A survey on the use of mesh for HH repair by members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) showed that 33% preferred nonabsorbable to absorbable mesh[25
]. This reflects the fact that prosthetic mesh has the advantage of reducing HH recurrence; biomaterial tends to be associated with failure[9
]. On the other hand, concerns still exist regarding mesh-related complications, including erosion, stricture, and fibrosis. Thus, there may be a trade-off in the choice of mesh repair for HH: permanent mesh risks erosion, while biologic mesh risks recurrence[9
has the advantages of permanent mesh, while reducing mesh-related complications. Chilintseva et al[10
] reported 38 cases who underwent HH repair using Crurasoft®
, with no recurrences. Priego et al[26
] concluded that Crurasoft®
-reinforced hiatoplasty reduced HH recurrence in patients with large hiatal defects (larger than 5 cm), similar to that in patients with smaller hiatal defects (2% vs
2.1%). Granderath et al[27
] selected a tailoring strategy for HH repair according to hiatal surface area (HAS). Those with HAS larger than 8 cm2
placement in a tension-free, posterior onlay fashion. During a mean follow-up period of 6.3 mo, only 1 patient (1.8%) developed postoperative partial intrathoracic wrap migration. In the Chinese literature review, recurrence was between 0% and 10% (Table ). The highest recurrence rate (2/20, 10%) was reported by Zou et al[21
], in whose series all HH were large, with orifices larger than 6 cm or herniation of more than half of the stomach. In our study cohort, we found a type IIHH anatomic recurrence. Paraesophageal herniation is a complication that occurs in the immediate postoperative period following laparoscopic antireflux surgery, with an incidence of up to 7%. Vomiting in the early post-operative period, which occurred in this patient, has been identified as a risk factor for recurrence[3
]. Violent diaphragmatic movements might also dislodge the mesh if fixation is inadequate[7
]. Sufficient fixation of the mesh and avoidance of lifting or straining have been advocated to reduce this complication.
Two patients suffered symptomatic recurrence without any proof of anatomic recurrence. Both patients underwent Nissen fundoplication and the barium meal examination showed an intact wrap. A possible explanation for this could be poor correlation between postoperative symptoms and actual reflux[28
]. Both patients presented with heartburn and acid regurgitation, the cardinal symptoms of GERD. However, these symptoms have a low specificity and sensitivity for the actual diagnosis of GERD. One patient agreed to resume manometry and pH monitoring, and all data indicated an improvement compared with that before surgery. As postoperative GERD symptoms actually indicate acid reflux in only 30% of patients and are not even accurate to rule out acid reflux in patients who are completely free of symptoms after surgery, Khajanchee et al[28
] insisted that surgeons should explain the presence of symptomatic recurrence cautiously and that objective testing should be introduced to determine the actual cause.
In a collection of case reports pertaining to mesh complications after prosthetic hiatoplasty with special emphasis on mesh erosion, Stadlhuber et al[7
] identified 17 cases of intraluminal erosion, involving not only different mesh material (polypropylene, PTFE, and biomaterial), but also different mesh configurations (keyhole, horseshoe and heart shaped). No apparent relationship between these parameters and mesh erosion was observed, thus the technique for mesh fixation was questioned. Fixation techniques such as the proximity of placement of the mesh at the esophagus are important factors in the development of postoperative complications. The edge of the mesh may “cheese wire” its way into the esophagus if it touches the esophagus or if shrinkage occurs. It is also possible that the mesh can migrate if fixation is insufficient, or traumatic events such as vomiting or repeated coughing may dislodge the mesh, causing it to be apposed to the esophageal wall, leading to erosion or stricture[7
]. Use of Crurasoft®
cannot completely eliminate this complication. In one case report, total migration of Crurasoft®
into the stomach was detected by endoscopy 2 years after repeat fundoplication[29
]. Both our series and a review of the Chinese literature failed to disclose any cases of this complication. However, a case of erosion was discussed at a conference without confirmation of its exact source and details (personal communication). Thus, the exact incidence of this complication may be underestimated[7,11
As opposed to erosion, esophageal stricture due to fibrosis associated with the prosthesis, may be a more common complication. Although ePTFE is less fibrogenic and is designed to prevent contact between the mesh and viscera, severe fibrosis enveloping the mesh can develop, leading to stricture refractory even to endoscopic dilatation[10
]. Even though Wassenaar’s recommendations to maintain a 2-3 mm distance between the mesh and esophagus were followed, postoperative dysphagia cannot be completely eliminated (38.10% in our cohort). Only 2 patients had permanent symptoms, due to stricture at the hiatus and not the fundoplication itself (confirmed radiographically). Fortunately, most of these patients presented with mild dysphagia, which resolved within the first postoperative year, and did not require reoperation.
In conclusion, the use of Crurasoft® mesh for HH repair results in satisfactory symptom control with a low recurrence rate. Postoperative dysphagia continues to be an issue, and requires more research to reduce its incidence.