Evaluating surgical outcomes of hiatal hernia repair techniques with and without fundoplication: a network meta-analysis

Abstract

Introduction: This network meta-analysis evaluated the effectiveness of different hiatal hernia repair techniques-primary repair, absorbable mesh, or non-absorbable mesh-on recurrence, postoperative dysphagia, complications, and reoperation. We hypothesized that mesh reinforcement may reduce recurrence but increase complications, and that fundoplication may reduce recurrence but increase dysphagia.

Methods: A systematic search of PubMed and Scopus identified randomized controlled trials (RCTs) comparing laparoscopic hiatal hernia repair with and without mesh. The primary outcome was recurrence, with secondary outcomes including dysphagia, complications, and reoperation. Frequentist network meta-analysis was performed using the netmeta package in EZR. Results were reported using network maps, rankograms with p scores, league tables, and forest plots to compare interventions. Transitivity, risk of bias (Risk of Bias 2 tool), and confidence in evidence (CINeMA) were also assessed.

Results: Nine RCTs (4 multicenter) from 2002 to 2020, including 815 patients (73% female, median age 60-67.5 years), were analyzed. 361 patients underwent primary repair, and 454 underwent mesh repair (98 absorbable and 356 non-absorbable). Most patients had concomitant fundoplication. Recurrence was reported in 157 (19.3) patients, with rates of 21.3% for primary repair and 17.6% for mesh repair (34.7% absorbable, 12.9% non-absorbable). Network meta-analyses revealed no significant differences between repair techniques. Rankograms indicated that non-absorbable mesh with fundoplication had the lowest recurrence (p score = 0.764) and dysphagia (p score = 0.727), absorbable mesh had the lowest complications (p score = 0.9285), and non-absorbable mesh without fundoplication had the lowest reoperation rates (p score = 0.889). Confidence in evidence for all outcomes was very low.

Conclusions: Non-absorbable mesh with fundoplication may reduce recurrence and dysphagia, while absorbable mesh is associated with fewer complications. No significant differences between primary repair and mesh reinforcement were observed. Further RCTs with long-term follow-up are needed.

Keywords: Absorbable mesh; Complications; Dysphagia; Fundoplication; Hiatal hernia; Mesh; Meta-analysis; Network meta-analysis; Non-absorbable mesh; Primary repair; Recurrence; Reoperation.