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Mesh Cruroplasty in Laparoscopic Repair of Paraesophageal Hernias Is Not Associated With Better Long-Term Outcomes Compared to Primary Repair
Vernissia Tam*, James D. Luketich, Ryan Levy, Neil a. Christie, Ghulam Abbas, Omar Awais, Manisha Shende, Katie S. Nason
Division of Thoracic and Foregut Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
Background: Due to high rates of radiographic recurrence, mesh cruroplasty has been advocated as a necessary component of the laparoscopic repair of large paraesophageal hernias(PEH). Recently, however, ~50% recurrence rates were reported for both groups in long-term follow-up from a randomized trial and the question of whether radiographic recurrence is clinically important was posed. In our center, mesh is used selectively when a tension-free primary closure cannot be achieved. We aimed to determine whether selective use of mesh cruroplasty is associated with differences in recurrence and quality of life outcomes.
Methods: We performed nonemergent PEH repair with fundoplication in 795 patients (n=106 with mesh). Multivariable logistic regression identified factors associated with mesh cruroplasty. Radiographic follow-up at least 3 months postoperatively (n=556) and symptom outcomes (n=688) were compared between mesh and no mesh groups as were radiographic recurrence (n=101; defined as at least 10%[or 2 cm] of proximal stomach above the hiatus), and reoperation rates (n=30). Impact of recurrence on quality of life was evaluated.
Results: A completely intrathoracic stomach, male sex, age 75 or greater and a history of connective tissue disorder were independently associated with mesh cruroplasty. Radiographic recurrence was identified in 22% of mesh patients (n=15) and 17% of non-mesh patients (n=86;p=0.32) at a median 27 months (IQR 14 to 53 mo). Time to radiographic assessment for recurrence (p=0.40) and symptoms (median 25 months [IQR 12 to 49 mo]; p=0.92) was similar between groups. Reoperation rates were higher in the mesh cohort (9% vs 3%; p=0.01). Good to excellent quality of life was reported by 88% in both groups (p=0.98). Comparing pre- and post-operative symptoms, the proportion with heartburn, regurgitation, epigastric pain, and PPI use decreased significantly in both groups while postoperative dysphagia in the mesh group (p=0.14) and bloating in the non-mesh group (p=0.32), were unchanged. Patients with radiographic recurrence were more likely to be dissatisfied with surgical outcome compared to those without recurrence (13% vs 4%; p=0.007) despite similar scores in the physical (p=0.51) and mental components (p=0.29) of the SF-36 and GERD-HRQoL (p=0.20).
Conclusions: Our data support selective use of mesh for laparoscopic repair of large PEH based on similar radiographic recurrence rates and symptom outcomes between groups. Reflecting the greater complexity of patients in whom we find mesh is needed, reoperations were more common in the mesh cohort. Quality of life was good-to-excellent in both groups, with symptom resolution in the majority of patients. Radiographic recurrence was associated with dissatisfaction with surgical outcomes, emphasizing the need to continue efforts to optimize the laparoscopic approach to large PEH repair.
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