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Karikis I, Pachos N, Mela E, Saliaris K, Kitsou E, Linardoutsos D, Triantafyllou S, Theodorou D. Comparative analysis of robotic and laparoscopic techniques in hiatal hernia and crural repair: a review of current evidence and outcomes. Hernia 2024:10.1007/s10029-024-03126-5. [PMID: 39123086 DOI: 10.1007/s10029-024-03126-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 07/24/2024] [Indexed: 08/12/2024]
Abstract
PURPOSE The purpose of this narrative review is to evaluate the implementation of robotic surgery in hiatal hernia and crural repair, based on the existing literature and to compare this approach to other established techniques. METHODS We performed a non- systematic literature search of PubMed and MEDLINE on February 25, 2024 for papers published to date focusing on the surgical repair of hiatal hernias using the robotic platform. After eliminating publications based on eligibility criteria, 13 studies were selected for analysis. RESULTS Robotic surgery is increasingly utilized in hiatal hernia repair due to its enhanced ergonomics and superior visualization capabilities. Operative times vary, with some studies indicating longer durations for robotic surgery (e.g., Giovannetti et al. demonstrated median operative time of 196 min for robotic compared to 145 min for laparoscopic) while others report shorter times (e.g., Lang F et al. demonstrated 88 min for robotic versus 102 min for laparoscopic). Recurrence rates between robotic and laparoscopic repairs are comparable, with reported recurrence rates of 1.8% for robotic and 1.2% for laparoscopic approaches by Benedix et al. Robotic surgery offers potential advantages, including reduced intraoperative blood loss (e.g., Giovannetti et al. mentioned median blood loss of 20 ml for robotic versus 50 ml for laparoscopic). The length of hospital stay and postoperative complication rates also vary, with some studies suggesting shorter stays and fewer complications for robotic surgery as surgeons become more proficient. Soliman et al. reported a statistically significant reduction in complication rates with robotic surgery (6.3% versus 19.2%). CONCLUSIONS Robotic surgery presents promising results regarding the length of hospital stay, conversion rate to open surgery and postoperative complication rates when compared to laparoscopy based on the existing literature. Despite the lack of striking differences, robotic hiatal hernia repair is a valid and evolving approach.
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Affiliation(s)
- I Karikis
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece.
| | - N Pachos
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | - E Mela
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | - K Saliaris
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | - E Kitsou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | - D Linardoutsos
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | - S Triantafyllou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | - D Theodorou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
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Priego P, Juez LD, Cuadrado M, García Pérez JC, Sánchez-Picot S, Blázquez LA, Gil P, Galindo J, Fernández-Cebrián JM. Risk factors associated with radiological and clinical recurrences after laparoscopic repair of large hiatal hernia with TiO 2Mesh™ reinforcement. Hernia 2024:10.1007/s10029-024-03107-8. [PMID: 39001940 DOI: 10.1007/s10029-024-03107-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 07/01/2024] [Indexed: 07/15/2024]
Abstract
INTRODUCTION Laparoscopic repair of large para-esophageal hiatal hernias (LPHH) remains controversial. Several meta-analyses suggest hiatus reinforcement with mesh has better outcomes over cruroplasty in terms of less recurrence. The aim of this study was to evaluate the medium-term results of treating LPHH with a biosynthetic monofilament polypropylene mesh coated with titanium dioxide to enhance biocompatibility (TiO2Mesh™). METHODS A retrospective observational study, using data extracted from a prospectively collected database was performed at XXX from December 2014 to June 2023. Included participants were all patients who underwent laparoscopic repair of large (> 5 cm) type III hiatal hernia in which a TiO2Mesh™ was used. The results of the study, including clinical and radiological recurrences as well as mesh-related morbidity, were analyzed. RESULTS Sixty-seven patients were finally analyzed. Laparoscopic approach was attempted in all but conversion was needed in one patient because of bleeding in the lesser curvature. With a median follow-up of 41 months (and 10 losses to follow-up), 22% of radiological recurrences and 19.3% of clinical recurrences were described. Regarding complications, one patient presented morbidity associated with the mesh (mesh erosion requiring endoscopic extraction). Recurrent hernia repair was an independent factor of clinical recurrence (OR 4.57 95% CI (1.28-16.31)). CONCLUSION LPHH with TiO2Mesh™ is safe and feasible with a satisfactory medium-term recurrence and a low complication rate. Prospective randomized studies are needed to establish the standard repair of LPHH.
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Affiliation(s)
- Pablo Priego
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Facultad de Medicina, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Luz Divina Juez
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Facultad de Medicina, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain.
| | - Marta Cuadrado
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Facultad de Medicina, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Juan Carlos García Pérez
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Facultad de Medicina, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
- Department of Surgery, Universidad de Alcalá, Madrid, Spain
| | - Silvia Sánchez-Picot
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Facultad de Medicina, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Luis Alberto Blázquez
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Facultad de Medicina, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
- Department of Surgery, Universidad de Alcalá, Madrid, Spain
| | - Pablo Gil
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Facultad de Medicina, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
- Department of Surgery, Universidad de Alcalá, Madrid, Spain
| | - Julio Galindo
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Facultad de Medicina, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
- Department of Surgery, Universidad de Alcalá, Madrid, Spain
| | - José María Fernández-Cebrián
- Division of Esophagogastric and Bariatric Surgery, Department of General and Digestive Surgery, Facultad de Medicina, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
- Department of Surgery, Universidad de Alcalá, Madrid, Spain
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Amprayil MA, Irvine T, Thompson SK, Bright T, Aly A, Devitt PG, Jamieson GG, Watson DI. Quality of life following repair of large hiatal hernia is not influenced by the use of mesh-Longer-term follow-up from a randomized trial. World J Surg 2024; 48:1448-1457. [PMID: 38629870 DOI: 10.1002/wjs.12185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 04/04/2024] [Indexed: 06/13/2024]
Abstract
INTRODUCTION The use of prosthetic mesh in laparoscopic repair of large hiatus hernias remains controversial. Clinical and quality of life outcomes from a randomized controlled trial of mesh versus suture repair previously showed few differences at early follow-up. This study evaluated longer-term quality of life outcomes from that trial. METHODS A prospective, multicentre, double blind randomized controlled trial assessed three methods of repair for large hiatus hernias: sutures-only versus absorbable mesh versus non-absorbable mesh. Quality of life was assessed using the Short-Form 36 (SF-36) questionnaire which was completed preoperatively and then at 3, 6, 12 months following surgery and annually thereafter. SF-36 outcomes were compared across the three repair techniques at longer-term follow-up (3-6 years), and to earlier baseline and 12-month outcomes. RESULTS 126 patients were randomized; 43-suture-only, 41-absorbable mesh and 42-non-absorbable mesh. Questionnaires were completed by 118 patients preoperatively, 115 at 12 months and 98 at longer-term follow-up (median 5 years). There were no significant differences between the repair techniques for the subscale and composite scores at longer-term follow-up. The mental component score improved significantly after surgery and was sustained across follow-up for all techniques. The physical component score also improved significantly but was lower at longer-term follow-up compared to the 12-month follow up in both mesh groups. CONCLUSION Surgical repair of large hiatus hernias provides sustained long-term improvement in quality of life. The addition of mesh does not improve quality of life. TRIAL REGISTRATION This trial is registered with the Australia and New Zealand Clinical Trials Registry ACTRN12605000725662.
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Affiliation(s)
- Mathew A Amprayil
- Flinders University Discipline of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Tanya Irvine
- Flinders University Discipline of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Sarah K Thompson
- Flinders University Discipline of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Tim Bright
- Flinders University Discipline of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Ahmad Aly
- University of Melbourne Department of Surgery, Austin Hospital, Heidelberg, Victoria, Australia
| | - Peter G Devitt
- Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Glyn G Jamieson
- Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - David I Watson
- Flinders University Discipline of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
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Vigneswaran Y, Hussain M, Varsanik MA, Corvin C, Gottlieb LJ, Alverdy JC. IDEAL Phase 2a Results: Posterior Rectus Sheath Flap for Hiatal Augmentation in Complex Paraesophageal Hernias. Ann Surg 2024; 279:1000-1007. [PMID: 38375674 PMCID: PMC11086674 DOI: 10.1097/sla.0000000000006247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
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.
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Affiliation(s)
- Yalini Vigneswaran
- Section of Minimally Invasive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Mustafa Hussain
- Section of Minimally Invasive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - M. Alyssa Varsanik
- Section of Minimally Invasive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Chase Corvin
- Section of Minimally Invasive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Lawrence J. Gottlieb
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - John C. Alverdy
- Section of Minimally Invasive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
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Hanna NM, Kumar SS, Collings AT, Pandya YK, Kurtz J, Kooragayala K, Barber MW, Paranyak M, Kurian M, Chiu J, Abou-Setta A, Ansari MT, Slater BJ, Kohn GP, Daly S. Management of symptomatic, asymptomatic, and recurrent hiatal hernia: a systematic review and meta-analysis. Surg Endosc 2024; 38:2917-2938. [PMID: 38630179 DOI: 10.1007/s00464-024-10816-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND The surgical management of hiatal hernia remains controversial. We aimed to compare outcomes of mesh versus no mesh and fundoplication versus no fundoplication in symptomatic patients; surgery versus observation in asymptomatic patients; and redo hernia repair versus conversion to Roux-en-Y reconstruction in recurrent hiatal hernia. METHODS We searched PubMed, Embase, CINAHL, Cochrane Library and the ClinicalTrials.gov databases between 2000 and 2022 for randomized controlled trials (RCTs), observational studies, and case series (asymptomatic and recurrent hernias). Screening was performed by two trained independent reviewers. Pooled analyses were performed on comparative data. Risk of bias was assessed using the Cochrane Risk of Bias tool and Newcastle Ottawa Scale for randomized and non-randomized studies, respectively. RESULTS We included 45 studies from 5152 retrieved records. Only six RCTs had low risk of bias. Mesh was associated with a lower recurrence risk (RR = 0.50, 95%CI 0.28, 0.88; I2 = 57%) in observational studies but not RCTs (RR = 0.98, 95%CI 0.47, 2.02; I2 = 34%), and higher total early dysphagia based on five observational studies (RR = 1.44, 95%CI 1.10, 1.89; I2 = 40%) but was not statistically significant in RCTs (RR = 3.00, 95%CI 0.64, 14.16). There was no difference in complications, reintervention, heartburn, reflux, or quality of life. There were no appropriate studies comparing surgery to observation in asymptomatic patients. Fundoplication resulted in higher early dysphagia in both observational studies and RCTs ([RR = 2.08, 95%CI 1.16, 3.76] and [RR = 20.58, 95%CI 1.34, 316.69]) but lower reflux in RCTs (RR = 0.31, 95%CI 0.17, 0.56, I2 = 0%). Conversion to Roux-en-Y was associated with a lower reintervention risk after 30 days compared to redo surgery. CONCLUSIONS The evidence for optimal management of symptomatic and recurrent hiatal hernia remains controversial, underpinned by studies with a high risk of bias. Shared decision making between surgeon and patient is essential for optimal outcomes.
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Affiliation(s)
- Nader M Hanna
- Department of Surgery, Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
| | - Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Yagnik K Pandya
- Department of Surgery, MetroWest Medical Center, Framingham, MA, USA
| | - James Kurtz
- Department of Surgery, Providence Portland Medical Center, Portland, OR, USA
| | | | - Meghan W Barber
- Department of Surgery, University of Toledo College of Medicine, Toledo, OH, USA
| | - Mykola Paranyak
- Department of General Surgery, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Marina Kurian
- Department of Surgery, NYU Langone Health, New York, NY, USA
| | | | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | | | | | - Geoffrey P Kohn
- Department of Surgery, Monash University, Melbourne, Australia
- Melbourne Upper GI Surgical Group, Melbourne, Australia
| | - Shaun Daly
- Department of Surgery, University of California Irvine, Irvine, USA
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Geerts JH, de Haas JWA, Nieuwenhuijs VB. Lessons learned from revision procedures: a case series pleading for reinforcement of the anterior hiatus in recurrent hiatal hernia. Surg Endosc 2024; 38:2398-2404. [PMID: 38565689 PMCID: PMC11078792 DOI: 10.1007/s00464-024-10703-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/16/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Hiatal Hernia (HH) is a common structural defect of the diaphragm. Laparoscopic repair with suturing of the hiatal pillars followed by fundoplication has become standard practice. In an attempt to lower HH recurrence rates, mesh reinforcement, commonly located at the posterior site of the esophageal hiatus, has been used. However, effectiveness of posterior mesh augmentation is still up to debate. There is a lack of understanding of the mechanism of recurrence requiring further investigation. We investigated the anatomic location of HH recurrences in an attempt to assess why HH recurrence rates remain high despite various attempts with mesh reinforcement. METHODS A retrospective case series of prospectively collected data from patients with hiatal hernia repair between 2012 and 2020 was performed. In total, 54 patients with a recurrent hiatal hernia operation were included in the study. Video clips from the revision procedure were analyzed by a surgical registrar and senior surgeon to assess the anatomic location of recurrent HH. For the assessment, the esophageal hiatus was divided into four equal quadrants. Additionally, patient demographics, hiatal hernia characteristics, and operation details were collected and analyzed. RESULTS 54 patients were included. The median time between primary repair and revision procedure was 25 months (IQR 13-95, range 0-250). The left-anterior quadrant was involved in 43 patients (80%), the right-anterior quadrant in 21 patients (39%), the left-posterior quadrant in 21 patients (39%), and the right-posterior quadrant in 10 patients (19%). CONCLUSION In this study, hiatal hernia recurrences occured most commonly at the left-anterior quadrant of the hiatus, however, posterior recurrences were not uncommon. Based on our results, we hypothesize that both posterior and anterior hiatal reinforcement might be a suitable solution to lower the recurrence rate of hiatal hernia. A randomized controlled trial using a circular, bio-absorbable mesh has been initiated to test our hypothesis.
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Tankel J, Safieddine N, Malthaner R, French D, Johnston B, Finley C, Darling G, Ferri L, Seely A, Gowing S. A trans-Canadian positive deviance seminar for paraesophageal hernia surgery: Reporting national postoperative outcomes and consensus recommendations. World J Surg 2024; 48:673-680. [PMID: 38358091 DOI: 10.1002/wjs.12087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/06/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND The incidence of adverse events (AEs) and length of stay (LOS) varies significantly following paraesophageal hernia surgery. We performed a Canadian multicenter positive deviance (PD) seminar to review individual center and national level data and establish holistic perioperative practice recommendations. METHODS A national virtual PD seminar was performed in October 2021. Recent best evidence focusing on AEs and LOS was presented. Subsequently, anonymized center-level AE and LOS data collected between 01/2017 and 01/2021 from a prospective, web-based database that tracks postoperative outcomes was presented. The top two performing centers with regards to these metrics were chosen and surgeons from these hospitals discussed elements of their treatment pathways that contributed to these outcomes. Consensus recommendations were then identified with participants independently rating their level of agreement. RESULTS Twenty-eight surgeons form 8 centers took part in the seminar across 5 Canadian provinces. Of the 680 included patients included, Clavien-Dindo grade I and II/III/IV/V complications occurred in 121/39/12/2 patients (17.8%/5.7%/1.8%/0.3%). Respiratory complications were the most common (effusion 12/680, 1.7% and pneumonia 9/680, 1.3%). Esophageal and gastric perforation occurred in 7 and 4/680, (1.0% and 0.6% respectively). Median LOS varied significantly between institutions (1 day, range 1-3 vs. 7 days, 3-8, p < 0.001). A strong level of agreement was achieved for 10/12 of the consensus statements generated. CONCLUSION PD seminars provide a supportive forum for centers to review best evidence and experience and generate recommendations based on expert opinion. Further research is ongoing to determine if this approach effectively accomplishes this objective.
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Affiliation(s)
- James Tankel
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Najib Safieddine
- Division of Thoracic Surgery, Department of Surgery, Michael Garron Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rick Malthaner
- Division of Thoracic Surgery, Schulich School of Medicine and Dentistry, London Health Sciences Center, Western University, London, Ontario, Canada
| | - Danny French
- Division of Thoracic Surgery, Department of Surgery, Queen Elizabeth II Hospital (Victoria Campus), Dalhousie University, Halifax, Nova Scotia, Canada
| | - Brian Johnston
- Division of Thoracic Surgery, Saint John Regional Hospital, Saint John, New Brunswick, Canada
| | - Christian Finley
- Division of Thoracic Surgery, St Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Gail Darling
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lorenzo Ferri
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Andrew Seely
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Stephen Gowing
- Section of Thoracic Surgery, Department of Surgery, Health Sciences Center, University of Manitoba, Winnipeg, Manitoba, Canada
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Analatos A, Håkanson BS, Ansorge C, Lindblad M, Lundell L, Thorell A. Hiatal Hernia Repair With Tension-Free Mesh or Crural Sutures Alone in Antireflux Surgery: A 13-Year Follow-Up of a Randomized Clinical Trial. JAMA Surg 2024; 159:11-18. [PMID: 37819652 PMCID: PMC10568445 DOI: 10.1001/jamasurg.2023.4976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/26/2023] [Indexed: 10/13/2023]
Abstract
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.
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Affiliation(s)
- Apostolos Analatos
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Nyköping Hospital, Nyköping, Sweden
- Centre for Clinical Research Sörmland, Uppsala University, Sweden
| | - Bengt S. Håkanson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery and Anaesthesiology, Ersta Hospital, Stockholm, Sweden
| | - Christoph Ansorge
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Nyköping Hospital, Nyköping, Sweden
| | - Mats Lindblad
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Lundell
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Anders Thorell
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery and Anaesthesiology, Ersta Hospital, Stockholm, Sweden
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9
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Patti MG, Herbella FAM. Mesh and Hiatal Hernia Repair-The Never-Ending Saga. JAMA Surg 2024; 159:18. [PMID: 37819634 DOI: 10.1001/jamasurg.2023.4965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Affiliation(s)
- Marco G Patti
- Department of Surgery, University of Virginia, Charlottesville
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
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10
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Nickel F, Müller PC, Cizmic A, Häberle F, Muller MK, Billeter AT, Linke GR, Mann O, Hackert T, Gutschow CA, Müller-Stich BP. Evidence mapping on how to perform an optimal surgical repair of large hiatal hernias. Langenbecks Arch Surg 2023; 409:15. [PMID: 38123861 PMCID: PMC10733223 DOI: 10.1007/s00423-023-03190-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 11/19/2023] [Indexed: 12/23/2023]
Abstract
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.
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Affiliation(s)
- Felix Nickel
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
- Department of General, Visceral and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany.
| | - Philip C Müller
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Amila Cizmic
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Frida Häberle
- Department of General, Visceral and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus K Muller
- Department of Surgery, Cantonal Hospital Thurgau, Frauenfeld, Switzerland
| | - Adrian T Billeter
- Department of Digestive Surgery, University Digestive Healthcare Center Basel, Basel, Switzerland
| | - Georg R Linke
- Department of Surgery, Hospital STS Thun AG, Thun, Switzerland
| | - Oliver Mann
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Christian A Gutschow
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Beat P Müller-Stich
- Department of Digestive Surgery, University Digestive Healthcare Center Basel, Basel, Switzerland
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11
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Nguyen CL, Tovmassian D, Zhou M, Seyfi D, Isaacs A, Gooley S, Falk GL. Recurrence in Paraesophageal Hernia: Patient Factors and Composite Surgical Repair in 862 Cases. J Gastrointest Surg 2023; 27:2733-2742. [PMID: 37962716 PMCID: PMC10837213 DOI: 10.1007/s11605-023-05856-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 09/29/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Repair of giant paraesophageal hernia (PEH) is associated with a considerable hernia recurrence rate by objective measures. This study analyzed a large series of laparoscopic giant PEH repair to determine factors associated with anatomical recurrence. METHOD Data was extracted from a single-surgeon prospective database of laparoscopic repair of giant PEH from 1991 to 2021. Upper endoscopy was performed within 12 months postoperatively and selectively thereafter. Any supra-diaphragmatic stomach was defined as anatomical recurrence. Patient and hernia characteristics and technical operative factors, including "composite repair" (360° fundoplication with esophagopexy and cardiopexy to right crus), were evaluated with univariate and multivariate analysis. RESULTS Laparoscopic primary repair was performed in 862 patients. The anatomical recurrence rate was 27.3% with median follow-up of 33 months (IQR 16, 68). Recurrence was symptomatic in 45% of cases and 29% of these underwent a revision operation. Hernia recurrence was associated with younger age, adversely affected quality of life, and were associated with non-composite repair. Multivariate analysis identified age < 70 years, presence of Barrett's esophagus, absence of "composite repair", and hiatus closure under tension as independent factors associated with recurrence (HR 1.27, 95%CI 0.88-1.82, p = 0.01; HR 1.58, 95%CI 1.12-2.23, p = 0.009; HR 1.72, 95%CI 1.2-2.44, p = 0.002; HR 2.05, 95%CI 1.33-3.17, p = 0.001, respectively). CONCLUSION Repair of giant PEH is associated with substantial anatomical recurrence associated with patient and technique factors. Patient factors included age < 70 years, Barrett's esophagus, and hiatus tension. "Composite repair" was associated with lower recurrence rate.
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Affiliation(s)
- Chu Luan Nguyen
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - David Tovmassian
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - Michael Zhou
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - Doruk Seyfi
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - Anna Isaacs
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - Suzanna Gooley
- Sydney Heartburn Clinic, Lindfield, NSW, 2070, Australia
| | - Gregory L Falk
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia.
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia.
- Sydney Heartburn Clinic, Lindfield, NSW, 2070, Australia.
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12
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Nguyen CL, Tovmassian D, Isaacs A, Gooley S, Falk GL. Trends in outcomes of 862 giant hiatus hernia repairs over 30 years. Hernia 2023; 27:1543-1553. [PMID: 37650983 DOI: 10.1007/s10029-023-02873-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/21/2023] [Indexed: 09/01/2023]
Abstract
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.
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Affiliation(s)
- C L Nguyen
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia.
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia.
| | - D Tovmassian
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - A Isaacs
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - S Gooley
- Sydney Heartburn Clinic, Lindfield, NSW, 2070, Australia
| | - G L Falk
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
- Sydney Heartburn Clinic, Lindfield, NSW, 2070, Australia
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13
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Tsoposidis A, Thorell A, Axelsson H, Reuterwall Hansson M, Lundell L, Wallenius V, Kostic S, Håkanson B. The value of "diaphragmatic relaxing incision" for the durability of the crural repair in patients with paraesophageal hernia: a double blind randomized clinical trial. Front Surg 2023; 10:1265370. [PMID: 38026477 PMCID: PMC10667682 DOI: 10.3389/fsurg.2023.1265370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Background Surgical repair of paraesophageal hernias (PEHs) is burdened with high recurrence rates, and hitherto various techniques explored to enforce the traditional crural repair have not been successful. The hiatal reconstruction in PEH is exposed to significant tension, which may be minimized by adding a diaphragmatic relaxing incision to enhance the durability of the crural repair. Patients and methods All individuals undergoing elective laparoscopic repair of a large PEH, irrespective of age, were considered eligible. PEHs were classified into types II-IV. The preoperative work-up program included multidetector computed tomography and symptom assessment questionnaires, which will be repeated during the postoperative follow-up. Patients were randomly divided into a control group with crural repair alone and an intervention group with the addition of a left-sided diaphragmatic relaxing incision at the edge of the upper pole of the spleen. The diaphragmatic defect was then covered by a synthetic mesh. Results The primary endpoint of this trial was the rate of anatomical PEH recurrence at 1 year. Secondary endpoints included symptomatic gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular and pulmonary symptoms, and patient satisfaction in the immediate postoperative course (3 months) and at 1 year. Postoperative complications, morbidity, and disease burden were recorded for each patient. This was a double-blind study, meaning that the operation report was filed in a locked archive to keep the patient, staff, and clinical assessors blinded to the study group allocation. Blinding must not be broken during the follow-up unless required by any emergencies in the clinical management of the patient. Likewise, the patients must not be informed about the details of the operation. Trial Registration ClinicalTrials.gov, identification number NCT04179578.
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Affiliation(s)
- A. Tsoposidis
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - A. Thorell
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - H. Axelsson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital Östra, University of Gothenburg, Gothenburg, Sweden
| | - M. Reuterwall Hansson
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - L. Lundell
- Division of Surgery and Oncology CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - V. Wallenius
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital Östra, University of Gothenburg, Gothenburg, Sweden
| | - S. Kostic
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital Östra, University of Gothenburg, Gothenburg, Sweden
| | - B. Håkanson
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Ersta Hospital, Stockholm, Sweden
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14
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Liu DS, Allan Z, Wong DJ, Goh SK, Stevens S, Aly A, Bright T, Watson DI. Pre-existing hiatal mesh increases morbidity during and after revisional antireflux surgery: A retrospective multicenter study. Surgery 2023; 174:549-557. [PMID: 37369605 DOI: 10.1016/j.surg.2023.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/06/2023] [Accepted: 05/24/2023] [Indexed: 06/29/2023]
Abstract
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.
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Affiliation(s)
- David S Liu
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Heidelberg, Victoria, Australia; General and Gastrointestinal Surgery Research and Trials Group, The University of Melbourne, Department of Surgery, Austin Precinct, Austin Health, Heidelberg, Victoria, Australia; Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; The University of Melbourne, Department of Surgery, Austin Precinct, Austin Health, Heidelberg, Victoria, Australia.
| | - Zexi Allan
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Darren J Wong
- General and Gastrointestinal Surgery Research and Trials Group, The University of Melbourne, Department of Surgery, Austin Precinct, Austin Health, Heidelberg, Victoria, Australia; Department of Gastroenterology, Austin Health, Heidelberg, Victoria, Australia
| | - Su Kah Goh
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Sean Stevens
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Heidelberg, Victoria, Australia; General and Gastrointestinal Surgery Research and Trials Group, The University of Melbourne, Department of Surgery, Austin Precinct, Austin Health, Heidelberg, Victoria, Australia
| | - Ahmad Aly
- Division of Surgery, Anaesthesia, and Procedural Medicine, Austin Health, Heidelberg, Victoria, Australia; The University of Melbourne, Department of Surgery, Austin Precinct, Austin Health, Heidelberg, Victoria, Australia
| | - Tim Bright
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia; Discipline of Surgery, College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - David I Watson
- Oesophagogastric Surgery Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia; Discipline of Surgery, College of Medicine and Public Health, Flinders University, South Australia, Australia
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15
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Aiolfi A, Sozzi A, Bona D. Comment to: Laparoscopic posterior cruroplasty: a patient tailored approach. Authors' reply. Hernia 2023; 27:717-718. [PMID: 36947310 DOI: 10.1007/s10029-023-02777-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 03/05/2023] [Indexed: 03/23/2023]
Affiliation(s)
- A Aiolfi
- I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio Hospital, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Via C. Belgioioso N.173, Zip Code, 20151, Milan, Italy.
| | - A Sozzi
- I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio Hospital, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Via C. Belgioioso N.173, Zip Code, 20151, Milan, Italy
| | - D Bona
- I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio Hospital, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Via C. Belgioioso N.173, Zip Code, 20151, Milan, Italy
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16
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Novel "starburst" mesh configuration for paraesophageal and recurrent hiatal hernia repair: comparison with keyhole mesh configuration. Surg Endosc 2023; 37:2239-2246. [PMID: 35902405 DOI: 10.1007/s00464-022-09447-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/04/2022] [Indexed: 10/16/2022]
Abstract
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.
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Gerdes S, Schoppmann SF, Bonavina L, Boyle N, Müller-Stich BP, Gutschow CA. Management of paraesophageal hiatus hernia: recommendations following a European expert Delphi consensus. Surg Endosc 2023:10.1007/s00464-023-09933-8. [PMID: 36849562 DOI: 10.1007/s00464-023-09933-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 02/05/2023] [Indexed: 03/01/2023]
Abstract
AIMS There is considerable controversy regarding optimal management of patients with paraesophageal hiatus hernia (pHH). This survey aims at identifying recommended strategies for work-up, surgical therapy, and postoperative follow-up using Delphi methodology. METHODS We conducted a 2-round, 33-question, web-based Delphi survey on perioperative management (preoperative work-up, surgical procedure and follow-up) of non-revisional, elective pHH among European surgeons with expertise in upper-GI. Responses were graded on a 5-point Likert scale and analyzed using descriptive statistics. Items from the questionnaire were defined as "recommended" or "discouraged" if positive or negative concordance among participants was > 75%. Items with lower concordance levels were labelled "acceptable" (neither recommended nor discouraged). RESULTS Seventy-two surgeons with a median (IQR) experience of 23 (14-30) years from 17 European countries participated (response rate 60%). The annual median (IQR) individual and institutional caseload was 25 (15-36) and 40 (28-60) pHH-surgeries, respectively. After Delphi round 2, "recommended" strategies were defined for preoperative work-up (endoscopy), indication for surgery (typical symptoms and/or chronic anemia), surgical dissection (hernia sac dissection and resection, preservation of the vagal nerves, crural fascia and pleura, resection of retrocardial lipoma) and reconstruction (posterior crurorrhaphy with single stitches, lower esophageal sphincter augmentation (Nissen or Toupet), and postoperative follow-up (contrast radiography). In addition, we identified "discouraged" strategies for preoperative work-up (endosonography), and surgical reconstruction (crurorrhaphy with running sutures, tension-free hiatus repair with mesh only). In contrast, many items from the questionnaire including most details of mesh augmentation (indication, material, shape, placement, and fixation technique) were "acceptable". CONCLUSIONS This multinational European Delphi survey represents the first expert-led process to identify recommended strategies for the management of pHH. Our work may be useful in clinical practice to guide the diagnostic process, increase procedural consistency and standardization, and to foster collaborative research.
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Affiliation(s)
- Stephan Gerdes
- Department of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | | | - Luigi Bonavina
- Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | | | - Beat P Müller-Stich
- Department of General, Visceral and Transplant Surgery, University Hospital, Heidelberg, Germany
| | - Christian A Gutschow
- Department of Surgery and Transplantation, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
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18
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Saad AR, Velanovich V. LAPAROSCOPIC ANTIREFLUX SURGERY: ARE OLD QUESTIONS ANSWERED? MESH HERNIOPLASTY. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2023; 35:e1710. [PMID: 36629688 PMCID: PMC9831632 DOI: 10.1590/0102-672020220002e1710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 07/04/2022] [Indexed: 01/10/2023]
Abstract
Hiatal hernias are at high risk of recurrence. Mesh reinforcement after primary approximation of the hiatal crura has been advocated to reduce this risk of recurrence, analogous to mesh repair of abdominal wall hernias. However, the results of such repairs have been mixed, at best. In addition, repairs using some type of mesh have led to significant complications, such as erosion and esophageal stricture. At present, there is no consensus as to (1) whether mesh should be used, (2) indications for use, (3) the type of mesh, and (4) in what configuration. This lack of consensus is likely secondary to the notion that recurrence occurs at the site of crural approximation. We have explored the theory that many, if not most, "recurrences" occur in the anterior and left lateral aspects of the hiatus, normally where the mesh is not placed. We theorized that "recurrence" actually represents progression of the hernia, rather than a true recurrence. This has led to our development of a new mesh configuration to enhance the tensile strength of the hiatus and counteract continued stresses from intra-abdominal pressure.
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Affiliation(s)
- Adham Raja Saad
- University of South Florida, Division of Gastrointestinal Surgery, Morsani College of Medicine - Tampa, Florida, USA
| | - Vic Velanovich
- University of South Florida, Division of Gastrointestinal Surgery, Morsani College of Medicine - Tampa, Florida, USA
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19
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Musbahi A, Mahawar K. Hiatal hernia. Br J Surg 2023; 110:401-402. [PMID: 36610072 DOI: 10.1093/bjs/znac449] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/09/2022] [Indexed: 01/09/2023]
Affiliation(s)
- Aya Musbahi
- Department of General Surgery, South Tyneside and Sunderland NHS Foundation Trust, Sunderland Royal Hospital, Sunderland SR4 7TP, UK
| | - Kamal Mahawar
- Department of General Surgery, South Tyneside and Sunderland NHS Foundation Trust, Sunderland Royal Hospital, Sunderland SR4 7TP, UK
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20
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Eroglu E, Altinli E. Poor Metabolic Profile Is an Independent Risk Factor for Recurrence After Hiatal Hernia Repair When Using Tension-Free Mesh. J Laparoendosc Adv Surg Tech A 2023; 33:32-37. [PMID: 35671514 DOI: 10.1089/lap.2022.0154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Purpose: The effect of metabolic risk factors on the recurrence rate of hiatal hernia (HH) after the initial repair is still controversial. In this study, we evaluated whether a poor preoperative metabolic profile is a risk factor for the recurrence of a HH after surgery. Methods: Perioperative patient data were obtained from hospital records. A poor metabolic profile was defined as having two or more metabolic conditions such as diabetes, hypertension, hyperlipidemia, or being overweight. The recurrence rates of HH were measured at 6 months, and again at 12 months after surgery. Results: Data were collected from a total of 221 patients. While 87 (39.4%) patients underwent tension-free mesh (TFM) repair, 137 (60.6%) were treated with suture repair. The poor metabolic profile has no effect on the recurrence rates in the suture-repair group. However, patients who underwent TFM repair displayed a significantly higher recurrence rate at the 12-month time point if they had poor metabolic profile, compared to the healthy group (respectively, 20.7% and 3.4%, P < .01). The logistic regression analysis showed that having a poor metabolic profile was an independent risk factor for recurrence after 12 months in the same group (odds ratio: 8.04 confidence interval [CI: 1.2-53.5] P = .03). Conclusion: The poor metabolic profile was found to be responsible for high recurrence rates only in patients who underwent TFM HH repair.
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Affiliation(s)
- Ersan Eroglu
- Department of General Surgery, Memorial Hospital, Istanbul, Turkey
| | - Ediz Altinli
- Department of General Surgery, Memorial Hospital, Istanbul, Turkey
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21
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Temperley HC, Davey MG, O'Sullivan NJ, Ryan ÉJ, Donlon NE, Donohoe CL, Reynolds JV. What works best in hiatus hernia repair, sutures alone, absorbable mesh or non-absorbable mesh? A systematic review and network meta-analysis of randomized clinical trials. Dis Esophagus 2022:6958659. [PMID: 36563005 DOI: 10.1093/dote/doac101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/19/2022] [Indexed: 12/24/2022]
Abstract
Laparoscopic hiatal hernia repair (HHR) and fundoplication is a common low risk procedure providing excellent control of gastro-oesophageal reflux disease and restoring of normal anatomy at the hiatus. HHR may fail, however, resulting in hiatus hernia (HH) recurrence, and the use of tension-free mesh-augmented hernioplasty has been proposed to reduce recurrence. Previous research on this topic has been heterogeneous, including study methods, mesh type used and technique performed. A systematic review and network meta-analysis were carried out. An electronic systematic research was carried out using 'PUBMED', 'EMBASE', 'Medline (OVID)' and 'Web of Science', of articles identifying HHR with suture cruroplasty, non-absorbable mesh (NAM) and absorbable mesh (AM) reinforcement. Eight RCTs with 766 patients were evaluated. NAM had significantly (P < 0.05) lower early recurrence rates (OR: 0.225, 95% CI 0.0342, 0.871) compared with suture repair alone; however, no differences in late recurrences were evident. For AM, no difference in early (0.508, 95% CI 0.0605, 4.81) or late (1.07. 95% CI 0.116, 11.4) recurrence rates were evident compared with the suture only group. Major complication rates were similar in all groups. NAM reinforcement significantly reduced early HH recurrence when compared with sutured cruroplasty alone; however, late recurrence rates were similar with all techniques. Given the limited data in comparing AM with NAM, this study was unable to conclude which composition was significant. We emphasize caution when interpreting small sample size RCTs, and recommend more research with larger randomized studies.
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Affiliation(s)
- Hugo C Temperley
- Department of Surgery, Trinity College and St James's Hospital, Dublin D08 NHY1, Ireland
| | - Matthew G Davey
- Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Republic of Ireland
| | - Niall J O'Sullivan
- Department of Surgery, Tallaght University Hospital, Dublin DO2 YN77, Republic of Ireland
| | - Éanna J Ryan
- Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Republic of Ireland
| | - Noel E Donlon
- Department of Surgery, Trinity College and St James's Hospital, Dublin D08 NHY1, Ireland.,Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Republic of Ireland
| | - Claire L Donohoe
- Department of Surgery, Trinity College and St James's Hospital, Dublin D08 NHY1, Ireland
| | - John V Reynolds
- Department of Surgery, Trinity College and St James's Hospital, Dublin D08 NHY1, Ireland
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22
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Mohr C, Ciomperlik H, Dhanani N, Olavarria OA, Hannon C, Hope W, Roth S, Liang MK, Holihan JL. Review of SAGES GERD guidelines and recommendations. Surg Endosc 2022; 36:9345-9354. [PMID: 35414134 DOI: 10.1007/s00464-022-09209-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 02/07/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) developed evidence-based guidelines for the management of patients with gastroesophageal reflux disease (GERD). The aim of this study is to evaluate guidelines lacking agreement among experts (grades B-D) or lacking support from randomized controlled trials (levels II-III). METHODS Six guidelines were chosen for evaluation. A retrospective review of a multicenter database of patients undergoing fundoplication surgery for treatment of GERD between 2015 and 2020 was performed. Patients that underwent a concurrent gastrectomy or were diagnosed with pre-operative achalasia were excluded. Demographics, pre-operative, intra-operative, and post-operative variables were collected. Post-operative outcomes were evaluated based on selected SAGES guidelines. Outcomes were assessed using multivariable regression or stratified analysis for each guideline. RESULTS A total of 444 patients from four institutions underwent surgery for the management of GERD with a median (interquartile range) follow-up of 16 (13) months. Guidelines supported by our data were (1) robotic repair has similar short-term outcomes to laparoscopic repair, (2) outcomes in older patients are similar to outcomes of younger patients undergoing antireflux surgery, and (3) following laparoscopic antireflux surgery, dysphagia has been reported to significantly improve from pre-operative values. Guidelines that were not supported were (1) mesh reinforcement may be beneficial in decreasing the incidence of wrap herniation, (2) a bougie has been found to be effective, and (3) the long-term effectiveness of fundoplication in obese individuals (BMI > 30) has been questioned due to higher failure rates. CONCLUSION Many SAGES GERD guidelines not receiving Grade A or Level I recommendation are supported by large, multicenter database findings. However, further studies at low risk for bias are needed to further refine these guidelines.
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Affiliation(s)
- Cassandra Mohr
- Department of Surgery, McGovern Medical School, Houston, TX, USA.
- Department of Surgery, Lyndon B. Johnson Hospital, 5656 Kelley St, Houston, TX, 77026, USA.
| | | | - Naila Dhanani
- Department of Surgery, McGovern Medical School, Houston, TX, USA
| | | | - Craig Hannon
- Department of Surgery, McGovern Medical School, Houston, TX, USA
| | - William Hope
- Department of Surgery, New Hanover Regional Medical Center, Wilmington, NC, USA
| | - Scott Roth
- Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Mike K Liang
- Department of Surgery, HCA Healthcare Kingwood, University of Houston, Kingwood, TX, USA
| | - Julie L Holihan
- Department of Surgery, McGovern Medical School, Houston, TX, USA
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23
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Hung CM, Lee PH, Lu K, Chiu CC. Comment on "Sutured Versus Mesh-augmented Hiatus Hernia Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials". ANNALS OF SURGERY OPEN 2022; 3:e173. [PMID: 37601144 PMCID: PMC10431498 DOI: 10.1097/as9.0000000000000173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 01/29/2022] [Indexed: 10/18/2022] Open
Affiliation(s)
- Chao-Ming Hung
- From the Department of General Surgery, E-Da Cancer Hospital, Kaohsiung, Taiwan
- College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Po-Huang Lee
- College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Department of General Surgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Kang Lu
- Department of Neurosurgery, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Chong-Chi Chiu
- From the Department of General Surgery, E-Da Cancer Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- Department of Medical Education and Research, E-Da Cancer Hospital, Kaohsiung, Taiwan
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24
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Gutschow CA. Comment on "Sutured Versus Mesh-Augmented Hiatus Hernia Repair: A Systematic Review and Meta-Analysis of Randomized Controlled Trials" by Petric J, Bright T, Liu DS, et al. Ann Surg. 2022;275:e45-e51. ANNALS OF SURGERY OPEN 2022; 3:e201. [PMID: 37601154 PMCID: PMC10431285 DOI: 10.1097/as9.0000000000000201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 07/25/2022] [Indexed: 11/27/2022] Open
Affiliation(s)
- Christian A. Gutschow
- From the Department of Visceral and Transplant Surgery, University Hospital Zürich, Zürich, Switzerland
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25
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Patient-tailored algorithm for laparoscopic cruroplasty standardization: comparison with hiatal surface area and medium-term outcomes. Langenbecks Arch Surg 2022; 407:2537-2545. [PMID: 35585260 DOI: 10.1007/s00423-022-02556-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 05/11/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Different methods have been described for laparoscopic hiatoplasty and hiatus hernia (HH) repair. All techniques are not standardized and the choice to reinforce or not the hiatus with a mesh is left to the operating surgeon's preference. Hiatal surface area (HSA) has been described as an attempt at standardization; in case the area is > 4 cm2, a mesh is used to reinforce the repair. OBJECTIVE The aim of this study was to describe a new patient-tailored algorithm (PTA), compare its performance in predicting crura mesh buttressing to HSA, and analyze outcomes. METHODS Retrospective, single-center, descriptive study (September 2018-September 2021). Adult patients (≥ 18 years old) who underwent laparoscopic HH repair. Outcomes and quality of life measured with the disease-specific gastroesophageal reflux disease health-related quality of life (GERD-HRQL) and reflux symptom index (RSI) were analyzed. RESULTS Fifty patients that underwent laparoscopic hiatoplasty and Toupet fundoplication were included. The median age was 61 years (range 32-83) and the median BMI was 26.7 (range 17-36). According to the PTA, 27 patients (54%) underwent simple suture repair while crural mesh buttressing with Phasix-ST® was used in 23 (46%). According to the HSA, the median hiatus area was 4.7 cm2 while 26 patients had an HSA greater than 4 cm2. The overall concordance rate between PTA and HSA was 94% (47/50). The median hospital stay was 1.9 days (range 1-8) and the 90-day complication rate was 4%. The median follow-up was 18.6 months (range 1-35). Hernia recurrence was diagnosed in 6%. Postoperative dysphagia occurred in one patient (2%). The GERD-HRQL (p < 0.001) and RSI (p = 0.001) were significantly improved. CONCLUSIONS The application of PTA for cruroplasty standardization in the setting of HH repair seems effective. While concordance with HSA is high, the PTA seems easier and promptly available in the operative theater with a potential increase in procedure standardization, reproducibility, and teaching.
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26
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Aiolfi A, Cavalli M, Sozzi A, Lombardo F, Lanzaro A, Panizzo V, Bonitta G, Mendogni P, Bruni PG, Campanelli G, Bona D. Medium-term safety and efficacy profile of paraesophageal hernia repair with Phasix-ST ® mesh: a single-institution experience. Hernia 2022; 26:279-286. [PMID: 34716832 DOI: 10.1007/s10029-021-02528-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/17/2021] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- A Aiolfi
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istitituto Clinico Sant'Ambrogio, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.
| | - M Cavalli
- Department of Surgery, University of Insubria, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - A Sozzi
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istitituto Clinico Sant'Ambrogio, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
| | - F Lombardo
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istitituto Clinico Sant'Ambrogio, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
| | - A Lanzaro
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istitituto Clinico Sant'Ambrogio, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
| | - V Panizzo
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istitituto Clinico Sant'Ambrogio, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
| | - G Bonitta
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istitituto Clinico Sant'Ambrogio, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
| | - P Mendogni
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istitituto Clinico Sant'Ambrogio, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
| | - P G Bruni
- Department of Surgery, University of Insubria, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - G Campanelli
- Department of Surgery, University of Insubria, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - D Bona
- Department of Biomedical Science for Health, Division of General Surgery, University of Milan, Istitituto Clinico Sant'Ambrogio, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
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