Hiatal mesh for paraesophageal hernia repair

A discussion in December included hiatal mesh for paraesophageal hernia repair.


Summary: In their 2006 study involving 4 institutions, Oelschlager et al hypothesized that using a small intestinal submucosa (SIS) to reinforce the closure of the hiatus in patients with paraesophageal hernia (PEH) would result in lower recurrence rate and improved outcomes. Indeed, they found that “adding a biologic prosthesis during LPEHR reduces the likelihood of recurrence at 6 months, without mesh-related complications or side effects” (p.481). In the 2006 publication, the authors admit the limitations of their 6 month follow-up, citing one co-investigator’s work that “created PEHs in dogs and repaired them with SIS. None of the dogs developed a stricture, erosion, dysphagia, or recurrence at 1 year” (p.487).

To better address the long-term performance of SIS, Oelschlager et al (2011) published a follow-up to their 2006 study. The authors were able to locate 72 of the original 108 patients; 2 died immediately postoperatively, 10 died in the follow-up interval, 26 could not be found. Of the 72 contacted (39 from PR group, 33 from SIS group) were assessed for symptoms and QOL, all showing long-term improvements in both areas. Although the use of mesh was advantageous at 6 months postop, there was no advantage by 5 years. At that time, the radiologically determined anatomic recurrects was similar between patients treated with mesh and those with primary closure. Additionally, it was found that mesh is not associated with any adverse side effects, short- or long-term.

Oelschlager et al (2011) concluded: “LPEHR results in long and durable relief of symptoms and improvement in QOL with primary diaphragm repair (PR) or SIS. There does not appear to be a higher rate of complications or side effects with biologic mesh, but its benefit in reducing hiatal hernia (HH) recurrence diminishes at long-term follow-up (more than 5 year postoperatively) or earlier” (p.461).

References:

Oelschlager BK, et al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair: long-term follow-up from a multicenter, prospective, randomized trial. Journal of the American College of Surgeons. 2011 Oct;213(4):461-468. doi:10.1016/j.jamcollsurg.2011.05.017.

Oelschlager BK, et al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial. Annals of Surgery. 2006 Oct;244(4):481-490.

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