Functional Results after Repair of Large Hiatal Hernia by Use of a Biologic Mesh

Abstract

Background: The aim of this observational study is to analyze the results of patients with large hiatal hernia and upside-down stomach after surgical closure with a biological mesh (Permacol(®), Covidien, Neustadt an der Donau, Germany). Biological mesh is used to prevent long-term detrimental effects of artificial meshes and to reduce recurrence rates.

Methods: A total of 13 patients with a large hiatal hernia and endothoracic stomach, who underwent surgery between 2010 and 2014, were included. Interviews and upper endoscopy were conducted to determine recurrences, lifestyle restrictions, and current complaints.

Results: After a mean follow-up of 26 ± 18 months (range: 3-58 months), 10 patients (3 men, mean age 73 ± 13, range: 26-81 years) were evaluated. A small recurrent axial hernia was found in one patient postoperatively. Dysphagia was the most common complaint (four cases); while in one case, the problem was solved after endoscopic dilatation. In three cases, bloat and postprandial pain were documented. In one case, an explantation of the mesh was necessary due to mesh migration and painful adhesions. In one further case with gastroparesis, pyloroplasty was performed without success. The data are compared to the available literature. It was found that dysphagia and recurrence rates are unrelated both in biological and in synthetic meshes if the esophagus is encircled. In series preserving the esophagus at least partially uncoated, recurrences after the use of biological meshes relieve dysphagia. After the application of synthetic meshes, dysphagia is aggravated by recurrences.

Conclusion: Recurrence is rare after encircling hiatal hernia repair with the biological mesh Permacol(®). Dysphagia, gas bloat, and intra-abdominal pain are frequent complaints. Despite the small number of patients, it can be concluded that a biological mesh may be an alternative to synthetic meshes to reduce recurrences at least for up to 2 years. Our study demonstrates that local fibrosis and thickening of the mesh can affect the outcome being associated with abdominal discomfort despite a successful repair. The review of the literature indicates comparable results after 2 years with both biologic and synthetic meshes embracing the esophagus. At the same point in time, reconstruction with synthetic and biologic materials differs when the esophagus is not or only partially encircled in the repair. This is important since encircling artificial meshes can erode the esophagus after 5-10 years.

Keywords: biologic mesh; complications; dysphagia; hiatal hernia repair; recurrence.

Figure 1

Preoperative computed tomography of the upside-down stomach of a 73-year-old male with the gastroesophageal junction being fully dislocated into the thoracic cavity (arrow).

Figure 2

Situs of a large hiatal hernia in this 72-year-old male operated on 2 years ago. The upside-down stomach is fully encased in both loose and dense adhesions.

Figure 3

Preparation of the hiatal sac with the right and the left crus of the diaphragm prepared in their ventral aspect (arrows).

Figure 4

A hiatoplasty is formed with three evenly spaced non-absorbable sutures (Ethibond 0, Ethicon, Norderstedt, Germany, arrows). The distal esophagus is encircled with a silastic band and held to the left. At this point of time, a 54-Ch Rüsch tube is passed through the esophagogastric junction and a 5-mm instrument is additionally placed from the left into the newly formed hiatus in order to ensure sufficient space for the passage of food. A similar instrument is placed at the low left corner of the picture for comparison of sizes. Another 5-mm instrument is inserted from the right in order to lift the ventral crural junction to facilitate instrumentation.

Figure 5

Short floppy Nissen’s fundoplication in place with the top suture fixing the stomach, esophagus, and right hiatal leg (white arrow).

Figure 6

Hiatal region of a 75-year-old female patient 1 year after implantation of the Permacol^® mesh as described above. The arrows show the position of the mesh. An upper endoscopy showed a mild gastritis without signs of esophageal reflux at this time.

Figure 7

Permacol^® reinforment of the hiatoplasty shown above. The Permacol^® is secured with non-absorbable interrupted stitches and additionally fastened with fibrin glue (Evicell^®) in critical areas (white arrow).

Figure 8

Dysphagia rates as a function of recurring hiatal hernia after 1–2 years using synthetic meshes leaving at least half of the circumference of the esophagus to move freely (data from Table 2). The line indicates the trendline.

Figure 9

Dysphagia rates as a function of recurring hiatal hernia after 1–2 years using biological meshes leaving at least half of the circumference of the esophagus to move freely (data from Table 2). The line indicates the trendline.