Follow Up Data of MRI-Visible Synthetic Meshes for Reinforcement in Large Hiatal Hernia in Comparison to None-Mesh Repair-A Prospective Cohort Study

Abstract

Background: Mesh augmentation for large hiatal hernia is still controversial because of high alleged risk of chronic reaction or shrinkage of mesh orifice surrounding the esophagus. The aim of this cohort study was to develop and establish an image analysis scheme, including 3D reconstruction, for MRI-visible meshes (DynaMesh®) to measure postoperative mesh shrinkage in order to observe potential complications. Methods: Between 12/2012 and 10/2016, n = 33 patients underwent surgery to correct symptomatic hiatal hernia (implantation indicated: n = 18). Intraoperative measurement of the hiatal surface area (HSA) > 5 cm² was indication for mesh implantation. Early postoperatively, and during long-term follow-up, MRI was performed and patients filled out the gastrointestinal quality of life index (GIQLI score). Results: Follow-up rate was 76% (n = 25/33). Overall recurrence rate was 4% (1/25). No other patient showed reflux or dysphagia symptoms. Mesh related complications were not observed during follow-up period. Median GIQLI score of patients with mesh was 123 (range: 67-144), and 93 (52-141) for patients without mesh. Comparison of early and mid-term postoperative MRI for patients with mesh showed changes in mesh orifice size of 3% (corresponding to a slight increase in size of about 6 mm²) without any significant correlations with BMI, HSA, or patient age. Conclusion: We established an image analysis and 3D reconstruction scheme for MRI visible meshes in hiatal hernia repair. MRI images of normal clinical quality are sufficient for this analysis. Mesh orifice size in MRI-visible meshes does not seem to change at a clinically relevant level in the small cohort observed here. Further studies of large cohorts are necessary to establish if HSA >5 cm² could be a suitable measure for indication of mesh implantation.

Keywords: DynaMesh; MRI-visible mesh; dysphagia; early results; hiatal hernia; mid-term results; quality of life.

Figure 1

Measurements of the HSA according to Granderath (14): the length of the crural commissure (R, yellow) and the length of the diaphragmatic commissure (B, blue; following the curve of the commissure) are measured and the HSA can then be calculated as B * R/2 or estimated by plotting B against R (see also Supplement Figure 2).

Figure 2

(Upper) Two images from one sequence used for analysis. Left column: the mesh edge closest to the esophagus was labeled using ImageJ (small, light gray square dots). These images were saved for control purposes. Right column: the same images with descriptions. (Lower) Calculation of the mesh orifice by stacking the images and generating a skewed plane between the marked points.

Figure 3

Flow chart of the study design.

Figure 4

Calculated peri- and post-operative esophageal orifice size. (A) Patients with size change < 10%; (B) Patients with size change > 10%, as published in (4) with permission.

Figure 5

Post-operative disorders at the late follow-up for patients with mesh (black bars) and without mesh (gray bars). Post-operative disorders include instances of pain, regurgitation, or reflux.

Figure 6

GIQLI score for all follow-up patients with mesh (black box, left) and for patients without mesh (gray, right); the GIQLI is scored by totaling the points from the survey. This figure shows the data for all patients as a median, quartiles and range; the dotted line indicates the average score of a healthy subject (123).