Mesh at the Hiatus in Revisional Surgery for Failed Fundoplication: A Case-control Evaluation

Rana M Higgins, MD, Matthew E Bosler, BA, Max Schumm, BS, Matthew J Frelich, MS, Jon C Gould, MD. Medical College of Wisconsin

Introduction: Laparoscopic revisional surgery for failed fundoplication has an increased morbidity compared to primary surgery. In an attempt to minimize recurrence, many surgeons will place hiatal mesh, although effectiveness has been debated. There is also controversy surrounding the safety of hiatal mesh, especially for future operations. We sought to determine the impact of pre-existing hiatal mesh on morbidity of revisional surgery for failed fundoplication.

Methods: A retrospective review was conducted of 104 patients with prior revisional antireflux surgery between 2010-2015. Fourteen patients (13.5%) had previous operations with hiatal mesh. Revisional procedures performed were reoperative Nissen (n=6), conversion of Nissen to Toupet (n=3), and Roux-en-Y gastric bypass (n=5). These 14 cases were matched 1:2 with 28 randomly selected control patients from the database who underwent revisional surgery without mesh, paired based on number of previous revision attempts and operation type. Perioperative outcomes included intraoperative perforation, readmission, morbidity, operative time and length of stay. Statistical analysis was performed using Fisher’s exact tests for categorical and unpaired t-tests for continuous variables with significance p < 0.05.

Results: There were no statistically significant differences in perioperative morbidity in patients with or without prior hiatal mesh in revisional antireflux surgery (Table 1). The mean number of prior operative attempts in the mesh group was 1.6 compared to 1.5 in the no mesh group (p=0.65). Among patients with prior mesh, there was no difference in 30-day morbidity between biologic (n=5) and synthetic (n=9) mesh (p=0.58).

Table 1. Perioperative outcomes in patients with/without prior hiatal mesh
 Prior mesh (n=14)Without mesh (n=28)p-value
Intraoperative perforation1 (7%)00.33
30-day readmission150.65
30-day morbidity3 (21.4%)7 (25%)1.00
Operative time232.9 minutes258.0 minutes0.50
Length of stay2.93 days4.21 days0.88

Conclusion: In the hands of experienced surgeons, hiatal mesh does not have an impact on morbidity or operative time. While this retrospective analysis cannot address the controversy of mesh and recurrence, we do feel that mesh at the hiatus does not increase the morbidity of reoperative procedures.  Revisional surgery for failed fundoplication remains a complex intervention best taken on by surgeons with expertise in reoperative foregut and bariatric surgery.

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