title: Objective follow-up after laparoscopic repair of large type III hiatal hernia. Assessment of safety and durability.
abstract: BACKGROUND
  Symptomatic results of laparoscopic repair of large type III hiatal hernias, with/without prosthetic mesh, are often excellent; however, a high recurrence rate is detected when objective radiological/endoscopic follow-up is performed. The use of mesh may reduce the incidence of postoperative hernia recurrence or wrap migration in the chest.
  
  
  METHODS
  We retrospectively studied 54 patients (10 men, 44 women; median: age 64.5 years) with a diagnosis of large type III hiatal hernia (>1/3 stomach in the chest on x-ray) who underwent laparoscopic repair at our department from January 1992 to June 2005. Complications, recurrences, and symptomatic and objective (radiological/endoscopic) long-term outcome were evaluated.
  
  
  RESULTS
  Nineteen patients had laparoscopic Nissen/Toupet fundoplication with simple suture; in 35 patients a double mesh was added. The median radiological/endoscopic follow-up was 64 months (interquartile range (IQR): 6-104) for the non-mesh group and 33 (IQR:12-61) for the mesh group (p = 0.26). Recurrences occurred in 11/54 (20%) patients: 8/19 (42.1%) without mesh and 3/35 (8.6%) with mesh (p = 0.01). The 3 recurrences in the mesh group all occurred < or =12 months postoperatively; 4/8 recurrences in the non-mesh group occurred > or =5 years after operation. On multivariate logistic regression analysis, only mesh absence significantly predicted hernia recurrence or wrap migration.
  
  
  CONCLUSIONS
  Laparoscopic repair of large type III hiatal hernias is safe and effective. Short-term symptomatic results are excellent, but mid-term objective radiological/endoscopic evaluation reveals a high recurrence rate. Possible reasons for failure of a laparoscopic hiatal repair are tension or poor muscle tissue characteristics in the hiatus. The use of a mesh, either by reducing tension or reinforcing muscle at the hiatus, might be associated with a lower recurrence rate. Longer-term follow-up will be needed before definitive conclusions can be drawn, however.
authors.affiliation: Department of Gastroenterological and Surgical Sciences, Clinica Chirurgica III, University of Padova School of Medicine, Via Giustiniani 2, 35128 Padova, Italy. giovanni.zaninotto@unipd.it
authors.forename: Giovanni
authors.initials: G
authors.lastname: Zaninotto
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Portale
authors.forename: Mario
authors.initials: M
authors.lastname: Costantini
authors.forename: Pietro
authors.initials: P
authors.lastname: Fiamingo
authors.forename: Sabrina
authors.initials: S
authors.lastname: Rampado
authors.forename: Emanuela
authors.initials: E
authors.lastname: Guirroli
authors.forename: Loredana
authors.initials: L
authors.lastname: Nicoletti
authors.forename: Ermanno
authors.initials: E
authors.lastname: Ancona
mesh_terms: D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006551:Hernia, Hiatal / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D055502:Secondary Prevention; D013526:Surgical Mesh