Allograft dermal matrix hiatoplasty during laparoscopic primary fundoplication, paraesophageal hernia repair, and reoperation for failed hiatal hernia repair

Abstract

BackgroundHiatal repair failure is the nemesis of laparoscopic paraesophageal hernia repair as well as the major cause of failure of primary fundoplication and reoperation on the hiatus. Biologic prosthetics offer the promise of reinforcing the repair without risks associated with permanent prosthetics.DesignRetrospective evaluation of safety and relative efficacy of laparoscopic hiatal hernia repair using an allograft (acellular dermal matrix) onlay. Patients with symptomatic failures underwent endoscopic or radiographic assessment of hiatal status.ResultsGreater than 6-month follow-up was available for 252 of 450 consecutive patients undergoing laparoscopic allograft-reinforced hiatal hernia repair between January 2007 and March 2011. No erosions, strictures, or persisting dysphagia were encountered. Adhesions were minimal in cases where reoperation was required. Failure of the hiatal repair at median 18 months (6–51 months) was significantly (p < 0.005) different between groups: group A (primary fundoplication with axial hernia ≤ 2 cm), 3.7 %; group B (primary fundoplication with axial hernia 2–5 cm), 7.1 %; group G (giant/paraesophageal), 8.8 %; group R (reoperative), 23.4 %. Additionally, mean time to failure was significantly shorter in group R (247 days) compared with the other groups (462–489 days).ConclusionsUse of allograft reinforcement to the hiatus is safe at 18 months median follow-up. Reoperations had a significantly higher failure rate and shorter time to failure than the other groups despite allograft, suggesting that primary repairs require utmost attention and that additional techniques may be needed in reoperations. Patients with hiatal hernias >2 cm axially had a recurrence rate equal to that of patients undergoing paraesophageal hiatal hernia repair, and should be treated similarly.

Reinforcement of hiatal defect repair with absorbable mesh fixed with non-permanent devices

“…Although the small intestine submucosal group had fewer radiographic hernia recurrences at a six-month follow-up (9% vs. 23%), this advantage had disappeared at the five-year follow-up, at which point both groups had high recurrence rates (54% vs. 59%). Still, it should be noted that, regardless of these radiographic recurrences, both groups experienced marked symptom improvement, and the need for reoperations was low (3%) and similar for both techniques (21 (22). In our study, a low recurrence rate (2,3%), the absence of mesh-related complications, good results obtained in both normal weight patients and obese patients, and the easy laparoscopic handling improved the attractiveness of the absorbable mesh.…”

Laparoscopic anti-reflux revision surgery after transoral incisionless fundoplication is safe and effective

“…In the current study, 25 (15 %) of our personal series of 165 patients having primary TIF subsequently underwent laparoscopic revisional surgery after a median of 14 (IQR = 7-38) months; the other 3 patients had primary TIF at other institutions. This percentage is greater than the 4 % revision rate we reported for patients having primary laparoscopic fundoplication with minimal hiatal hernia [7].…”

“…Hiatal closure using 0-braided polyethylene suture was performed in 27 of 28 patients (96 %). Based on our own experience with failures of primary laparoscopic fundoplication (90 % involved hiatal failure) [7] and results from randomized controlled trials suggesting that mesh reinforcement leads to decreased recurrence rate [8][9][10], we elected to reinforce all of the hiatal repair with an acellular allograft mesh.…”

Complications and relapses after alloplasty of large and giant hernia of the esophageal aperture of the diaphragm

“…Стриктур и аррозий пищевода не было. Было отмечено три реоперации по поводу инфицирования имплантата с его удалением [24].…”