Evidence - Nissen fundoplication - general and visceral surgery
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Antireflux surgery - mesh augmentation in hiatal hernias
The management of hiatal hernias in the setting of antireflux surgery by primary hiatoplasty is associated with a recurrent hernia rate of 10% to 20%, depending on the study [1,2,3,4,6,10,11,15,18,19,23], causing the fundus cuff to migrate craniad and reside within the chest, which is referred to as "slipped Nissen fundoplication."
The use of plastic mesh in hiatal hernia repair was first explored as early as 1993. However, in the past the increasing use of mesh at the hiatus has raised concerns about alloplastic buttressing in light of the complications that have been observed.[12,17,22] On the other hand, the incidence of recurrent hernias decreases after hiatal mesh augmentation.
The main problems seen with alloplastic reinforcement at the hiatus include:
1. Rise in postoperative dysphagia
The use of mesh at the hiatus increases the rate of dysphagia in the immediate postoperative period compared with management without mesh, but after one year the outcomes do not differ. However, persistent stenosis due to scarring and fibrosis in the peri-esophageal tissue is a problem, as it usually cannot be resolved by bougienage but requires resection.[20,21]
2. Mesh perforation into the esophagus and stomach
Mesh perforation, first reported in 1998, is considered the most dramatic complication of hiatal augmentation. It may arise very late after surgery; cases after 7 or 9 years have been reported. Sometimes, retrieval of the foreign body by endoscopy may be successful, but most cases require partial esophagogastrectomy.
3. Risk of infection
The implantation of a foreign body is always associated with a certain risk of infection. With 0.5% of cases , the incidence is low but generally serious in consequence, requiring surgical revision of the cardiac region.
4. Secondary problems
Problems can arise due to the way the mesh is fixed to the hiatus. Helical tacks should be used with great caution, as several cases of pericardial lesions have already been reported. In 2000, one case of coronary vascular injury with fatal outcome was reported. One recommended alternative to the use of tacks is fixation by fibrin sealant or suture.
Regarding the potential complications from the use of alloplastic mesh at the hiatus, the trend is toward the use of absorbable mesh materials, which are expected to better blend into the tissue matrix and reduce fibrosis and adhesion formation. Initial results demonstrate fewer stenoses and erosions, but suggest an increase in the recurrence rate, compared with nonabsorbable meshes. At present, the extent to which nonabsorbable lightweight meshes whose mesh design and/or coating are intended to prevent foreign body reaction, are helpful remains unclear.[5, 7, 8, 9]
In 2010, the Society of American Gastrointestinal and Endoscopic Surgeons, SAGES, published the results of a survey on hiatal hernia repair with alloplastic mesh. The outcomes on some 5,500 hiatal hernias augmented with mesh are as follows:
§ 77% of procedures were performed laparoscopically and 23% by open surgery
§ Types of mesh used: 28% biomaterial, 25% PTFE (polytetrafluoroethylene), 21% PP (polypropylene)
§ Mesh fixation: 56 % suture
§ Recurrent hernia: 3% ( mostly absorbable mesh)
§ Stenoses and erosions: 0.2% and 0.3% respectively (mostly non-absorbable meshes)
The authors concluded that hiatal hernia repair with alloplastic mesh can significantly reduce the recurrence rate of hiatal hernias, and with acceptable risk of complications, compared to hiatal hernia repair without mesh.
Ongoing trials on this topic
Onlay Synthetic Bioabsorbable Mesh Herniorrhaphy Versus Herniorrhaphy Only in the Primary Treatment of Large Hiatal Hernia: a Multicenter, Randomized, Parallel-group, Evaluator Blinded, Phase III Clinical Trial
Literature on this topic
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2: Diaz S, Brunt LM, Klingensmith ME, Frisella PM, Soper NJ. Laparoscopic paraesophageal hernia repair, a challenging operation: medium-term outcome of 116 patients. J Gastrointest Surg. 2003 Jan;7(1):59-66; discussion 66-7.
3: Ellis FH Jr, Crozier RE, Shea JA. Paraesophageal hiatus hernia. Arch Surg. 1986 Apr;121(4):416-20.
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5: Frantzides CT, Carlson MA, Loizides S, Papafili A, Luu M, Roberts J, Zeni T, Frantzides A. Hiatal hernia repair with mesh: a survey of SAGES members. Surg Endosc. 2010 May;24(5):1017-24.
6: Hashemi M, Peters JH, DeMeester TR, Huprich JE, Quek M, Hagen JA, Crookes PF, Theisen J, DeMeester SR, Sillin LF, Bremner CG. Laparoscopic repair of large type III hiatal hernia: objective followup reveals high recurrence rate. J Am Coll
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7: Hazebroek EJ, Koak Y, Berry H, Leibman S, Smith GS. Critical evaluation of a novel DualMesh repair for large hiatal hernias. Surg Endosc. 2009 Jan;23(1):193-6.
8: Hazebroek EJ, Leibman S, Smith GS. Erosion of a composite PTFE/ePTFE mesh after hiatal hernia repair. Surg Laparosc Endosc Percutan Tech. 2009 Apr;19(2):175-7.
9: Hazebroek EJ, Ng A, Yong DH, Berry H, Leibman S, Smith GS. Evaluation of lightweight titanium-coated polypropylene mesh (TiMesh) for laparoscopic repair of large hiatal hernias. Surg Endosc. 2008 Nov;22(11):2428-32.
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11: Jacobs M, Gomez E, Plasencia G, Lopez-Penalver C, Lujan H, Velarde D, Jessee T. Use of surgisis mesh in laparoscopic repair of hiatal hernias. Surg Laparosc Endosc Percutan Tech. 2007 Oct;17(5):365-8.
12: Jansen M, Otto J, Jansen PL, Anurov M, Titkova S, Willis S, Rosch R, Ottinger A, Schumpelick V. Mesh migration into the esophageal wall after mesh hiatoplasty:comparison of two alloplastic materials. Surg Endosc. 2007 Dec;21(12):2298-303.
13: Kemppainen E, Kiviluoto T. Fatal cardiac tamponade after emergency
tension-free repair of a large paraesophageal hernia. Surg Endosc. 2000
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15: Nason KS, Luketich JD, Qureshi I, Keeley S, Trainor S, Awais O, Shende M, Landreneau RJ, Jobe BA, Pennathur A. Laparoscopic repair of giant paraesophageal hernia results in long-term patient satisfaction and a durable repair. J Gastrointest Surg. 2008 Dec;12(12):2066-75; discussion 2075-7.
16: Rieder E, Stoiber M, Scheikl V, Poglitsch M, Dal Borgo A, Prager G, Schima H. Mesh fixation in laparoscopic incisional hernia repair: glue fixation provides attachment strength similar to absorbable tacks but differs substantially in different meshes. J Am Coll Surg. 2011 Jan;212(1):80-6.
17: Schauer PR, Ikramuddin S, McLaughlin RH, Graham TO, Slivka A, Lee KK, Schraut WH, Luketich JD. Comparison of laparoscopic versus open repair of paraesophageal hernia. Am J Surg. 1998 Dec;176(6):659-65.
18: Smith GS, Isaacson JR, Draganic BD, Baladas HG, Falk GL. Symptomatic and radiological follow-up after para-esophageal hernia repair. Dis Esophagus. 2004;17(4):279-84.
19: Stirling MC, Orringer MB. Surgical treatment after the failed antireflux operation. J Thorac Cardiovasc Surg. 1986 Oct;92(4):667-72.
20: Trus TL, Bax T, Richardson WS, Branum GD, Mauren SJ, Swanstrom LL, Hunter JG. Complications of laparoscopic paraesophageal hernia repair. J Gastrointest Surg. 1997 May-Jun;1(3):221-7; discussion 228.
21: van der Peet DL, Klinkenberg-Knol EC, Alonso Poza A, Sietses C, Eijsbouts QA, Cuesta MA. Laparoscopic treatment of large paraesophageal hernias: both excision of the sac and gastropexy are imperative for adequate surgical treatment. Surg Endosc. 2000 Nov;14(11):1015-8.
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23: Zaninotto G, Portale G, Costantini M, Rizzetto C, Guirroli E, Ceolin M, Salvador R, Rampado S, Prandin O, Ruol A, Ancona E. Long-term results (6-10 years) of laparoscopic fundoplication. J Gastrointest Surg. 2007 Sep;11(9):1138-45. Epub 2007 Jul 10.