Clinical and Quality of Life Assessment of Patients Undergoing Laparoscopic Hiatal Hernia Repair

Daniel Borman, Kyle Sunshein, Daniel Davenport, Margaret Plymale, John S Roth. University of Kentucky

Introduction:  The role of reinforcing mesh in the repair of hiatal hernias is often debated.  Synthetic mesh has been demonstrated to reduce recurrences, although mesh erosions have been reported and can be catastrophic.  Prospective randomized trials utilizing biologic mesh materials have demonstrated a reduction in short-term recurrences.  Polyglycolic acid/Trimethycellulose (PGA/TMC) mesh is an absorbable synthetic that may be utilized to reinforce the hiatal closure during repair.  This study evaluates quality of life (QOL) and clinical outcomes of patients undergoing laparoscopic hiatal hernia repair (HHR) with PGA/TMC mesh. 

Methods: A retrospective review of a single surgeon’s cases of HHR utilizing PGA/TMC  mesh between August 2012 and April 2014 was performed.  Patients were identified from an institutional surgical database and demographics, preoperative studies, intraoperative details and postoperative outcomes were recorded.  For symptom evaluation, patients completed a gastroesophageal reflux disease quality of life (GERD QOL) questionnaire during each office visit.  Questionnaire responses were evaluated according to 3 time periods: preoperative, postoperative within 6 weeks and postoperative between 6 weeks and 6 months. For patients that returned demonstrating post-operative symptoms, additional evaluation occurred and was noted.

Results:  97 patients underwent HHR with PGA/TMC mesh and either Nissen (n= 69) or Toupet (n= 27) fundoplication.  Average age was 58.2 years (SD = 14.8); 66% of the patients were female. Average BMI was 30.3 (SD = 6.2).  Hernia defect size was classified as large (> 5cm, n= 49), moderate (3-5cm, n= 32) or small (< 3cm, n= 12).  Mean hernia defect size increased in proportion to the mean age of the patient (Large 65y, moderate 53y, small 46 y, ANOVA p < .001).  Operative time was noted to be higher in patients with a large defect (Large 169 min., moderate 142 min., small 145 min., ANOVA p=.004)  A total of 224 GERD QOL questionnaires were recorded and analyzed.  Postoperatively, the number of patients reporting heartburn, solid dysphagia, liquid dysphagia, vomiting, regurgitation, hoarseness and chronic cough significantly decreased (p < .05).  While post-operatively  patients initially reported decreased bloating, this number returned to baseline by the second follow up period.  During the entire study period, 6 patients were noted to have radiographic hernia recurrence with 2 of these patients requiring reoperation.

Conclusions: Patients undergoing HHR with PGA/TMC mesh experience positive clinical and quality of life outcomes, as indicated by patient-reported surveys and postoperative radiographic findings.  In addition, our patients experienced decreased rates of dysphagia and minimal radiographic recurrence.

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