Page 40 - Read Online

Page 4 of 6 Bitner et al. Mini-invasive Surg 2022;6:46 https://dx.doi.org/10.20517/2574-1225.2022.46

cardiophrenicopexy (LMAH-C) with laparoscopic Nissen fundoplication (LNF) in patients with GERD but
[35]
excluded those with Type II-IV HH . Considering endoscopy findings and symptom scores as primary
endpoints, they showed that treatment failure with higher reflux-related symptom scores and esophagitis
[35]
findings was worse in the LMAH-C arm compared to LNF . Although this is a demonstration of improved
symptom control in non-HH-related ARS without the use of mesh, it is not clear that the lack of mesh is
what was operative in this case as two different operations were compared independent of the mesh use or
non-use: a gastropexy vs. a fundoplication. Generally, few data exist about mesh- vs. non-mesh repairs
during non-HH-related ARS.

Reoperative anti-reflux surgery
Little data exists comparing mesh- and non-mesh-based repairs of reoperative ARS. Many surgeons
consider reoperation an indication of mesh usage, and so perhaps the lack of data owes to the suspected lack
of equipoise . Nevertheless, in the only comparative study of mesh use in reoperative ARS - essentially a
[4,9]
case series that discusses the use of mesh or not in reoperative ARS - Desai et al. found similar
re-reoperation rates (16% vs. 20%) in mesh-based and non-mesh-based repairs of failed HHR (n = 82) .
[36]
Additionally, some of the RCTs for HHR include reoperative HHR, but none provide subgroup analysis of
this population . In general, the use of mesh in reoperative ARS has not been sufficiently studied.
[27]

Complicated HHs
Almost no data exist to guide the surgeon in choosing how to operate on the difficult population that
[3]
presents with acute complicated HH, including gastric volvulus, perforation, or obstruction . No
comparative studies comparing mesh and non-mesh-based repairs in complicated HH are available.

Reasons not to use mesh
Finally, there are particular risks to the use of mesh not reflected in the apparently benign results in which
no difference in complication rates is seen in mesh-based and non-mesh-based arms of RCTs in ARS. Mesh
erosion is a feared complication in which the mesh burrows into the esophagus. Mesh erosion can present
with dysphagia, abdominal pain, fistula, reduced oral intake, odynophagia, or weight loss. In a recent
systematic review, the risk of this complication is about 0.035% of all ARS cases in which mesh is used, and
non-biologic mesh is the more frequently associated culprit, with the complication generally occurring
within 5 years of the procedure .
[37]

Though perhaps less often considered, there is a more common reason to avoid mesh if it does not benefit
the patient: cost. Although the dollars-and-cents cost of mesh usage was not reported in any of the RCTs
and few observational studies, mesh has an obvious cost on top of the simple sutures that would otherwise
be used for crural approximation during ARS. In the study cited previously, several biologic meshes are
[34]
compared and the costs vary but do not seem to affect the overall charge . Aside from that report,
however, very few data exist as to the financial cost-benefit analysis of mesh usage in ARS.

CONCLUSIONS
Although the data suffers from biases including heterogeneity in definition, materials applied in mesh-based
repairs, follow-up duration, and drop-out, there is little evidence to recommend the routine use of mesh in
anti-reflux surgery and a lack of strong evidence to promote selective mesh use, even for commonly cited
indications like the large size of hernia or crural tension. Mesh usage for anti-reflux surgery in the United
States and Europe remains prevalent, with more than 75% of surgeons selectively using mesh augmentation
in 35%-40% of their cases.