Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial

Abstract

Objective: Laparoscopic paraesophageal hernia repair (LPEHR) is associated with a high recurrence rate. Repair with synthetic mesh lowers recurrence but can cause dysphagia and visceral erosions. This trial was designed to study the value of a biologic prosthesis, small intestinal submucosa (SIS), in LPEHR.

Methods: Patients undergoing LPEHR (n = 108) at 4 institutions were randomized to primary repair -1 degrees (n = 57) or primary repair buttressed with SIS (n = 51) using a standardized technique. The primary outcome measure was evidence of recurrent hernia (> or =2 cm) on UGI, read by a study radiologist blinded to the randomization status, 6 months after operation.

Results: At 6 months, 99 (93%) patients completed clinical symptomatic follow-up and 95 (90%) patients had an UGI. The groups had similar clinical presentations (symptom profile, quality of life, type and size of hernia, esophageal length, and BMI). Operative times (SIS 202 minutes vs. 1 degrees 183 minutes, P = 0.15) and perioperative complications did not differ. There were no operations for recurrent hernia nor mesh-related complications. At 6 months, 4 patients (9%) developed a recurrent hernia >2 cm in the SIS group and 12 patients (24%) in the 1 degrees group (P = 0.04). Both groups experienced a significant reduction in all measured symptoms (heartburn, regurgitation, dysphagia, chest pain, early satiety, and postprandial pain) and improved QOL (SF-36) after operation. There was no difference between groups in either pre or postoperative symptom severity. Patients with a recurrent hernia had more chest pain (2.7 vs. 1.0, P = 0.03) and early satiety (2.8 vs. 1.3, P = 0.02) and worse physical functioning (63 vs. 72, P = 0.03 per SF-36).

Conclusions: Adding a biologic prosthesis during LPEHR reduces the likelihood of recurrence at 6 months, without mesh-related complications or side effects.

Figures

FIGURE 1. Schematic of SIS reinforced hiatal repair as performed in this trial.

FIGURE 2. Upper gastrointestinal x-ray postoperative examples. A, Intact fundoplication located below the diaphragm. B, Intact fundoplication, but indeterminate positioning (fundoplication seen within 2 cm of the level of the left hemidiaphragm). C, Intact fundoplication with small sliding hiatal hernia (2–5 cm above the left hemidiaphragm).

FIGURE 3. A, SF-36 results preoperative and 6 months after operation for all study patients. U.S. norms included for comparison. *Preoperative versus 6 months (P ≤ 0.01). B, SF-36 results preoperative and 6 months after operation for primary group. U.S. norms included for comparison. *Preoperative versus 6 months (P < 0.05). C, SF-36 results preoperative and 6 months after operation for SIS group. U.S. norms included for comparison.*Preoperative versus 6 months (P ≤ 0.01).