The increasingly widespread use of prosthetic mesh to reinforce hiatal repair has been demonstrated in recent surveys of American and European gastrointestinal surgeons [7–9]. These studies have also highlighted the large diversity in practice and approach to using prostheses at the hiatus, where the indication for use, mesh type, configuration, and placement technique vary.
The advantage of prosthetic mesh in preventing hiatal hernia recurrence is not conclusively established. Five meta-analyses examining mesh-reinforced hiatal repair versus suture-only repair demonstrated a lower recurrence rate in patients undergoing a non-resorbable mesh-reinforced repair at short to medium-term follow up [1–5]. However, more recent meta-analyses involving randomised controlled trials have not shown this benefit [6–8]. Most recently, Petric et al. presented their systematic review and meta-analysis of randomised controlled trials that demonstrated no benefit of mesh augmentation with respect to recurrence rates, both in the short and long term. Quite reasonably, the authors conclude that ‘as both techniques delivered comparable clinical outcomes, a suture technique for primary hiatus hernia repair is simpler and should be recommended’ [6]. It is worth noting that the prosthetic materials used in the included studies varied, and some may no longer be in widespread use. This is particularly the case with expanded polytetrafluoroethylene (ePTFE), which was shown to decrease recurrence rates in one randomised trial [17]. There are two prospective randomised trials comparing TiMesh augmentation to primary closure [18, 19], with 5-year follow up recently published for one trial [20]. Neither study reported a benefit in recurrence rate with TiMesh repair compared to primary suture repair.
Reports of complications with various types of mesh and fixation techniques illustrate that mesh repair at the hiatus is not without risk. Cardiac vascular injury may occur at the time of mesh fixation resulting in bleeding or cardiac tamponade [20–22]. Mesh erosion may require foregut resection, which may be technically difficult and result in compromised patient quality of life and nutrition [12–14, 23, 24]. It must be noted that various mesh types have different physical characteristics which influence tissue incorporation and propensity to erode [25], and not all case reports of complications identify the type of mesh utilised.
While mesh related complications appear to be rare, their true incidence is unknown. As suggested by Tatum and colleagues, complications such as these probably suffer from natural publication and reporting bias against poor outcomes [26]. Secondly, complication reporting has primarily been the focus of case reports and small case series, which lack denominators through which incidence can be calculated.
In their survey of European surgeons, Furnee and colleagues report that approximately one-third of the 165 respondents had seen one or more complications related to mesh use in hiatal repair during their careers [11]. From a survey of SAGES members, Franztides and colleagues propose the mesh-related complication rate to be approximately 2 to 4 patients per 1000, reporting an incidence for erosion and strictures of 0.27% and 0.20%, respectively [9]. The authors recognise this should be taken only as an estimate of real-world results as the respondents’ data could not be verified, but it does appear to align with other reports of mesh complications. A systematic review of the literature by Furnee and Hazebroek calculated the incidence of oesophageal erosion and dense fibrosis causing oesophageal stenosis as 0.2% and 0.5%, respectively [2].
Our reported rate of mesh erosion of 0.51% appears to be consistent with previously reported rates of mesh complications. In both cases, the patients were asymptomatic and have not required mesh explantation. We believe our erosion cases reflect inadequate fixation of the mesh to the diaphragm, resulting in incomplete incorporation. Our single case of explantation occurred in a patient who had undergone laparoscopic repair of an acute hernia. A subsequent laparotomy was performed to address an unrecognised oesophageal perforation, and at that time, the mesh was explanted. There were no cardiac or vascular injury related complications relating to fixation screws in this series. Cardiac injuries are likely to be avoided if mesh is placed posteriorly over the hiatal repair, obviating the need to place screws anteriorly.
The most obvious limitation in a study such as this is the lack of long-term symptomatic and objective follow-up with either contrast study or endoscopy. Routine anatomical follow-up with either of these modalities outside the context of a clinical trial on a cohort this large would prove challenging from a logistical viewpoint. With that in mind, we are unable to report rates of asymptomatic hernia recurrence or mesh erosion.