strict criteria to define nomenclature in LHH and discuss ways of subcategorising them. Next, we discuss preoperative workup strategies, paying particular attention to any relevant often atypical symptoms, indications for surgery, timing of surgery, role of surgery in the elderly and emphasizing the key role of a preoperative CT imaging in evaluating the mediastinum. Some key dissection methods are then discussed with respect to approach to the mediastinal sac, techniques to avoid/deal with pleural breach and rationale to avoid Collis gastroplasty. The issues pertaining to the repair phase are also discussed by evaluating the merits of the cruroplasty, fundoplication types and gastropexy. We end up debating the role of mesh reinforcement and assess the evidence with regards to recurrence, reoperation rate, complications, esophageal dilatation, delayed gastric emptying and mortality. Lastly, we propose a rationale for routine postoperative investigations.

Postoperative diaphragmatic hernia with upside-down stomach: a case report

A 31-year-old man presented to our hospital’s Emergency Department with sudden epigastric pain and vomiting. He had undergone endoscopic resection via the retroperitoneal route for a retroperitoneal tumor located in the left diaphragmatic crus of the esophageal hiatus at another hospital 8 months previously. Radiography and computed tomography showed inversion of the stomach beyond the diaphragm into the thoracic cavity, with the gastroesophageal junction serving as the fulcrum point. This finding led to a diagnosis of postoperative diaphragmatic hernia accompanied by an upside-down stomach (UDS). The prolapsed stomach in the thoracic cavity was reduced to the abdominal cavity using laparoscopic surgery. The postoperative course was favorable, and the patient was discharged from the hospital on postoperative day 7. No recurrence has been observed in the past 5 years. The pathological condition of a UDS observed in esophageal hiatal hernias may be found in postoperative diaphragmatic hernias. Laparoscopic surgery for a postoperative diaphragmatic hernia with a UDS is considered a useful surgical procedure. Laparoscopic surgery can simultaneously confirm the viability of the herniated organs, reduce the organs to the abdominal cavity, and close and reinforce the diaphragm.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sutured Versus Mesh-augmented Hiatus Hernia Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

This meta-analysis systematically reviewed published randomized control trials comparing sutured versus mesh-augmented hiatus hernia (HH) repair. Our primary endpoint was HH recurrence at short- and long-term follow-up. Secondary endpoints were: surgical complications, operative times, dysphagia and quality of life.

SUMMARY BACKGROUND DATA

Repair of large HHs is increasingly being performed. However, there is no consensus for the optimal technique for hiatal closure between sutured versus mesh-augmented (absorbable or nonabsorbable) repair.

METHODS

A systematic review of Medline, Scopus (which encompassed Embase), Cochrane Central Register of Controlled Trials, Web of Science, and PubMed was performed to identify relevant studies comparing mesh-augmented versus sutured HH repair. Data were extracted and compared by meta-analysis, using odds ratio and mean differences with 95% confidence intervals.

RESULTS

Seven randomized control trials were found which compared mesh-augmented (nonabsorbable mesh: n = 296; absorbable mesh: n = 92) with sutured repair (n = 347). There were no significant differences for short-term hernia recurrence (defined as 6-12 months, 10.1% mesh vs 15.5% sutured, P = 0.22), long-term hernia recurrence (defined as 3-5 years, 30.7% mesh vs 31.3% sutured, P = 0.69), functional outcomes and patient satisfaction. The only statistically significant difference was that the mesh repair required a longer operation time (P = 0.05, OR 2.33, 95% confidence interval 0.03-24.69).

CONCLUSIONS

Mesh repair for HH does not offer any advantage over sutured hiatal closure. As both techniques deliver good and comparable clinical outcomes, a suture only technique is still an appropriate approach.

Laparoscopic Paraesophageal Hernia Repair: To Mesh or not to Mesh. Systematic Review and Meta-analysis

OBJECTIVE

This study aimed to compare outcomes after laparoscopic paraesophageal hernia repair (LPEHR) with mesh or primary repair alone.

SUMMARY OF BACKGROUND DATA

High recurrence rates after LPEHR have been reported. Whether the use of mesh improves outcomes remains elusive.

METHODS

A systematic literature search was performed to identify randomized controlled trials (RCTs) comparing LPEHR with mesh repair versus suture repair alone. Early (≤6 months) and late (>6 months) recurrence rates were used as primary endpoints to assess efficacy. Intraoperative complications, overall morbidity, and reoperation rates were used as secondary endpoints to assess safety. A meta-analysis was conducted using relative risks (RR) with 95% confidence intervals (CI) for the analyzed outcomes.

RESULTS

Seven RCTs comparing mesh (n = 383) versus suture only (n = 352) repair were included for analysis. Patients undergoing LPEHR with mesh reinforcement had similar early (RR = 0.74, 95% CI = 0.26-2.07, P = 0.46) and late (RR = 0.75, 95% CI = 0.27-2.08, P = 0.48) recurrence rates as those with primary repair. Similar recurrence rates were also found when stratifying the analysis by the type of mesh utilized (absorbable and nonabsorbable). Intraoperative complications (RR = 1.03, 95% CI = 0.33-3.28, P = 0.92) and reoperation rates (RR = 0.75, 95% CI = 0.29-1.92, P = 0.45) were also similar in both groups. Overall morbidity, however, was higher after mesh repair with nonabsorbable mesh (RR = 1.45, 95% CI = 1.24-1.71, P < 0.01).

CONCLUSIONS

Patients undergoing LPEHR have similar early and late recurrence rates with either mesh reinforcement or suture only repair, regardless of the type of mesh utilized. Overall morbidity, however, seems to be higher in patients repaired with nonabsorbable mesh.

Laparoscopic repair of giant paraesophageal hernia

Video 1Video available at: https://www.jtcvs.org/article/S2666-2507(21)00514-9/fulltext.Video 2Video available at: https://www.jtcvs.org/article/S2666-2507(21)00514-9/fulltext.Video 3Video available at: https://www.jtcvs.org/article/S2666-2507(21)00514-9/fulltext.Video 4Video available at: https://www.jtcvs.org/article/S2666-2507(21)00514-9/fulltext.Video 5Video available at: https://www.jtcvs.org/article/S2666-2507(21)00514-9/fulltext.Video 6Video available at: https://www.jtcvs.org/article/S2666-2507(21)00514-9/fulltext.Video 7Video available at: https://www.jtcvs.org/article/S2666-2507(21)00514-9/fulltext.Video 8Video available at: https://www.jtcvs.org/article/S2666-2507(21)00514-9/fulltext.Video 9Video available at: https://www.jtcvs.org/article/S2666-2507(21)00514-9/fulltext.Video 10Video available at: https://www.jtcvs.org/article/S2666-2507(21)00514-9/fulltext.Video 11Video available at: https://www.jtcvs.org/article/S2666-2507(21)00514-9/fulltext.

A Polymer-Biologic Hybrid Hernia Construct: Review of Data and Early Experiences

Surgical mesh reinforcement of the human abdominal wall has been found to reduce the chance of recurrence in hernia repairs. While traditionally polymer meshes have been used in hernia repair, alternative mesh options have been engineered to prevent the inflammatory foreign body response invoked by polymers. A reinforced tissue matrix (RTM) mesh has been developed by embedding a polymer within a decellularized extracellular matrix. This combination has been attributed to the recruitment of host cells, a pro-healing response, and attenuation of the foreign body response. This has been observed to lead to the regeneration of functional tissue within the repair site that is reinforced by the polymer to offload abdominal pressures over time. This manuscript presents the review of OviTex, an RTM, in several types of hernia repair. The authors have found that the use of RTM in hernia repair is effective in preventing foreign body response, promoting wound healing, and providing reinforcement to lower the risk of hernia recurrence.

[Mesh Implantation in Anti-Reflux and Hiatal Hernia Surgery - Contra Statement]

In the surgical treatment of gastroesophageal reflux disease and of hiatal hernias, the high rate of recurrence of hiatal hernias is a central problem. Against this background, various, primarily alloplastic, meshes are used to augment suture closure on the esophageal hiatus. Very different results have been reported in the past and the use of meshes in hiatus reconstruction is controversial. In addition to the frequency of recurrences, reports about complications of mesh augmentation are in the foreground. On the basis of several prospective randomised double-blinded comparative studies and meta-analyses (class Ia and Ib evidence), the current data do not show any advantages of mesh-augmented hiatoplasty for the prevention of recurrence of hiatal hernia. At the same time, there exist reports of more long-term postoperative complications, especially dysphagia, after use of meshes for augmentation of hiatus reconstruction. Therefore, routine use of mesh augmentation for hiatus reconstruction is currently not recommended.

Laparoscopic fixation of biological mesh at hiatus with glue and suture during hiatal hernia repair

BACKGROUND

Laparoscopic paraesophageal hernia repair is associated with higher recurrence rate. Mesh is used to reduce the recurrence rate. This retrospective study is to review our experience of biological mesh fixed with suture and medical glue in hiatal hernias repairs.

METHODS

A retrospective chart review was conducted for a consecutive series of patients undergoing laparoscopic hiatal herniorrhaphy between January 2018 and January 2019. After hiatus closure, a piece of biological prosthesis was fixed with medical glue and suture for reinforcement of the crural closure. Clinical outcomes were reviewed, and data were collected regarding operative details, complications, symptoms, and follow-up imaging. Radiological evidence of any size of hiatal hernia was considered to indicate a recurrence.

RESULTS

Thirty-six patients underwent surgery uneventfully without any serious complication. There was no mortality. The follow-up was, on average, 18.4 months, and there was no symptomatic recurrence. There was one anatomical recurrence without any related presentation. The method of mesh fixation with medical glue and suture took 12 min on average, and the handling was fairly easy.

CONCLUSIONS

Biological mesh fixed with suture and medical glue was safe and effective for repairing large hiatal hernias. Of course, a longer follow-up is still needed for determining long-term outcomes.

[Planning and Design of a Prospective Randomised Multi-Centre Trial on the Repair of Large Hiatal Hernias with Sutures vs. Pledgeted Sutures vs. Absorbable Mesh]

BACKGROUND

The hernia recurrence rate after surgical treatment of large hiatal hernias is still very high. The optimal technique to reduce the recurrence rate is still under debate. The aim of this work is to clarify whether pledgeted reinforced sutures or a resorbable mesh can reduce the recurrence rate compared to hiatus closure with only sutures.

MATERIALS AND METHODS

An Austria-wide, multi-centre, prospective, randomised study was planned. The study protocol was prepared by the main test centre (University Clinic for General, Visceral and Thoracic Surgery, Paracelsus Medical University Salzburg). The study includes patients who are scheduled to undergo laparoscopic or robot-assisted surgery for a large symptomatic hiatal hernia. A large hiatal hernia is defined as > 5 cm in manometry or gastroscopy or at least ⅓ of the stomach lying intrathoracically. The primary study endpoint is defined as the hernia recurrence rate, objectively assessed by gastroscopy. After inclusion in the study, patients will be followed up for 6 months, 1 year, 3 years and 5 years after the operation, using standardised questionnaires and gastroscopy. The power calculation showed a requirement of 55 patients per group. Preoperative randomisation and data management are software-based.

RESULTS

The study approval by the leading ethics committee is currently pending and the study itself has been registered on ClinicalTrials.gov since October 2020. The Clinical Trials Registration Number is NCT04591860. Five clinics are participating in the study at the moment and all centres are actively enrolling patients. The duration of the study is set until January 2027.

CONCLUSION

This study is the world's first prospective randomised study that examines the value of pledgets and resorbable mesh to reduce the recurrence rate after treatment of large hiatal hernias. The results will help to find the optimal technique to close the hiatus of large hiatal hernias.

[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.

Laparoscopic repair of giant Morgagni hernia by direct suturing with V-Loc

BACKGROUND

Morgagni hernias present technical challenges. The laparoscopic approach for repair was first described in 1992; however, as these hernias are uncommon in adult life, few data exist on the optimal method for surgical management. The purpose of this study was to analyze a method for laparoscopic repair of Morgagni giant hernias using laparoscopic primary closure with V lock (Medtronic, Covidien).

METHODS

This case series describes a method of laparoscopic Morgagni hernia repair using primary closure. In all patients, a laparoscopic transabdominal approach was used. The content of the hernia was reduced into the abdomen, and the diaphragmatic defect was closed with a running laparoscopic suture using a self-fixating suture. Clips were placed at the edges of the suture to secure the pledged sutures to both the anterior and posterior fascia. Demographic data such as BMI and operative and postoperative data were collected.

RESULTS

Retrospectively collected data for 9 patients were analyzed. There were 1 (11.1%) males and 8 (88.8%) females. The median BMI was 29.14±52 kg/m². The median operative time was 80±25 minutes. There were no intraoperative complications or conversions to open surgery. Patients began a fluid diet on the first postoperative day and were discharged after a median hospital stay of 3±1.87 days. In a median follow-up of 36 months, we did not observe any recurrences.

CONCLUSIONS

Transabdominal laparoscopic approach with primary closure of the diaphragmatic defect is a viable approach for the repair of Morgagni hernia. In our experience, the use of laparoscopic transabdominal suture fixed to the fascia allowed the closure of the defect laparoscopically with minimal tension on the repairs.

Does composite repair of giant paraoesophageal hernia improve patient outcomes?

BACKGROUND

Paraoesophageal hernia (PEH) is often symptomatic and reduces patients' quality of life (QoL). There is ongoing debate regarding the most effective surgical technique to repair giant PEH. This study aimed to see if an elective laparoscopic non-mesh composite technique of giant PEH repair offered an advantage in symptom control, hernia recurrence, QoL, morbidity and mortality.

METHODS

Data were extracted from a prospectively maintained database of patients undergoing hiatal hernia repair. Composite hernia repairs from inception for giant PEH between March 2009 and December 2015 were included. Perioperative mortality, complications, hernia recurrence rates, prevalence, recurrence of symptoms and QoL were included in analysis.

RESULTS

Inclusion criteria were met by 218 patients. Mean age was 70 (49-93). The average hernia size was 62% (range 30-100%; SD 21). There was one perioperative death and three significant complications (Clavien-Dindo grade III and IV). Recurrence rate was 24.8%. Without recurrence, QoL improved significantly across all domains. Recurrence of hiatus hernia reduced QoL. Surgery resulted in resolution of symptoms other than dysphagia which was incompletely improved. Patients' overall satisfaction with surgery was high.

CONCLUSION

Composite repair of giant PEH is safe with overall good outcomes. Majority of hernia recurrence are small and asymptomatic. Hernia recurrence negatively affected long-term QoL scores.

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.

Intragastric laparoscopy for oesophageal eroded mesh removal: An approach to avoid resection

The augmentation of hiatal repair for large hiatus hernia with mesh is controversial. There is some evidence that recurrence rates are less with mesh repair; however, there is a risk of mesh erosion. Complicated erosion may require complex revisional surgery and oesophagogastric resection. We present a novel approach to the treatment of oesophageal mesh erosion, by utilising a combined approach of endoscopy and intragastric laparoscopy. The symptomatic relief from this procedure may obviate the need for foregut resection in some patients.