K. A. Schlosser1, S. R. Maloney1, T. Prasad1, V. A. Augenstein1, B. T. Heniford1, P. D. Colavita1 1Carolinas Medical Center,Division Of Gastrointestinal And Minimally Invasive Surgery,Charlotte, NC, USA
Introduction:
Mesh placement in paraesophageal hernia repair (PEHR) is controversial. Following encouraging early results, in 2012, Oelschlager et al demonstrated no reduction of recurrence with mesh after five years. This study examines the trends of mesh use before and after this publication, as well as outcomes of PEHR.
Methods:
The American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent PEHR with or without mesh (2010-2016). Bariatric procedures were excluded. Demographics, operative approach, and outcomes were compared over time.
Results:
20,798 patients underwent PEHR from 2010-2016. 90.8% were performed laparoscopically (LPEHR). Mean age was 62.1±14.0yr, mean BMI was 30.2±6.2m2/kg, 70.9% were female, 9.0% had diabetes, and 9.1% were active smokers. Most cases were elective (88.9%) and without mesh (61.2%). LPEHR patients had higher BMI (30.3±6.2 vs 29.6±6.7, p<0.0001), and had lower rates of reoperation, readmission, mortality, overall complications, and major complications (2.7 vs 4.8%, 6.3 vs 9.9%, 0.6 vs 3.0%, 7.3 vs 21.5%, 3.9 vs 11.4% respectively; all p<0.0001). Mesh placement was more common in LPEHR (39.8 vs 29.3, p<0.0001).
In primary LPEHR with mesh, patients were older (63.1±13.5yr vs. 61.0±14.3, p<0.0001) and more obese (BMI 31±5.9 vs 30.4±6.4, p=0.0003). Mesh placement was not associated with adverse outcomes. Trends of LPEHR with mesh were examined over time. From 2010 to 2016, mesh placement decreased from 46.2 to 37.0% of LPEHRs (Figure 1). Mean operative times for LPEHR with mesh also decreased (176.0±71.0 to 152.9±73.3min), while mean operative times for LPEHR without mesh were consistently lower (148.6±71.4 to 134.7±70.4). There were no significant changes in comorbidities or adverse outcomes over time.
Using multivariate analysis to control for potential confounding factors, COPD was most strongly associated with multiple adverse outcomes, including reoperation (OR 1.4, CI 1.02-2.0), readmission (OR 1.17, CI 1.03-1.33), mortality (OR 1.57, CI 1.04-2.36), any complications (OR 1.81, 1.48-2.2), and major complications (OR 1.78, CI 1.36-2.31). Other factors associated with adverse outcomes included older age, higher BMI, male sex, non-elective repair, contaminated operation, diabetes, steroid use, and smoking.
Conclusion:
The placement of mesh during LPEHR is not associated with adverse outcomes despite an older patient population. Use of mesh with LPEHR is decreasing with no apparent adverse impact on available short-term patient outcomes. Further research needs to investigate patient factors not captured by this national database, such as symptoms, hernia recurrence, and hernia type and size. Additionally, the mesh type and fixation in these cases needs to be separated and short and long term outcomes further defined.
