title: Laparoscopic repair of hiatus hernia: Does mesh type influence outcome? A meta-analysis and European survey study.
abstract: Synthetic mesh (SM) has been used in the laparoscopic repair of hiatus hernia but remains controversial due to reports of complications, most notably esophageal erosion. Biological mesh (BM) has been proposed as an alternative to mitigate this risk. The aim of this study is to establish the incidence of complications, recurrence and revision surgery in patients following suture (SR), SM or BM repair and undertake a survey of surgeons to establish a perspective of current practice.
  
  
  
  An electronic search of EMBASE, MEDLINE and Cochrane database was performed. Pooled odds ratios (PORs) were calculated for discrete variables. To survey current practice an online questionnaire was sent to emails registered to the European Association for Endoscopic Surgery.
  
  
  
  Nine studies were included, comprising 676 patients (310 with SR, 214 with SM and 152 with BM). There was no significant difference in the incidence of complications with mesh compared to SR (P = 0.993). Mesh significantly reduced overall recurrence rates compared to SR [14.5 vs. 24.5 %; POR = 0.36 (95 % CI 0.17-0.77); P = 0.009]. Overall recurrence rates were reduced in the SM compared to BM groups (12.6 vs. 17.1 %), and similarly compared to the SR group, the POR for recurrence was lower in the SM group than the BM group [0.30 (95 % CI 0.12-0.73); P = 0.008 vs. 0.69 (95 % CI 0.26-1.83); P = 0.457]. Regarding surgical technique 503 survey responses were included. Mesh reinforcement of the crura was undertaken by 67 % of surgeons in all or selected cases with 67 % of these preferring synthetic mesh to absorbable mesh. One-fifth of the respondents had encountered mesh erosion in their career.
  
  
  
  Both SM and BM reduce rates of recurrence compared to SR, with SM proving most effective. Surgical practice is varied, and there remains insufficient evidence regarding the optimum technique for the repair of hiatal hernia.
authors.affiliation: Division of Surgery, Department of Surgery and Cancer, Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St Mary's Hospital, South Wharf Road, London, W2 1NY, UK.
authors.forename: Jeremy R
authors.initials: JR
authors.lastname: Huddy
authors.affiliation: Division of Surgery, Department of Surgery and Cancer, Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St Mary's Hospital, South Wharf Road, London, W2 1NY, UK.
authors.forename: Sheraz R
authors.initials: SR
authors.lastname: Markar
authors.affiliation: Division of Surgery, Department of Surgery and Cancer, Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St Mary's Hospital, South Wharf Road, London, W2 1NY, UK.
authors.forename: Melody Z
authors.initials: MZ
authors.lastname: Ni
authors.affiliation: Department of Surgical Sciences, University of Torino, Turin, Italy.
authors.forename: Mario
authors.initials: M
authors.lastname: Morino
authors.affiliation: Department of General Surgery and Cancer, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
authors.forename: Edoardo M
authors.initials: EM
authors.lastname: Targarona
authors.affiliation: Division of Surgery, Department of Surgery and Cancer, Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St Mary's Hospital, South Wharf Road, London, W2 1NY, UK.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Zaninotto
authors.affiliation: Division of Surgery, Department of Surgery and Cancer, Imperial College London, Academic Surgical Unit, 10th Floor, QEQM Building, St Mary's Hospital, South Wharf Road, London, W2 1NY, UK. g.hanna@imperial.ac.uk.
authors.forename: George B
authors.initials: GB
authors.lastname: Hanna
mesh_terms: D005060:Europe; D006551:Hernia, Hiatal / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D019736:Prostheses and Implants; D012008:Recurrence; D013526:Surgical Mesh; D011795:Surveys and Questionnaires; D016896:Treatment Outcome
keywords: Hiatal hernia; Laparoscopy; Mesh