Mesh for Paraesophageal Hernia Repair

Educational Objectives

The goal of this program is to improve the treatment of patients with paraesophageal hernias. After hearing and assimilating this program, the clinician will be better able to:

1. Employ appropriate techniques to enhance outcomes in patients undergoing repair of paraesophageal hernias.

Summary

Principles of repair of paraesophageal hernia (PH): reduce visceral contents; dissect sac from mediastinum; close hiatal defect; use permanent sutures; controversies — use of mesh; role of fundoplication and gastropexy

Recurrences following laparoscopic repair of PH: initial studies found rate of radiologic recurrence 42%; study from France found rate with ≈8-yr follow-up 67%; causes of high rate of recurrence — crura lack tendon or fascia; atrophic in patients with PH; pressure differential between abdomen and mediastinum favors herniation into mediastinum; crura separate during inspiration; peristalsis of esophagus precludes tight closure; prevalence of deficiency in connective tissue in patients with hernias high (eg, concomitant inguinal or umbilical hernia)

Rationale for use of mesh: use allows tension-free repair; repair of PH requires resection of anterior and posterior hernia sacs; fascia allowing secure closure lacking; randomized studies suggest that placement of mesh reduces rate of recurrence (follow-up data not sufficient)

Risks of mesh: erosion — reported rate 0.5% (underreported); dysphagia — caused by scarring and narrowing of esophagus; reoperation — incidence of esophagectomy, gastrectomy, and death higher in reoperations following previous repair with mesh; erosion (continued) — can occur many years later

Innovations: studies of patients undergoing repair with biologic mesh found no reduction in incidence of recurrence with 5-yr follow-up; data on use of bioabsorbable meshes lacking

Conclusions: correlation of anatomic failure with symptomatic failure poor; placement of permanent mesh at hiatus may cause problems; outcomes using new mesh materials and optimal methods to fixate and configure mesh unknown

Readings

Jacobs M et al: Use of Surgisis mesh in laparoscopic repair of hiatal hernias. Surg Laparosc Endosc Percutan Tech 2007 Oct;17(5):365-8; Zehetner J et al: Laparoscopic versus open repair of paraesophageal hernia: the second decade. J Am Coll Surg 2011 May;212(5):813-20.

Disclosures

For this program, the following has been disclosed: Dr. Alaedeen reported nothing to disclose. The planning committee reported nothing to disclose.

Acknowledgements

Dr. Alaedeen was recorded at Updates in Abdominal Wall Reconstruction, presented by the Cleveland Clinic Foundation Center for Continuing Education and held January 12-14, 2017, in Orlando, FL. For information on upcoming CME activities presented by the Cleveland Clinic Foundation Center for Continuing Education, please visit ccfcme.org. The Audio Digest Foundation thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GS642403

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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