Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series

Background  Primary laparoscopic hiatal hernia repair is associated with up to a 42% recurrence rate. This has lead to the use of mesh for crural repair, which has resulted in an improved recurrence rate (0–24%). However, mesh complications have been observed. Methods  We compiled two cases, and our senior author contacted other experienced esophageal surgeons who provided 26 additional cases with mesh-related complications. Care was taken to retrieve technical operative details concerning mesh size and shape and implantation technique used. Results  Twenty-six patients underwent laparoscopic and two patients open surgery for large hiatal hernia (n = 28). Twenty-five patients had a concomitant Nissen fundoplication, two a Toupet fundoplication, and one a Watson fundoplication. Mesh types placed were polypropylene (n = 8), polytetrafluoroethylene (PTFE) (n = 12), biological mesh (n = 7), and dual mesh (n = 1). Presenting symptoms associated with mesh complications were dysphagia (n = 22), heartburn (n = 10), chest pain (n = 14), fever (n = 1), epigastric pain (n = 2), and weight loss (n = 4). Main reoperative findings were intraluminal mesh erosion (n = 17), esophageal stenosis (n = 6), and dense fibrosis (n = 5). Six patients required esophagectomy, two patients had partial gastrectomy, and 1 patient had total gastrectomy. Five patients did not require surgery. In this group one patient had mesh removal by endoscopy. There was no immediate postoperative mortality, however one patient has severe gastroparesis and five patients are dependent on tube feeding. Two patients died 3 months postoperatively of unknown cause. There is no apparent relationship between mesh type and configuration with the complications encountered. Conclusion  Complications related to synthetic mesh placement at the esophageal hiatus are more common than previously reported. Multicenter prospective studies are needed to determine the best method and type of mesh for implantation.