title: Hiatal mesh is associated with major resection at revisional operation.
abstract: BACKGROUND
  Mesh-assisted hiatal closure during foregut surgery is increasing. Our aim was to evaluate the complications that follow revisional foregut surgery. Specifically, we compared surgical indications and perioperative outcomes between patients with and without prior hiatal mesh (PHM).
  
  
  METHODS
  We conducted an institutional review board (IRB)-approved retrospective cohort study from a single tertiary-care referral center. Over 37 months, 91 patients underwent revisional foregut surgery. We excluded 13 cases including operations performed primarily for obesity or achalasia. Of the remaining 78 patients, 10 had PHM and 68 were nonmesh patients (NM).
  
  
  RESULTS
  The groups were similar in terms of age, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, and rates and types of anatomic failure. Compared with NM patients, PHM patients had increased estimated blood loss (410 vs. 127 ml, p < 0.01) and operative time (4.07 vs. 2.89 h, p < 0.01). The groups had no difference in perioperative blood transfusion or length of stay. Complete fundoplication was more commonly created in NM patients (2/10 vs. 42/68, p = 0.03). Three of the 10 PHM patients and 3 of the 68 NM patients required major resection. Therefore, PHM patients had 6.8-fold increased risk of major resection compared with NM patients [95% confidence interval (CI) = 1.585, 29.17; p = 0.05]. The NM patients with multiple prior hiatal operations had 4.6-fold increased risk of major resection compared with those with one prior operation (95% CI = 2.919, 7.384; p = 0.03). In PHM patients, however, the number of prior hiatal operations was not associated with major resection.
  
  
  CONCLUSIONS
  PHM is associated with increased risk of major resection at revision. The pattern of failure was not different in patients with hiatal mesh, suggesting that hiatal mesh does not eliminate the potential for revision. When performing hiatal herniorrhaphy, the increased risk of recurrence without mesh must be weighed against the potential risk for subsequent major resection when using mesh.
authors.affiliation: Department of Surgery, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Parker
authors.forename: Steven P
authors.initials: SP
authors.lastname: Bowers
authors.forename: Jillian M
authors.initials: JM
authors.lastname: Bray
authors.forename: Adam S
authors.initials: AS
authors.lastname: Harris
authors.forename: Erol V
authors.initials: EV
authors.lastname: Belli
authors.forename: Jason M
authors.initials: JM
authors.lastname: Pfluke
authors.forename: Susanne
authors.initials: S
authors.lastname: Preissler
authors.forename: Horacio J
authors.initials: HJ
authors.lastname: Asbun
authors.forename: C Daniel
authors.initials: CD
authors.lastname: Smith
mesh_terms: D015331:Cohort Studies; D005260:Female; D006551:Hernia, Hiatal / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012086:Reoperation; D012189:Retrospective Studies; D013526:Surgical Mesh; D017211:Treatment Failure
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