Tension-free crural repair with nonabsorbable mesh did not reduce the incidence of hiatal hernia recurrence in patients undergoing antireflux surgery for treatment of gastroesophageal reflux disease (GERD), according to long-term follow-up of a randomized trial.
At a mean follow-up of 13 years among 103 patients, the verified radiologic hiatal hernia recurrence rates were 38% in the mesh reinforcement group compared with 31% in the group who received crural sutures alone (P=0.61), reported Apostolos Analatos, MD, PhD, of Nyköping Hospital in Sweden, and colleagues.
However, there was still a statistically significant difference between the groups in dysphagia scores for solids in favor of the suture-alone group at 13 years (1.9 vs 1.6, P=0.01), they noted in JAMA Surgery.
These findings do not support the routine use of tension-free polytetrafluoroethylene mesh closure in laparoscopic hiatal hernia repair for treatment of GERD, Analatos and team concluded.
Laparoscopic antireflux surgery is considered a safe and lasting treatment for GERD. However, most patients with GERD who are being considered for surgery also have a hiatal hernia. The use of mesh in correcting hiatal hernias has been linked to complications such as stenosis of the esophagus, erosion, or fibrosis, and can lead to persistent dysphagia or pain.
Initial findings from the randomized trial at 3-year follow-up in 159 patients with chronic GERD and a hiatal hernia with axial length longer than 2 cm who underwent laparoscopic antireflux surgery showed no difference between tension-free polytetrafluoroethylene mesh reinforcement and suture-only cruroplasty in terms of radiologically verified hiatal hernia recurrence.
However, there was a statistically significant difference in dysphagia scores for solid food items at 3 years in favor of the suture group, “implying that mesh reinforcement may expose the patient to a time-dependent increased risk of mechanical complications,” the researchers wrote.
Other previous randomized trials with short-term outcomes showed lower rates of hiatal hernia recurrence in patients with mesh reinforcement compared with crural closure using sutures only, but more recent studies with longer follow-up did not show significant differences, the authors noted.
In an accompanying editorial, Marco Patti, MD, of the University of Virginia in Charlottesville, and Fernando Herbella, MD, of Federal University of São Paulo in Brazil, noted that “this study confirms the results of many other studies that have shown that a cruroplasty with sutures is as effective as a cruroplasty reinforced by either absorbable or nonabsorbable mesh.”
“Overall, the message for surgeons who take care of these patients is that the routine use of mesh should be avoided and reserved only for situations when the crura cannot be approximated by sutures, even after diaphragmatic relaxing incisions,” they wrote.
For this analysis, Analatos and team evaluated 103 patients from the randomized trial, which was conducted at a single center in Stockholm from January 2006 to December 2010. Mean age at follow-up was 65, and 53% were women. All patients in this analysis agreed to undergo a CT scan of the upper abdomen.
Of these patients, 53 were initially allocated to the mesh group, and 50 to the suture-alone group.
During the 13-year follow-up, three patients in the mesh group and four patients in the suture group underwent reoperation, all due to recurrent GERD (P=0.71). None of the included patients required reoperation due to complications caused by the mesh, such as local erosion or penetration at the gastroesophageal junction.
Of the patients who used proton pump inhibitors daily 13 years after surgery, 26% were in the mesh group and 14% were in the suture group (P=0.15). More reflux symptoms were observed among patients with a recurrent hiatal hernia compared with those without.
A major limitation of this analysis was the low number of patients who underwent a CT scan to detect hiatal hernia recurrence.
Analatos reported receiving grants from the Centre for Clinical Research Sörmland, Uppsala University. A co-author reported receiving grants from the Stockholm City Council and the Erling-Persson Foundation.
The editorialists reported no conflicts of interest.
Source Reference: Analatos A, et al “Hiatal hernia repair with tension-free mesh or crural sutures alone in antireflux surgery: a 13-year follow-up of a randomized clinical trial” JAMA Surg 2023; DOI: 10.1001/jamasurg.2023.4976.
Source Reference: Patti MG, Herbella FAM “Mesh and hiatal hernia repair — the never-ending saga” JAMA Surg 2023; DOI: 10.1001/jamasurg.2023.4965.