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Three Part Question

In [a patient with large hiatal hernia] is [a laparoscopic hiatal hernia repair with mesh better that a simple suture cruroplasty] at [reducing recurrences, complications and symptomatic outcome]?

Clinical Scenario

A forty years old male attends the emergency department, with abdominal pain, nausea, heartburn, dyspepsia, reflux and bloating. Physical examination with stable vital signs, abdominal pain without peritoneal irritation. Contrast studies and upper endoscopy reveals a large hiatal hernia. We decided a laparoscopic repair, it has be with mesh or simple suture.

Search Strategy

Pubmed 1966 - sept 2016
Cochrane Library

(("Hernia, Hiatal"[Mesh]) OR Giant hiatal hernia OR Paraesophageal hernia OR Large hiatal hernia OR hiatus hernia) AND (("Surgical Mesh"[Mesh]) OR Buttressed repair OR Reinforced repair OR Mesh repair OR Prosthesis OR synthetic mesh OR polypropylene mesh OR biologic prosthesis OR Absorbable Mesh OR Nonabsorbable Mesh OR PTFE) AND (Cruroplasty OR laparoscopic repair OR Sutures OR sutured repair OR mesh repair OR simple cruroplasty)

LIMIT to human, English and Spanish, abstract available and Publication type: clinical trial, clinical study, controlled clinical trial, randomized controlled trial, metaanalysis and systematic reviews.

Search Outcome

Papers found 307, applying the limits 36
Cochrane Library 31, included in the papers found in PubMed
Excluding Irrelevant for the question and Insufficient quality, the Papers found relevant are three. Other 7 relevants are included in systematic review and meta-analysis.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Memon MA, et al. 2016 Australia	Four studies, RCTs comparing 406 adults with suture (186) versus prosthetic (220). (Frantzides 2002 – 72 patients, Granderath 2005 – 100 patients, Oelschlager 2006 – 108 patients and Watson 2015 – 126 patients).	Meta- analysis and systematic review	Operative time	SMD -0.46, 95% CI -1.16, -0.24 P=0.19	Jadad score reported of 1.7. 2 described randomization 1 single blinding Significant heterogeneity only for operating time Variations in the definition of recurrent hernia
			Complication rate	OR 1.06, 95% CI 0.45, 2.5, P=0.9
			Recurrence of hiatal hernia or wrap migration	OR 2.01, 95% CI 0.92, 4.39, P=0.07
			Reoperation rate	OR 3.73, 95% CI 1.18, 11.82, P=0.02 favored prosthetic
Tam V, et al. 2016. USA	Large hiatal hernia repair in adults. 13 studies (1,194 patients; 521 suture and 673 mesh), 3 RCT and 10 OCS.	Meta- analysis and systematic review	Symptom assessment	Reported in 50% with substantial variability. Similar symptomatic results.	Objective definition of large hiatal hernia varied between studies and was not specified in 3. Mild to serious limitations in quality. Quality of evidence supporting routine use of mesh cruroplasty is low.
			Objective recurrence	OR 0.51, 95% CI 0.30 to 0.87; P= 0.014
			Reoperation	OR 0.42, 95% CI 0.13 to 1.37; P= 0.149
Muller-Stich BP, et al. 2015. Germany	For the meta-analysis of recurrences 12 studies (3 RCTs and 9 OCSs). The meta-analysis of complications was based on 3 RCTs and 6 OCSs with 638 patients in total	Meta- analysis, systematic review and risk-benefit analysis	Recurrences	12.1% (CI 6.3 to 22.2%) mesh and 20.5 (CI 12.9% to 31%) mesh-free.	Not blinded Not all describe the randomization strategy. Studies used different mesh material and fundoplication. In the systematic review they included since case reports.
			Reduction of recurrences with mesh after an overall mean length of follow-up of 34 months	OR, 0.55; 95% CI, 0.34 to 0.89, p = 0.04
			Complication	OR 1.02, 95%, CI 0.63 to 1.65, p= 0.94. Proportions of 15.3% (9.4 to 23.9%) with mesh and 14.2% (8.5 to 22.7%) without mesh
			Reoperation following recurrences	20.3% with mesh and 39% without mesh
			Mesh associated complications	1.9%, death due to mesh application of 0.073% (4/5499)

Comment(s)

Available evidence of hiatal hernia repair whit mesh and suture cruroplasty is of low quality and there are not similar in definitions, making it difficult to compare characteristics and outcomes. Prosthetic hiatal herniorrhaphy and suture cruroplasty produces comparable results for repair hiatal hernias. Some papers favored the use of prosthetic in reducing recurrence and reoperation rate, but the benefit diminish at long-term follow-up. Determination of symptomatic recurrences were rarely assessed, objective follow-up was substantially shorter after mesh compared with suture cruroplasty and mesh-related complications were rarely reported. More well-designed and randomized controlled studies are needed, and long term follow up.

Clinical Bottom Line

The use of mesh for reinforcement of the cruroplasty should reduce recurrence with similar complications, but the evidence is weak and it use can’t be routine.

References

1. Memon MA(1), Memon B, Yunus RM, Khan S. Suture Cruroplasty Versus Prosthetic Hiatal Herniorrhaphy for Large Hiatal Hernia: A Meta-analysis and Systematic Review of Randomized Controlled Trials Ann Surg. 2016 Feb;263(2):258-66.
2. Tam V, Winger DG, Nason KS. A systematic review and meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair Am J Surg. 2016 Jan;211(1):226-38
3. Müller-Stich BP, Kenngott HG, Gondan M, Stock C, Linke GR, Fritz F, Nickel F, Diener MK, Gutt CN, Wente M, Büchler MW, Fischer L Use of Mesh in Laparoscopic Paraesophageal Hernia Repair: A Meta-Analysis and Risk-Benefit Analysis. PLoS One. 2015 Oct 15;10(10):e0139547