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

Long-term outcomes of laparoscopic large hiatus hernia repair with nonabsorbable mesh Summary The use of mesh to augment suture repair of large hiatus hernias remains controversial. Repair with mesh may help reduce the recurrence rate of primary repair, but concerns about the potential for serious complications, such as mesh erosion or stricturing, continue to limit its use. We aim to evaluate the long-term outcome of primary hiatus hernia repair with lightweight polypropylene mesh (TiMesh) specifically looking at rates of clinical recurrence, dysphagia, and mesh-related complications. From a prospectively maintained database, 50 consecutive patients who underwent elective primary laparoscopic hiatal hernia repair with TiMesh between January 2005 and December 2007 were identified. Case notes and postoperative endoscopy reports were reviewed. Clinical outcomes were evaluated using a structured questionnaire, including a validated dysphagia score. Of the 50 patients identified, 36 (72%) were contactable for follow-up. At a median follow-up of 9 years, the majority of patients (97%) regarded their surgery as successful. Twelve patients (33%) reported a recurrence of their symptoms, but only 4 (11%) reported that their symptoms were as severe as prior to the surgery. There was no significant difference between pre- and postoperative dysphagia scores. Postoperative endoscopy reports were available for 32 patients at a median time point of 4 years postoperatively, none of which revealed any mesh-related complications. One patient had undergone a revision procedure for a recurrent hernia at another institution. In this series, primary repair of large hiatus hernia with nonabsorbable mesh was not associated with any adverse effects over time. Patient satisfaction with symptomatic outcome remained high in the long term. INTRODUCTION The use of fascial prostheses has become widespread as an adjunct to primary crural closure in the repair of large hiatal defects.1–3 Universal enthusiasm for the use of mesh is tempered by the risk of complications related specifically to its use. Stricture and erosion have been reported, usually in case reports or small collaborative series.4–6 Reoperation for mesh complication is often technically challenging and may ultimately result in esophageal or gastric resection and/or dependency on supplemental nutrition.5,7 There is some evidence that the use of nonabsorbable mesh in large hiatal hernia repair is associated with a decreased rate of recurrence.8 A meta-analysis of three RCTs9 and a systematic review10 found that mesh-augmented hiatal hernia repair decreased the risk of recurrence compared to suture-only repair. A more recent meta-analysis looking hiatal hernia repair augmented with biological mesh, however, failed to demonstrate a difference in recurrence rates compared to suture alone.11 TiMesh (PFM Medical, Köln, Germany) is a lightweight titanium-coated polypropylene mesh, weighing 35 g/m2. Experimental data suggest that the light weight and the large pores of the titanium-coated mesh are associated with a number of benefits.12 Due to the large pore size, the bridging effect is absent, and the titanium further improves biocompatibility.13 In another experimental study, shrinkage of the mesh was limited, which may be associated with a reduction in recurrence rates.14 We have been using TiMesh in our unit routinely for large hiatal hernia repairs for the last 10 years. The aim of this study is to review our results, looking particularly at the rate of long-term mesh-related complications such as erosion and stricture. METHODS A prospective database of patients undergoing elective surgical repair of large hiatal defects with associated paraesophageal herniation using TiMesh was analyzed retrospectively. Fifty consecutive patients who underwent surgery between January 2005 and December 2007 were evaluated to allow adequate length of follow-up. We included all patients with a large hiatal defect resulting in herniation of the gastric fundus above the cardioesophageal junction into the posterior mediastinum with a true hernia sac. The size of the hernia was routinely recorded in the prospective database. No other types of mesh repairs were employed during the study period. Patients undergoing emergency or reoperative surgery were excluded from review. Dysphagia scores were calculated preoperatively for all patients using a validated scoring method as described by Dakkak and Bennett,15 which combines questions about difficulty swallowing different types of liquids and solids to form a numeral score. Using this method, a patient with no dysphagia scores 45 and a patient with profound dysphagia scores 0. Operative technique All operations were performed by the senior authors or trainees under their supervision. The hernia sac was dissected from its mediastinal attachments using ultrasonic shears (Ultrascision Coagulating Shears, Ethicon Endosurgery Inc., Cincinatti, Ohio, USA). A posterior sutured hiatoplasty was carried out with polyester sutures (0 Ethibond Ethicon, Johnson & Johnson, Cincinnati, Ohio, USA) placed 1 centimeter apart (Fig. 1). Onlay mesh reinforcement was then undertaken with TiMesh fixed with helical screws (ProTack 5 mm; Covidien, Mansfield, MA, USA). The mesh typically measured 3 × 4 cm with a curve cut on the ventral side of the prosthesis to ensure that the esophagus was not in direct contact with the mesh (Fig. 2). A posterior partial fundoplication was then carried out. Routine postoperative contrast studies were performed prior to the commencement of oral intake. Fig. 1 View largeDownload slide Operative view of primary crural closure using polyester sutures placed 1cm apart (0 Ethibond Ethicon, Johnson & Johnson, Cincinnati Ohio, USA). Fig. 1 View largeDownload slide Operative view of primary crural closure using polyester sutures placed 1cm apart (0 Ethibond Ethicon, Johnson & Johnson, Cincinnati Ohio, USA). Fig. 2 View largeDownload slide Operative view of TiMesh. After primary closure the mesh is fixed to the diaphragmatic crura with titanium helical screws (ProTack 5mm; Covidien, Mansfield MA, USA). Fig. 2 View largeDownload slide Operative view of TiMesh. After primary closure the mesh is fixed to the diaphragmatic crura with titanium helical screws (ProTack 5mm; Covidien, Mansfield MA, USA). Follow-up data were collected by chart review and telephone interview. A structured questionnaire was administered in which the following information was obtained: The presence or absence of recurrent symptoms; the severity of these symptoms as compared to before the surgery; and the presence of any new symptoms which they felt were attributable to the surgery. Patients were asked whether they had undergone endoscopy since the surgery, and we attempted to obtain the report if it had been done in another center. Patients were also questioned as to whether they had undergone revisional surgery at another center. The validated dysphagia score by Dakkak and Bennett was also applied. Overall patient satisfaction with the long-term result of their surgery was assessed using an outcome score (1 = excellent result, 5 = very poor result). Finally, patients were asked if they consider their surgery to be successful (yes/no) and whether, if faced with similar preoperative circumstances, they would make the same choice to undergo hiatal hernia repair. The telephone interviews were administered by a member of the research team who was independent of the clinical team. RESULTS Patients Patient characteristics and presenting symptoms are summarized in Table 1. There were 36 women and 14 men in this series. The median age at surgery was 65 years (range: 35 to 93 years). The most common preoperative symptoms were regurgitation, chest pain, and respiratory compromise (Table 2). Table 1 Patient characteristics and operative findings All Followed-up Lost to follow n = 50 n = 36 up n = 14 Age [median (range)] 65 (35–94) 65 (50–93) 64 (35–89) Gender M:F 14:36 8:28 6:8 Size of hiatus (cm) [mean (range)] 4.4 (3–6) 4.5 (3–6) 4.2 (3–6) Number of crural sutures [mean (range)] 4.6 (2–8) 4.6 (2–8) 4.6 (2–8) All Followed-up Lost to follow n = 50 n = 36 up n = 14 Age [median (range)] 65 (35–94) 65 (50–93) 64 (35–89) Gender M:F 14:36 8:28 6:8 Size of hiatus (cm) [mean (range)] 4.4 (3–6) 4.5 (3–6) 4.2 (3–6) Number of crural sutures [mean (range)] 4.6 (2–8) 4.6 (2–8) 4.6 (2–8) View Large Table 1 Patient characteristics and operative findings All Followed-up Lost to follow n = 50 n = 36 up n = 14 Age [median (range)] 65 (35–94) 65 (50–93) 64 (35–89) Gender M:F 14:36 8:28 6:8 Size of hiatus (cm) [mean (range)] 4.4 (3–6) 4.5 (3–6) 4.2 (3–6) Number of crural sutures [mean (range)] 4.6 (2–8) 4.6 (2–8) 4.6 (2–8) All Followed-up Lost to follow n = 50 n = 36 up n = 14 Age [median (range)] 65 (35–94) 65 (50–93) 64 (35–89) Gender M:F 14:36 8:28 6:8 Size of hiatus (cm) [mean (range)] 4.4 (3–6) 4.5 (3–6) 4.2 (3–6) Number of crural sutures [mean (range)] 4.6 (2–8) 4.6 (2–8) 4.6 (2–8) View Large Table 2 Patient pre and postoperative symptoms Symptom Preoperative all patients (n = 50) n(%) Preoperative of those followed up (n = 36) n (%) Postoperative (n = 36) n (%) New symptoms (n = 36) n (%) Heartburn 10 (20) 7 (19.4) 2 (5.6) 0 (0) Regurgitation 29 (58) 23 (63.9) 9 (25) 1 (2.8) Chest pain 29 (58) 21 (58.3) 2 (5.6) 1 (2.8) Respiratory compromise 16 (32) 12 (33.3) 0 0 (0) Dysphagia 8 (16) 5 (13.9) 1 (2.8) 2 (5.6) Anemia 8 (16) 5 (13.9) 0 0 (0) Symptom Preoperative all patients (n = 50) n(%) Preoperative of those followed up (n = 36) n (%) Postoperative (n = 36) n (%) New symptoms (n = 36) n (%) Heartburn 10 (20) 7 (19.4) 2 (5.6) 0 (0) Regurgitation 29 (58) 23 (63.9) 9 (25) 1 (2.8) Chest pain 29 (58) 21 (58.3) 2 (5.6) 1 (2.8) Respiratory compromise 16 (32) 12 (33.3) 0 0 (0) Dysphagia 8 (16) 5 (13.9) 1 (2.8) 2 (5.6) Anemia 8 (16) 5 (13.9) 0 0 (0) View Large Table 2 Patient pre and postoperative symptoms Symptom Preoperative all patients (n = 50) n(%) Preoperative of those followed up (n = 36) n (%) Postoperative (n = 36) n (%) New symptoms (n = 36) n (%) Heartburn 10 (20) 7 (19.4) 2 (5.6) 0 (0) Regurgitation 29 (58) 23 (63.9) 9 (25) 1 (2.8) Chest pain 29 (58) 21 (58.3) 2 (5.6) 1 (2.8) Respiratory compromise 16 (32) 12 (33.3) 0 0 (0) Dysphagia 8 (16) 5 (13.9) 1 (2.8) 2 (5.6) Anemia 8 (16) 5 (13.9) 0 0 (0) Symptom Preoperative all patients (n = 50) n(%) Preoperative of those followed up (n = 36) n (%) Postoperative (n = 36) n (%) New symptoms (n = 36) n (%) Heartburn 10 (20) 7 (19.4) 2 (5.6) 0 (0) Regurgitation 29 (58) 23 (63.9) 9 (25) 1 (2.8) Chest pain 29 (58) 21 (58.3) 2 (5.6) 1 (2.8) Respiratory compromise 16 (32) 12 (33.3) 0 0 (0) Dysphagia 8 (16) 5 (13.9) 1 (2.8) 2 (5.6) Anemia 8 (16) 5 (13.9) 0 0 (0) View Large Complications Median length of stay was 3 days (2–21 days). Five patients (10%) experienced postoperative complications (Table 3). One patient developed significant subcutaneous emphysema, but this was self-resolving and required no intervention. There were two early representations to hospital with nonspecific abdominal pain and shortness of breath, respectively. Both patients had negative investigations and were discharged well. Two esophageal perforations occurred, one of these resulting in a postoperative death. The first was an 88-year-old female who sustained a bougie perforation of the esophagus intraoperatively. This was recognized intraoperatively and repaired. Despite this, the patient developed an ongoing leak and required a thoracotomy. Subsequent to this the patient refused further treatment and ultimately succumbed to respiratory failure. The second patient, a 70-year-old female, presented with chest pain 6 days postdischarge. Imaging revealed a small leak presumably due to suture perforation. She was treated with insertion of a removable polyester stent, and underwent subsequent follow-up at another institution. Table 3 Perioperative complications Complication (n) % Clavien–Dindo grade Subcutaneous emphysema (1) 2 I Representation to hospital (2) 4 I Perforation (2) 4  Return to OT (1) 2 IIIb  Death (1) 2 V Complication (n) % Clavien–Dindo grade Subcutaneous emphysema (1) 2 I Representation to hospital (2) 4 I Perforation (2) 4  Return to OT (1) 2 IIIb  Death (1) 2 V View Large Table 3 Perioperative complications Complication (n) % Clavien–Dindo grade Subcutaneous emphysema (1) 2 I Representation to hospital (2) 4 I Perforation (2) 4  Return to OT (1) 2 IIIb  Death (1) 2 V Complication (n) % Clavien–Dindo grade Subcutaneous emphysema (1) 2 I Representation to hospital (2) 4 I Perforation (2) 4  Return to OT (1) 2 IIIb  Death (1) 2 V View Large Clinical follow-up Of the 50 patients in this series 36 (72%) were contactable for follow-up. Reasons for being lost to follow up were: deceased (6 patients); declined to be involved in further follow-up (2 patients); and patients no longer residing at previously recorded address (6 patients). For those 14 patients who were lost to follow-up, contact was made with their primary care providers and information sought on whether they had been referred to any other centers for endoscopy or revisional surgery. No referrals to other gastrointestinal surgeons were recorded and there were no cases of mesh-related complications documented in the primary care records. Patient satisfaction scores are shown in Table 4. The mean score was 1.5 (where 1 indicates an excellent result and 5 indicates a very poor result). The majority of patients (97%) regarded their surgery as successful overall. Ninety-two percent of patients stated that they would undergo the same surgery again if faced with similar preoperative circumstances. Table 4 Patient satisfaction outcomes Patients [n (%)] Outcome score  Excellent 21 (58)  Very good 12 (33)  Average 2 (6)  Poor 1 (3)  Very poor Nil Consider operation a success  Yes 35 (97)  No 1 (3) Would undergo again if similar circumstances  Yes 33 (92)  No 3 (8) Patients [n (%)] Outcome score  Excellent 21 (58)  Very good 12 (33)  Average 2 (6)  Poor 1 (3)  Very poor Nil Consider operation a success  Yes 35 (97)  No 1 (3) Would undergo again if similar circumstances  Yes 33 (92)  No 3 (8) View Large Table 4 Patient satisfaction outcomes Patients [n (%)] Outcome score  Excellent 21 (58)  Very good 12 (33)  Average 2 (6)  Poor 1 (3)  Very poor Nil Consider operation a success  Yes 35 (97)  No 1 (3) Would undergo again if similar circumstances  Yes 33 (92)  No 3 (8) Patients [n (%)] Outcome score  Excellent 21 (58)  Very good 12 (33)  Average 2 (6)  Poor 1 (3)  Very poor Nil Consider operation a success  Yes 35 (97)  No 1 (3) Would undergo again if similar circumstances  Yes 33 (92)  No 3 (8) View Large At a median follow-up of 9 years, 12 patients (33%) reported a recurrence of their symptoms (Table 2). Four patients (11%) described their symptoms as being as severe as prior to surgery. Of the 36 patients interviewed, 14 (39%) reported taking regular proton pump inhibitors (PPI), 4 (8%) reported occasional PPI use and 18 (50%) reported no PPI use. There was no significant difference in the mean preoperative dysphagia score (35.2) and the mean postoperative dysphagia score (39). Two patients reported new onset dysphagia following the surgery. The first patient, however, when closely questioned, could tolerate both solids and liquids without difficulty and had a Dakkak score of 45. The second patient had experienced the postoperative leak and stent insertion. This patient had undergone a reoperation for recurrence 4 year after her original repair. This was done at another institution. At reoperation an anterior recurrence was found; no mesh related complications were encountered. Endoscopy follow-up Postoperative endoscopy reports were available for 32 patients at varying length of follow-up (median 4 years; range: 1–10 years). No mesh erosion or strictures at the GOJ were noted in any of the endoscopy reports. The hiatal repair was intact in 20/32 patients (62%), whereas there was evidence of a small hernia recurrence (<2 cm) in 12 patients (38%). No large recurrences were observed. DISCUSSION The high failure rate of primary suture crural repair of large hiatal hernia defects has provided impetus for various techniques of prosthetic repair augmentation for many years. Autologous grafts of fascia lata were used as early as the 1930s and 1940s.16–19 Tantalum mesh was used in the 1960s, and in the 1960s and 1970s the use of early petroleum-based meshes, such as polyvinyl formalinized sponge and nonexpanded polytetrafluoroethylene (Goretex) were adopted.20–22 Two reviews by Johnson et al.23 and Furnee and Hazebroek10 outline the variety of modern biomaterials in current usage. Both reviews and a meta-analysis by Antoniou9,24 identify lower recurrence rates associated with the use of mesh when compared to primary hiatal closure. Currently, a large Australasian multicenter RCT is underway comparing suture repair alone, repair augmented with biological mesh and repair with TiMesh in large hiatal hernias.25 At 12 months follow-up a significant difference has not been shown in terms of recurrence in the three groups. In our study a number of small, clinically insignificant recurrent hernias were identified at endoscopy. Whether these patients develop larger symptomatic hernias remains to be seen. One could postulate that the presence of mesh posteriorly may minimize ongoing dilatation of the hiatal aperture and potentially decrease the rate of clinically significant recurrence rates in the long term. There were no large recurrences and no recurrences that required revisional surgery to correct. The current widespread use of modern prostheses in the repair of large hiatal defects was confirmed in a recent survey of members of the Society of American Gastrointestinal and Endoscopic Surgeons.1 The use of fascial prosthesis in 5486 patients undergoing hiatus hernia repair was reported by 264 surgeon responders. The most commonly used meshes were polypropylene, expanded polytetrafluoroethylene, and biological mesh. Reassuringly, mesh-related complications were reported in less than 1% of patients in this survey. However, as discussed below mesh-related complications may be catastrophic. Where mesh is utilized in close proximity to abdominal viscera, the risk of mesh adhesion and erosion are always present. This risk is particularly high at the esophageal hiatus, which is a mechanically dynamic region. In 2008, Stadlhuber and others5 reviewed 14 case reports from the literature and 14 from the authors. They presented a sobering variety of complication presentations, including 16 cases of intraluminal migration or erosion. Nine of the patients in this series of case reports ultimately required foregut resection. While the type of prosthesis is identified in each case, it is not possible to glean from this study whether specific errors in mesh usage led to the presented complications. Furthermore, the primary mechanism of repair failure which leads to migration of mesh into the esophagogastric lumen remains unclear. We have tried to address the potential mechanisms for mesh erosion in several ways: First, by ensuring robust fixation of the mesh to the hiatus using multiple screws to ensure that the mesh lays flat against the hiatal pillars and thus prevents buckling and dislocation. This approach to mesh fixation would not be possible if the mesh was placed anteriorly and therefore overlying the central diaphragmatic tendon and pericardium. We feel that this is a safe technique as there have been reports of anteriorly placed tacks causing cardiac tamponade.26 Second, we also take care to preserve a cuff of muscle between the cut edge of the mesh and the esophagus to ensure that the mesh is never placed in direct contact with the esophagus. Finally, we use a ‘soft’ large-pore mesh, which incorporates readily into host tissues. TiMesh is lightweight polypropylene mesh and its large pore size encourages incorporation into the native crural pillars and diaphragm.12–14,27–29 Significantly, in this series of 50 patients, we were unable to identify any cases of mesh erosion at a median follow-up of 9 years. Our study has some limitations. First, there was a loss to follow-up rate of 28%. During a relatively long follow-up period of median 9 years, some amount of loss to follow-up is expected. Nearly 50% those lost to follow-up were due to patient death (all unrelated to their hiatal surgery). This reflects the fact that it is often older patients with comorbidities who undergo this procedure. Potentially the group of patients that we were able contact for interview is therefore made up of younger and less comorbid patients. However, as shown in Table 1, there was no significant difference in the two groups in terms of baseline characteristics. Second, there is a risk of interviewer bias when administering telephone questionnaires. We attempted to minimize this bias by having the interviews performed by a member of the research team who was independent of the clinical team. The patients were not contacted by the operating surgeon(s) at any stage. Finally, formal quality of life scores were not administered. This was a pragmatic decision based on study design. We chose to focus on patient reported outcomes in the form of a symptom specific questionnaire, as well as using a pre- and postoperative validated dysphagia score. In conclusion, we have shown that our symptomatic recurrence rates, rates of reoperation for recurrence, and rates of mesh-related complications are all low. Rates of anatomic recurrence detected at endoscopy were moderate (38%) but despite this, at a median follow-up of 9 years, patient reported satisfaction was high. Postoperative dysphagia rates were minimal and there were no cases of mesh-related stricture or erosion. The use of mesh in hiatus hernia repair remains contentious and further evidence from the long-term analysis of randomized controlled trials is awaited. Our series shows that it is possible to utilize mesh safely with high patient satisfaction rates and low complication rates long term. Acknowledgments The authors Ms Alexandra Gordon, Dr Carla Gillespie, Dr Ji Son, Dr Tania Polhill, Mr Steven Leibman, and Mr Garett Smith have no conflicts of interest or financial ties to disclose. Notes Specific author contributions: Study conception: Alexandra C. Gordon; Manuscript draft: Alexandra C. Gordon, Carla Gillespie, Steven Leibman; Interpretation of data: Alexandra C. Gordon; Review and approval of final manuscript: Alexandra C. Gordon, Carla Gillespie, Ji Son, Tania Polhill, Steven Leibman, Garett S. Smith; Revision of content: Carla Gillespie; Preparation for submission: Carla Gillespie; Acquisition, analysis and interpretation of data: Ji Son, Tania Polhill; Study design: Garett S. Smith; Manuscript preparation: Garett S. Smith. No external funding has been received for this paper. References 1. Pfluke J M , Parker M , Bowers S P , Asbun H J , Daniel Smith C . Use of mesh for hiatal hernia repair: a survey of SAGES members . Surg Endosc 2012 ; 26 : 1843 – 8 . Google Scholar CrossRef Search ADS PubMed 2. Furnée E J B . The use of mesh in laparoscopic large hiatal hernia repair: a survey of European surgeons . Surg Laparosc Endosc Percutan Tech 2015 ; 25 : 307 – 11 . Google Scholar CrossRef Search ADS PubMed 3. Tam V , Winger D G , Nason K S . A systematic review and meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair . Am J Surg 2016 ; 211 : 226 – 38 . Google Scholar CrossRef Search ADS PubMed 4. Fenton-Lee D , Tsang C . A series of complications after paraesophageal hernia repair with the used of Timesh: a case report . Surg Laparosc Endosc Percutan Tech 2010 ; 20 : e95 – 6 . Google Scholar CrossRef Search ADS PubMed 5. Stadlhuber R J R J. Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series . Surg Endosc 2009 ; 23 : 1219 – 26 . Google Scholar CrossRef Search ADS PubMed 6. De Moor V , Zalcman M , Delhaye M , El Nakadi I . Complications of mesh repair in hiatal surgery: about 3 cases and review of the literature . Surg Laparosc Endosc Percutan Tech 2012 ; 22 : e222 – 5 . Google Scholar CrossRef Search ADS PubMed 7. Nandipati K , Bye M , Yamamoto S R , Pallati P , Lee T , Mittal S K . Reoperative intervention in patients with mesh at the hiatus is associated with high incidence of esophageal resection–a single-center experience . J Gastrointest Surg 2013 ; 17 : 2039 – 44 . Google Scholar CrossRef Search ADS PubMed 8. Furnee E , Hazebroek E . Mesh in laparoscopic large hiatal hernia repair: a systematic review of the literature . Surg Endosc 2013 ; 27 : 3998 – 4008 . Google Scholar CrossRef Search ADS PubMed 9. Antoniou S A , Antoniou G A , Koch O O , Pointner R , Granderath F A . Lower recurrence rates after mesh-reinforced versus simple hiatal hernia repair: a meta-analysis of randomized trials . Surg Laparosc Endosc Percutan Tech 2012 ; 22 : 498 – 502 . Google Scholar CrossRef Search ADS PubMed 10. Furnee E , Hazebroek E . Mesh in laparoscopic large hiatal hernia repair: a systematic review of the literature . Surg Endosc 2013 ; 27 : 3998 – 4008 . Google Scholar CrossRef Search ADS PubMed 11. Antoniou S , Müller-Stich B , Antoniou G et al. Laparoscopic augmentation of the diaphragmatic hiatus with biologic mesh versus suture repair: a systematic review and meta-analysis . Langenbecks Arch Surg 2015 ; 400 : 577 – 83 . Google Scholar CrossRef Search ADS PubMed 12. Klosterhalfen B , Junge K , Klinge U . The lightweight and large porous mesh concept for hernia repair . Expert Rev Med Devices 2005 ; 2 : 103 – 17 . Google Scholar CrossRef Search ADS PubMed 13. Scheidbach H , Tamme C , Tannapfel A , Lippert H , Kockerling F . In vivo studies comparing the biocompatibility of various polypropylene meshes and their handling properties during endoscopic total extraperitoneal (TEP) patchplasty: an experimental study in pigs . Surg Endosc 2004 ; 18 : 211 – 20 . Google Scholar CrossRef Search ADS PubMed 14. Schug-Pass C , Tamme C , Tannapfel A , Kockerling F . A lightweight polypropylene mesh (TiMesh) for laparoscopic intraperitoneal repair of abdominal wall hernias: comparison of biocompatibility with the DualMesh in an experimental study using the porcine model . Surg Endosc 2006 ; 20 : 402 – 9 . Google Scholar CrossRef Search ADS PubMed 15. Dakkak M , Bennett J R . A new dysphagia score with objective validation . J Clin Gastroenterol 1992 ; 14 : 99 – 100 . Google Scholar CrossRef Search ADS PubMed 16. Hedblom C . Diaphragmatic hernia . JAMA 1925 ; 85, 947 . 17. Harrington S W . Diaphragmatic hernia: symptoms and surgical treatment in sixty cases . JAMA 1933 ; 101 : 987 – 94 . Google Scholar CrossRef Search ADS 18. Harrington S W . Diagnosis and treatment of various types of diaphragmatic hernia . Am J Surg 1940 ; 50 : 381 – 446 . Google Scholar CrossRef Search ADS 19. Lake N C . Para-oesophageal diaphragmatic hernia . BMJ 1933 ; 2 : 331 – 2 . Google Scholar CrossRef Search ADS PubMed 20. Friedman M H , Mackenzie W C . The clinical use of polyvinyl sponge ivalon in the repair of esophageal hiatus hernia . Can J Surg 1961 ; 4 : 176 – 82 . Google Scholar PubMed 21. Merendino K A , Dillard D H . Permanent fixation by teflon mesh of the size of the esophageal diaphragmatic aperture in hiatus hernioplasty . Am J Surg 1965 ; 110 : 416 – 20 . Google Scholar CrossRef Search ADS PubMed 22. Kennedy M C , Sutherland H D . Hiatus hernia repair. Clinical and radiological results of a new combined thoracoabdominal technique . Med J Aust 1974 ; 1 : 386 – 90 . Google Scholar PubMed 23. Johnson J M , Carbonell A M , Carmody B J et al. Laparoscopic mesh hiatoplasty for paraesophageal hernias and fundoplications: a critical analysis of the available literature . Surg Endosc 2006 ; 20 : 362 – 6 . Google Scholar CrossRef Search ADS PubMed 24. Antoniou S A , Pointner R , Granderath F A . Hiatal hernia repair with the use of biologic meshes: a literature review . Surg Laparosc Endosc Percutan Tech 2011 ; 21 : 1 – 9 . Google Scholar CrossRef Search ADS PubMed 25. Watson D I , Thompson S K , Devitt P G et al. Laparoscopic repair of very large hiatus hernia with sutures versus absorbable mesh versus nonabsorbable mesh: a randomized controlled trial . Ann Surg 2015 ; 261 : 282 – 9 . Google Scholar CrossRef Search ADS PubMed 26. Makarewicz W , Jaworski L , Bobowicz M et al. Paraesophageal hernia repair followed by cardiac tamponade caused by ProTacks . Ann Thorac Surg 2012 ; 94 : e87 – 9 . Google Scholar CrossRef Search ADS PubMed 27. Kockerling F , Schug-Pass C . What do we know about titanized polypropylene meshes? An evidence-based review of the literature . Hernia 2014 ; 18 : 445 – 57 . Google Scholar CrossRef Search ADS PubMed 28. Hazebroek E J , Ng A , Yong D H , Berry H , Leibman S , Smith G S . Evaluation of lightweight titanium-coated polypropylene mesh (TiMesh) for laparoscopic repair of large hiatal hernias . Surg Endosc 2008 ; 22 : 2428 – 32 . Google Scholar CrossRef Search ADS PubMed 29. Delibegovic S , Koluh A , Cickusic E , Katica M , Mustedanagic J , Krupic F . Formation of adhesion after intraperitoneal application of TiMesh: experimental study on a rodent model . Acta Chir Belg 2016 ; 116 : 293 – 300 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Diseases of the Esophagus Oxford University Press

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

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The International Society for Diseases of the Esophagus
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© The Author(s) 2018. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus.
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Abstract

Summary The use of mesh to augment suture repair of large hiatus hernias remains controversial. Repair with mesh may help reduce the recurrence rate of primary repair, but concerns about the potential for serious complications, such as mesh erosion or stricturing, continue to limit its use. We aim to evaluate the long-term outcome of primary hiatus hernia repair with lightweight polypropylene mesh (TiMesh) specifically looking at rates of clinical recurrence, dysphagia, and mesh-related complications. From a prospectively maintained database, 50 consecutive patients who underwent elective primary laparoscopic hiatal hernia repair with TiMesh between January 2005 and December 2007 were identified. Case notes and postoperative endoscopy reports were reviewed. Clinical outcomes were evaluated using a structured questionnaire, including a validated dysphagia score. Of the 50 patients identified, 36 (72%) were contactable for follow-up. At a median follow-up of 9 years, the majority of patients (97%) regarded their surgery as successful. Twelve patients (33%) reported a recurrence of their symptoms, but only 4 (11%) reported that their symptoms were as severe as prior to the surgery. There was no significant difference between pre- and postoperative dysphagia scores. Postoperative endoscopy reports were available for 32 patients at a median time point of 4 years postoperatively, none of which revealed any mesh-related complications. One patient had undergone a revision procedure for a recurrent hernia at another institution. In this series, primary repair of large hiatus hernia with nonabsorbable mesh was not associated with any adverse effects over time. Patient satisfaction with symptomatic outcome remained high in the long term. INTRODUCTION The use of fascial prostheses has become widespread as an adjunct to primary crural closure in the repair of large hiatal defects.1–3 Universal enthusiasm for the use of mesh is tempered by the risk of complications related specifically to its use. Stricture and erosion have been reported, usually in case reports or small collaborative series.4–6 Reoperation for mesh complication is often technically challenging and may ultimately result in esophageal or gastric resection and/or dependency on supplemental nutrition.5,7 There is some evidence that the use of nonabsorbable mesh in large hiatal hernia repair is associated with a decreased rate of recurrence.8 A meta-analysis of three RCTs9 and a systematic review10 found that mesh-augmented hiatal hernia repair decreased the risk of recurrence compared to suture-only repair. A more recent meta-analysis looking hiatal hernia repair augmented with biological mesh, however, failed to demonstrate a difference in recurrence rates compared to suture alone.11 TiMesh (PFM Medical, Köln, Germany) is a lightweight titanium-coated polypropylene mesh, weighing 35 g/m2. Experimental data suggest that the light weight and the large pores of the titanium-coated mesh are associated with a number of benefits.12 Due to the large pore size, the bridging effect is absent, and the titanium further improves biocompatibility.13 In another experimental study, shrinkage of the mesh was limited, which may be associated with a reduction in recurrence rates.14 We have been using TiMesh in our unit routinely for large hiatal hernia repairs for the last 10 years. The aim of this study is to review our results, looking particularly at the rate of long-term mesh-related complications such as erosion and stricture. METHODS A prospective database of patients undergoing elective surgical repair of large hiatal defects with associated paraesophageal herniation using TiMesh was analyzed retrospectively. Fifty consecutive patients who underwent surgery between January 2005 and December 2007 were evaluated to allow adequate length of follow-up. We included all patients with a large hiatal defect resulting in herniation of the gastric fundus above the cardioesophageal junction into the posterior mediastinum with a true hernia sac. The size of the hernia was routinely recorded in the prospective database. No other types of mesh repairs were employed during the study period. Patients undergoing emergency or reoperative surgery were excluded from review. Dysphagia scores were calculated preoperatively for all patients using a validated scoring method as described by Dakkak and Bennett,15 which combines questions about difficulty swallowing different types of liquids and solids to form a numeral score. Using this method, a patient with no dysphagia scores 45 and a patient with profound dysphagia scores 0. Operative technique All operations were performed by the senior authors or trainees under their supervision. The hernia sac was dissected from its mediastinal attachments using ultrasonic shears (Ultrascision Coagulating Shears, Ethicon Endosurgery Inc., Cincinatti, Ohio, USA). A posterior sutured hiatoplasty was carried out with polyester sutures (0 Ethibond Ethicon, Johnson & Johnson, Cincinnati, Ohio, USA) placed 1 centimeter apart (Fig. 1). Onlay mesh reinforcement was then undertaken with TiMesh fixed with helical screws (ProTack 5 mm; Covidien, Mansfield, MA, USA). The mesh typically measured 3 × 4 cm with a curve cut on the ventral side of the prosthesis to ensure that the esophagus was not in direct contact with the mesh (Fig. 2). A posterior partial fundoplication was then carried out. Routine postoperative contrast studies were performed prior to the commencement of oral intake. Fig. 1 View largeDownload slide Operative view of primary crural closure using polyester sutures placed 1cm apart (0 Ethibond Ethicon, Johnson & Johnson, Cincinnati Ohio, USA). Fig. 1 View largeDownload slide Operative view of primary crural closure using polyester sutures placed 1cm apart (0 Ethibond Ethicon, Johnson & Johnson, Cincinnati Ohio, USA). Fig. 2 View largeDownload slide Operative view of TiMesh. After primary closure the mesh is fixed to the diaphragmatic crura with titanium helical screws (ProTack 5mm; Covidien, Mansfield MA, USA). Fig. 2 View largeDownload slide Operative view of TiMesh. After primary closure the mesh is fixed to the diaphragmatic crura with titanium helical screws (ProTack 5mm; Covidien, Mansfield MA, USA). Follow-up data were collected by chart review and telephone interview. A structured questionnaire was administered in which the following information was obtained: The presence or absence of recurrent symptoms; the severity of these symptoms as compared to before the surgery; and the presence of any new symptoms which they felt were attributable to the surgery. Patients were asked whether they had undergone endoscopy since the surgery, and we attempted to obtain the report if it had been done in another center. Patients were also questioned as to whether they had undergone revisional surgery at another center. The validated dysphagia score by Dakkak and Bennett was also applied. Overall patient satisfaction with the long-term result of their surgery was assessed using an outcome score (1 = excellent result, 5 = very poor result). Finally, patients were asked if they consider their surgery to be successful (yes/no) and whether, if faced with similar preoperative circumstances, they would make the same choice to undergo hiatal hernia repair. The telephone interviews were administered by a member of the research team who was independent of the clinical team. RESULTS Patients Patient characteristics and presenting symptoms are summarized in Table 1. There were 36 women and 14 men in this series. The median age at surgery was 65 years (range: 35 to 93 years). The most common preoperative symptoms were regurgitation, chest pain, and respiratory compromise (Table 2). Table 1 Patient characteristics and operative findings All Followed-up Lost to follow n = 50 n = 36 up n = 14 Age [median (range)] 65 (35–94) 65 (50–93) 64 (35–89) Gender M:F 14:36 8:28 6:8 Size of hiatus (cm) [mean (range)] 4.4 (3–6) 4.5 (3–6) 4.2 (3–6) Number of crural sutures [mean (range)] 4.6 (2–8) 4.6 (2–8) 4.6 (2–8) All Followed-up Lost to follow n = 50 n = 36 up n = 14 Age [median (range)] 65 (35–94) 65 (50–93) 64 (35–89) Gender M:F 14:36 8:28 6:8 Size of hiatus (cm) [mean (range)] 4.4 (3–6) 4.5 (3–6) 4.2 (3–6) Number of crural sutures [mean (range)] 4.6 (2–8) 4.6 (2–8) 4.6 (2–8) View Large Table 1 Patient characteristics and operative findings All Followed-up Lost to follow n = 50 n = 36 up n = 14 Age [median (range)] 65 (35–94) 65 (50–93) 64 (35–89) Gender M:F 14:36 8:28 6:8 Size of hiatus (cm) [mean (range)] 4.4 (3–6) 4.5 (3–6) 4.2 (3–6) Number of crural sutures [mean (range)] 4.6 (2–8) 4.6 (2–8) 4.6 (2–8) All Followed-up Lost to follow n = 50 n = 36 up n = 14 Age [median (range)] 65 (35–94) 65 (50–93) 64 (35–89) Gender M:F 14:36 8:28 6:8 Size of hiatus (cm) [mean (range)] 4.4 (3–6) 4.5 (3–6) 4.2 (3–6) Number of crural sutures [mean (range)] 4.6 (2–8) 4.6 (2–8) 4.6 (2–8) View Large Table 2 Patient pre and postoperative symptoms Symptom Preoperative all patients (n = 50) n(%) Preoperative of those followed up (n = 36) n (%) Postoperative (n = 36) n (%) New symptoms (n = 36) n (%) Heartburn 10 (20) 7 (19.4) 2 (5.6) 0 (0) Regurgitation 29 (58) 23 (63.9) 9 (25) 1 (2.8) Chest pain 29 (58) 21 (58.3) 2 (5.6) 1 (2.8) Respiratory compromise 16 (32) 12 (33.3) 0 0 (0) Dysphagia 8 (16) 5 (13.9) 1 (2.8) 2 (5.6) Anemia 8 (16) 5 (13.9) 0 0 (0) Symptom Preoperative all patients (n = 50) n(%) Preoperative of those followed up (n = 36) n (%) Postoperative (n = 36) n (%) New symptoms (n = 36) n (%) Heartburn 10 (20) 7 (19.4) 2 (5.6) 0 (0) Regurgitation 29 (58) 23 (63.9) 9 (25) 1 (2.8) Chest pain 29 (58) 21 (58.3) 2 (5.6) 1 (2.8) Respiratory compromise 16 (32) 12 (33.3) 0 0 (0) Dysphagia 8 (16) 5 (13.9) 1 (2.8) 2 (5.6) Anemia 8 (16) 5 (13.9) 0 0 (0) View Large Table 2 Patient pre and postoperative symptoms Symptom Preoperative all patients (n = 50) n(%) Preoperative of those followed up (n = 36) n (%) Postoperative (n = 36) n (%) New symptoms (n = 36) n (%) Heartburn 10 (20) 7 (19.4) 2 (5.6) 0 (0) Regurgitation 29 (58) 23 (63.9) 9 (25) 1 (2.8) Chest pain 29 (58) 21 (58.3) 2 (5.6) 1 (2.8) Respiratory compromise 16 (32) 12 (33.3) 0 0 (0) Dysphagia 8 (16) 5 (13.9) 1 (2.8) 2 (5.6) Anemia 8 (16) 5 (13.9) 0 0 (0) Symptom Preoperative all patients (n = 50) n(%) Preoperative of those followed up (n = 36) n (%) Postoperative (n = 36) n (%) New symptoms (n = 36) n (%) Heartburn 10 (20) 7 (19.4) 2 (5.6) 0 (0) Regurgitation 29 (58) 23 (63.9) 9 (25) 1 (2.8) Chest pain 29 (58) 21 (58.3) 2 (5.6) 1 (2.8) Respiratory compromise 16 (32) 12 (33.3) 0 0 (0) Dysphagia 8 (16) 5 (13.9) 1 (2.8) 2 (5.6) Anemia 8 (16) 5 (13.9) 0 0 (0) View Large Complications Median length of stay was 3 days (2–21 days). Five patients (10%) experienced postoperative complications (Table 3). One patient developed significant subcutaneous emphysema, but this was self-resolving and required no intervention. There were two early representations to hospital with nonspecific abdominal pain and shortness of breath, respectively. Both patients had negative investigations and were discharged well. Two esophageal perforations occurred, one of these resulting in a postoperative death. The first was an 88-year-old female who sustained a bougie perforation of the esophagus intraoperatively. This was recognized intraoperatively and repaired. Despite this, the patient developed an ongoing leak and required a thoracotomy. Subsequent to this the patient refused further treatment and ultimately succumbed to respiratory failure. The second patient, a 70-year-old female, presented with chest pain 6 days postdischarge. Imaging revealed a small leak presumably due to suture perforation. She was treated with insertion of a removable polyester stent, and underwent subsequent follow-up at another institution. Table 3 Perioperative complications Complication (n) % Clavien–Dindo grade Subcutaneous emphysema (1) 2 I Representation to hospital (2) 4 I Perforation (2) 4  Return to OT (1) 2 IIIb  Death (1) 2 V Complication (n) % Clavien–Dindo grade Subcutaneous emphysema (1) 2 I Representation to hospital (2) 4 I Perforation (2) 4  Return to OT (1) 2 IIIb  Death (1) 2 V View Large Table 3 Perioperative complications Complication (n) % Clavien–Dindo grade Subcutaneous emphysema (1) 2 I Representation to hospital (2) 4 I Perforation (2) 4  Return to OT (1) 2 IIIb  Death (1) 2 V Complication (n) % Clavien–Dindo grade Subcutaneous emphysema (1) 2 I Representation to hospital (2) 4 I Perforation (2) 4  Return to OT (1) 2 IIIb  Death (1) 2 V View Large Clinical follow-up Of the 50 patients in this series 36 (72%) were contactable for follow-up. Reasons for being lost to follow up were: deceased (6 patients); declined to be involved in further follow-up (2 patients); and patients no longer residing at previously recorded address (6 patients). For those 14 patients who were lost to follow-up, contact was made with their primary care providers and information sought on whether they had been referred to any other centers for endoscopy or revisional surgery. No referrals to other gastrointestinal surgeons were recorded and there were no cases of mesh-related complications documented in the primary care records. Patient satisfaction scores are shown in Table 4. The mean score was 1.5 (where 1 indicates an excellent result and 5 indicates a very poor result). The majority of patients (97%) regarded their surgery as successful overall. Ninety-two percent of patients stated that they would undergo the same surgery again if faced with similar preoperative circumstances. Table 4 Patient satisfaction outcomes Patients [n (%)] Outcome score  Excellent 21 (58)  Very good 12 (33)  Average 2 (6)  Poor 1 (3)  Very poor Nil Consider operation a success  Yes 35 (97)  No 1 (3) Would undergo again if similar circumstances  Yes 33 (92)  No 3 (8) Patients [n (%)] Outcome score  Excellent 21 (58)  Very good 12 (33)  Average 2 (6)  Poor 1 (3)  Very poor Nil Consider operation a success  Yes 35 (97)  No 1 (3) Would undergo again if similar circumstances  Yes 33 (92)  No 3 (8) View Large Table 4 Patient satisfaction outcomes Patients [n (%)] Outcome score  Excellent 21 (58)  Very good 12 (33)  Average 2 (6)  Poor 1 (3)  Very poor Nil Consider operation a success  Yes 35 (97)  No 1 (3) Would undergo again if similar circumstances  Yes 33 (92)  No 3 (8) Patients [n (%)] Outcome score  Excellent 21 (58)  Very good 12 (33)  Average 2 (6)  Poor 1 (3)  Very poor Nil Consider operation a success  Yes 35 (97)  No 1 (3) Would undergo again if similar circumstances  Yes 33 (92)  No 3 (8) View Large At a median follow-up of 9 years, 12 patients (33%) reported a recurrence of their symptoms (Table 2). Four patients (11%) described their symptoms as being as severe as prior to surgery. Of the 36 patients interviewed, 14 (39%) reported taking regular proton pump inhibitors (PPI), 4 (8%) reported occasional PPI use and 18 (50%) reported no PPI use. There was no significant difference in the mean preoperative dysphagia score (35.2) and the mean postoperative dysphagia score (39). Two patients reported new onset dysphagia following the surgery. The first patient, however, when closely questioned, could tolerate both solids and liquids without difficulty and had a Dakkak score of 45. The second patient had experienced the postoperative leak and stent insertion. This patient had undergone a reoperation for recurrence 4 year after her original repair. This was done at another institution. At reoperation an anterior recurrence was found; no mesh related complications were encountered. Endoscopy follow-up Postoperative endoscopy reports were available for 32 patients at varying length of follow-up (median 4 years; range: 1–10 years). No mesh erosion or strictures at the GOJ were noted in any of the endoscopy reports. The hiatal repair was intact in 20/32 patients (62%), whereas there was evidence of a small hernia recurrence (<2 cm) in 12 patients (38%). No large recurrences were observed. DISCUSSION The high failure rate of primary suture crural repair of large hiatal hernia defects has provided impetus for various techniques of prosthetic repair augmentation for many years. Autologous grafts of fascia lata were used as early as the 1930s and 1940s.16–19 Tantalum mesh was used in the 1960s, and in the 1960s and 1970s the use of early petroleum-based meshes, such as polyvinyl formalinized sponge and nonexpanded polytetrafluoroethylene (Goretex) were adopted.20–22 Two reviews by Johnson et al.23 and Furnee and Hazebroek10 outline the variety of modern biomaterials in current usage. Both reviews and a meta-analysis by Antoniou9,24 identify lower recurrence rates associated with the use of mesh when compared to primary hiatal closure. Currently, a large Australasian multicenter RCT is underway comparing suture repair alone, repair augmented with biological mesh and repair with TiMesh in large hiatal hernias.25 At 12 months follow-up a significant difference has not been shown in terms of recurrence in the three groups. In our study a number of small, clinically insignificant recurrent hernias were identified at endoscopy. Whether these patients develop larger symptomatic hernias remains to be seen. One could postulate that the presence of mesh posteriorly may minimize ongoing dilatation of the hiatal aperture and potentially decrease the rate of clinically significant recurrence rates in the long term. There were no large recurrences and no recurrences that required revisional surgery to correct. The current widespread use of modern prostheses in the repair of large hiatal defects was confirmed in a recent survey of members of the Society of American Gastrointestinal and Endoscopic Surgeons.1 The use of fascial prosthesis in 5486 patients undergoing hiatus hernia repair was reported by 264 surgeon responders. The most commonly used meshes were polypropylene, expanded polytetrafluoroethylene, and biological mesh. Reassuringly, mesh-related complications were reported in less than 1% of patients in this survey. However, as discussed below mesh-related complications may be catastrophic. Where mesh is utilized in close proximity to abdominal viscera, the risk of mesh adhesion and erosion are always present. This risk is particularly high at the esophageal hiatus, which is a mechanically dynamic region. In 2008, Stadlhuber and others5 reviewed 14 case reports from the literature and 14 from the authors. They presented a sobering variety of complication presentations, including 16 cases of intraluminal migration or erosion. Nine of the patients in this series of case reports ultimately required foregut resection. While the type of prosthesis is identified in each case, it is not possible to glean from this study whether specific errors in mesh usage led to the presented complications. Furthermore, the primary mechanism of repair failure which leads to migration of mesh into the esophagogastric lumen remains unclear. We have tried to address the potential mechanisms for mesh erosion in several ways: First, by ensuring robust fixation of the mesh to the hiatus using multiple screws to ensure that the mesh lays flat against the hiatal pillars and thus prevents buckling and dislocation. This approach to mesh fixation would not be possible if the mesh was placed anteriorly and therefore overlying the central diaphragmatic tendon and pericardium. We feel that this is a safe technique as there have been reports of anteriorly placed tacks causing cardiac tamponade.26 Second, we also take care to preserve a cuff of muscle between the cut edge of the mesh and the esophagus to ensure that the mesh is never placed in direct contact with the esophagus. Finally, we use a ‘soft’ large-pore mesh, which incorporates readily into host tissues. TiMesh is lightweight polypropylene mesh and its large pore size encourages incorporation into the native crural pillars and diaphragm.12–14,27–29 Significantly, in this series of 50 patients, we were unable to identify any cases of mesh erosion at a median follow-up of 9 years. Our study has some limitations. First, there was a loss to follow-up rate of 28%. During a relatively long follow-up period of median 9 years, some amount of loss to follow-up is expected. Nearly 50% those lost to follow-up were due to patient death (all unrelated to their hiatal surgery). This reflects the fact that it is often older patients with comorbidities who undergo this procedure. Potentially the group of patients that we were able contact for interview is therefore made up of younger and less comorbid patients. However, as shown in Table 1, there was no significant difference in the two groups in terms of baseline characteristics. Second, there is a risk of interviewer bias when administering telephone questionnaires. We attempted to minimize this bias by having the interviews performed by a member of the research team who was independent of the clinical team. The patients were not contacted by the operating surgeon(s) at any stage. Finally, formal quality of life scores were not administered. This was a pragmatic decision based on study design. We chose to focus on patient reported outcomes in the form of a symptom specific questionnaire, as well as using a pre- and postoperative validated dysphagia score. In conclusion, we have shown that our symptomatic recurrence rates, rates of reoperation for recurrence, and rates of mesh-related complications are all low. Rates of anatomic recurrence detected at endoscopy were moderate (38%) but despite this, at a median follow-up of 9 years, patient reported satisfaction was high. Postoperative dysphagia rates were minimal and there were no cases of mesh-related stricture or erosion. The use of mesh in hiatus hernia repair remains contentious and further evidence from the long-term analysis of randomized controlled trials is awaited. Our series shows that it is possible to utilize mesh safely with high patient satisfaction rates and low complication rates long term. Acknowledgments The authors Ms Alexandra Gordon, Dr Carla Gillespie, Dr Ji Son, Dr Tania Polhill, Mr Steven Leibman, and Mr Garett Smith have no conflicts of interest or financial ties to disclose. Notes Specific author contributions: Study conception: Alexandra C. Gordon; Manuscript draft: Alexandra C. Gordon, Carla Gillespie, Steven Leibman; Interpretation of data: Alexandra C. Gordon; Review and approval of final manuscript: Alexandra C. Gordon, Carla Gillespie, Ji Son, Tania Polhill, Steven Leibman, Garett S. Smith; Revision of content: Carla Gillespie; Preparation for submission: Carla Gillespie; Acquisition, analysis and interpretation of data: Ji Son, Tania Polhill; Study design: Garett S. Smith; Manuscript preparation: Garett S. Smith. No external funding has been received for this paper. References 1. Pfluke J M , Parker M , Bowers S P , Asbun H J , Daniel Smith C . Use of mesh for hiatal hernia repair: a survey of SAGES members . Surg Endosc 2012 ; 26 : 1843 – 8 . Google Scholar CrossRef Search ADS PubMed 2. Furnée E J B . The use of mesh in laparoscopic large hiatal hernia repair: a survey of European surgeons . Surg Laparosc Endosc Percutan Tech 2015 ; 25 : 307 – 11 . Google Scholar CrossRef Search ADS PubMed 3. Tam V , Winger D G , Nason K S . A systematic review and meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair . Am J Surg 2016 ; 211 : 226 – 38 . Google Scholar CrossRef Search ADS PubMed 4. Fenton-Lee D , Tsang C . A series of complications after paraesophageal hernia repair with the used of Timesh: a case report . Surg Laparosc Endosc Percutan Tech 2010 ; 20 : e95 – 6 . Google Scholar CrossRef Search ADS PubMed 5. Stadlhuber R J R J. Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series . Surg Endosc 2009 ; 23 : 1219 – 26 . Google Scholar CrossRef Search ADS PubMed 6. De Moor V , Zalcman M , Delhaye M , El Nakadi I . Complications of mesh repair in hiatal surgery: about 3 cases and review of the literature . Surg Laparosc Endosc Percutan Tech 2012 ; 22 : e222 – 5 . Google Scholar CrossRef Search ADS PubMed 7. Nandipati K , Bye M , Yamamoto S R , Pallati P , Lee T , Mittal S K . Reoperative intervention in patients with mesh at the hiatus is associated with high incidence of esophageal resection–a single-center experience . J Gastrointest Surg 2013 ; 17 : 2039 – 44 . Google Scholar CrossRef Search ADS PubMed 8. Furnee E , Hazebroek E . Mesh in laparoscopic large hiatal hernia repair: a systematic review of the literature . Surg Endosc 2013 ; 27 : 3998 – 4008 . Google Scholar CrossRef Search ADS PubMed 9. Antoniou S A , Antoniou G A , Koch O O , Pointner R , Granderath F A . Lower recurrence rates after mesh-reinforced versus simple hiatal hernia repair: a meta-analysis of randomized trials . Surg Laparosc Endosc Percutan Tech 2012 ; 22 : 498 – 502 . Google Scholar CrossRef Search ADS PubMed 10. Furnee E , Hazebroek E . Mesh in laparoscopic large hiatal hernia repair: a systematic review of the literature . Surg Endosc 2013 ; 27 : 3998 – 4008 . Google Scholar CrossRef Search ADS PubMed 11. Antoniou S , Müller-Stich B , Antoniou G et al. Laparoscopic augmentation of the diaphragmatic hiatus with biologic mesh versus suture repair: a systematic review and meta-analysis . Langenbecks Arch Surg 2015 ; 400 : 577 – 83 . Google Scholar CrossRef Search ADS PubMed 12. Klosterhalfen B , Junge K , Klinge U . The lightweight and large porous mesh concept for hernia repair . Expert Rev Med Devices 2005 ; 2 : 103 – 17 . Google Scholar CrossRef Search ADS PubMed 13. Scheidbach H , Tamme C , Tannapfel A , Lippert H , Kockerling F . In vivo studies comparing the biocompatibility of various polypropylene meshes and their handling properties during endoscopic total extraperitoneal (TEP) patchplasty: an experimental study in pigs . Surg Endosc 2004 ; 18 : 211 – 20 . Google Scholar CrossRef Search ADS PubMed 14. Schug-Pass C , Tamme C , Tannapfel A , Kockerling F . A lightweight polypropylene mesh (TiMesh) for laparoscopic intraperitoneal repair of abdominal wall hernias: comparison of biocompatibility with the DualMesh in an experimental study using the porcine model . Surg Endosc 2006 ; 20 : 402 – 9 . Google Scholar CrossRef Search ADS PubMed 15. Dakkak M , Bennett J R . A new dysphagia score with objective validation . J Clin Gastroenterol 1992 ; 14 : 99 – 100 . Google Scholar CrossRef Search ADS PubMed 16. Hedblom C . Diaphragmatic hernia . JAMA 1925 ; 85, 947 . 17. Harrington S W . Diaphragmatic hernia: symptoms and surgical treatment in sixty cases . JAMA 1933 ; 101 : 987 – 94 . Google Scholar CrossRef Search ADS 18. Harrington S W . Diagnosis and treatment of various types of diaphragmatic hernia . Am J Surg 1940 ; 50 : 381 – 446 . Google Scholar CrossRef Search ADS 19. Lake N C . Para-oesophageal diaphragmatic hernia . BMJ 1933 ; 2 : 331 – 2 . Google Scholar CrossRef Search ADS PubMed 20. Friedman M H , Mackenzie W C . The clinical use of polyvinyl sponge ivalon in the repair of esophageal hiatus hernia . Can J Surg 1961 ; 4 : 176 – 82 . Google Scholar PubMed 21. Merendino K A , Dillard D H . Permanent fixation by teflon mesh of the size of the esophageal diaphragmatic aperture in hiatus hernioplasty . Am J Surg 1965 ; 110 : 416 – 20 . Google Scholar CrossRef Search ADS PubMed 22. Kennedy M C , Sutherland H D . Hiatus hernia repair. Clinical and radiological results of a new combined thoracoabdominal technique . Med J Aust 1974 ; 1 : 386 – 90 . Google Scholar PubMed 23. Johnson J M , Carbonell A M , Carmody B J et al. Laparoscopic mesh hiatoplasty for paraesophageal hernias and fundoplications: a critical analysis of the available literature . Surg Endosc 2006 ; 20 : 362 – 6 . Google Scholar CrossRef Search ADS PubMed 24. Antoniou S A , Pointner R , Granderath F A . Hiatal hernia repair with the use of biologic meshes: a literature review . Surg Laparosc Endosc Percutan Tech 2011 ; 21 : 1 – 9 . Google Scholar CrossRef Search ADS PubMed 25. Watson D I , Thompson S K , Devitt P G et al. Laparoscopic repair of very large hiatus hernia with sutures versus absorbable mesh versus nonabsorbable mesh: a randomized controlled trial . Ann Surg 2015 ; 261 : 282 – 9 . Google Scholar CrossRef Search ADS PubMed 26. Makarewicz W , Jaworski L , Bobowicz M et al. Paraesophageal hernia repair followed by cardiac tamponade caused by ProTacks . Ann Thorac Surg 2012 ; 94 : e87 – 9 . Google Scholar CrossRef Search ADS PubMed 27. Kockerling F , Schug-Pass C . What do we know about titanized polypropylene meshes? An evidence-based review of the literature . Hernia 2014 ; 18 : 445 – 57 . Google Scholar CrossRef Search ADS PubMed 28. Hazebroek E J , Ng A , Yong D H , Berry H , Leibman S , Smith G S . Evaluation of lightweight titanium-coated polypropylene mesh (TiMesh) for laparoscopic repair of large hiatal hernias . Surg Endosc 2008 ; 22 : 2428 – 32 . Google Scholar CrossRef Search ADS PubMed 29. Delibegovic S , Koluh A , Cickusic E , Katica M , Mustedanagic J , Krupic F . Formation of adhesion after intraperitoneal application of TiMesh: experimental study on a rodent model . Acta Chir Belg 2016 ; 116 : 293 – 300 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Diseases of the EsophagusOxford University Press

Published: Feb 9, 2018

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