Previous Hiatal Mesh Is Associated with Significant Morbidity After Laparoscopic Revisional Paraesphageal Hernia Repair (pehr)

Vladan N Obradovic, MD, Horatiu C Dancea, MD, Aamir Akmal, MD, Wai M Yeung, MD, Mohanbabu Alaparthi, MD, Jon D Gabrielsen, MD, Anthony T Petrick, MD. Geisinger Medical Center – Danville, PA

Introduction: Recent studies have suggested increased morbidity associated with revisional foregut surgery utilizing mesh reinforcement. Optimizing the outcome of revisional PEHR remains a challenge. Mesh reinforcement of the hiatal closure has been shown to effectively decrease recurrence rate after PEHR. Our aim was to compare outcomes between patients undergoing laparoscopic revisional PEHR who had a prior mesh repair and those who initially had a primary cruroplasty without mesh reinforcement.

Methods: A database was created from retrospective review of the EMR of all patients undergoing laparoscopic PEHR at our institution from October 2001 through 2009. There were 251 total laparoscopic PEH repairs performed. These included 30 laparoscopic revisional PEHR. Data collected included GI symptom and QOLRAD scores, antacid use, gender, BMI, age, and type of previous repair. This was compared between groups. Perioperative data including method of crural repair, type of mesh used if used, OR time, EBL, and mechanism of failure was obtained. Outcome measures included Gi symptom scores, QOLRAD, antacid use scores, OR Time, EBL, perioperative morbidity and mortality, and whether or not gastric or esophageal resection was necessary.

Results: At initial PEHR, 21 patients had primary cruroplasty and 9 patients had mesh reinforcement. Average age, M/F ratio, and preoperative BMI were not significantly different between the two groups. There were significant increases in EBL (212.5 ml vs. 51.0 ml, p=0.0013) and length of stay (7.0 days vs. 2.68 days, p=0.0343) in those with previous mesh repair. Revisional surgery in presence of mesh required gastric resection in 5/9 (56%) patients, whereas 1/21 (5%) patients required resection in the group without mesh (p=0.0046). Only one patient in the entire group required conversion to open laparotomy (nonmesh group) and all procedures were completed through the abdomen. No patient required esophageal resection. Surgical morbidity was significantly higher in the prior mesh repair group (6/9 patients vs. 4/21 patients, p=0.0301), though there was no difference in mortality rates. Postoperatively, recurrence of hiatal hernia after revisional PEHR was lower in the nonmesh group (4.8% vs 11.1%) but this was not significant. Postoperative symptoms scores, QOLRAD scores and antacid use after revisonal PEHR were not significantly different between the groups.

Conclusions: Our study shows that patients with hiatal mesh in place who undergo laparoscopic revisional PEHR have a significantly greater likelihood of requiring gastric resection and experience increased perioperative morbidity when compared to patients who have not had prior mesh placed. However, previous mesh placement is not associated significantly poorer outcomes of the revisional PEHR when considering recurrences, antacid use or GI symptoms post-operatively. Conversion to open procedure was not increased by prior mesh placment.. This study confirms previous findings that mesh reinforcement of the hiatus, while decreasing PEH recurrence rates, leads to a more complicated revisional surgery should it be required. The risks and benefits of mesh need to be weighed carefully when performing a primary PEHR.

Session: Resident/Fellow
Program Number: S112

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