Surgical Endoscopy and Other Interventional Techniques

https://doi.org/10.1007/s00464-020-07703-4

Surgical and clinical outcomes comparison of mesh usage

in laparoscopic hiatal hernia repair
Priscila R. Armijo1,2 · Crystal Krause1,2 · Tailong Xu3 · Valerie Shostrom4 · Dmitry Oleynikov2

Received: 20 March 2020 / Accepted: 9 June 2020

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Purpose Use of absorbable mesh in hiatal hernia (HH) repair has been shown to decrease recurrence rates. Our aim was to
compare the efficiency of three meshes in relation to the surgical outcomes of patients undergoing HH repair.
Methods A single-institution retrospective review was done for adult patients who underwent HH repair with mesh between
2004 and 2016. Demographics, intra-operative, and cost data were collected. Esophageal symptoms and medication use
were assessed pre- and postoperatively. Surgical outcomes were evaluated at 6-, 12-months, and long-term follow-up. Three
groups were created based on type of mesh: human tissue matrix (HTM), biosynthetic mesh (BIOS), or porcine tissue matrix
(PTM). Comparisons were performed between groups using SPSS v.26.0 and PC SAS v9.4, α = 0.05.
Results 292 patients were included (HTM:N = 162, BIOS:N = 83, PTM:N = 47). Majority were male (60.4%), Caucasian
(93.2%), median age, and BMI of 59 years [25–90 years] and 29.19 kg/m2 [18.9–58.0 kg/m2], respectively. 69% had a large
HH. Median follow-up time was 27 months [1–166 months]. Overall recurrence rate was 39%, being significantly lower in
BIOS at long-term (HTM: 31%, BIOS: 17%, PTM: 19%, p = 0.038). All groups had a significant postoperative improvement
of esophageal symptoms, all p < 0.001. 65–70% of the cost difference between the groups was incurred by the cost of mesh
alone (HTM: $1072, BIOS: $548, PTM: $1295), with the remainder attributable to the surgery itself.
Conclusion While outcomes of the three mesh groups were similar in our data, there was a significant difference in mesh cost.
Surgeon and hospital preference still play a role in choosing the type of mesh used; however, knowledge of the individual
mesh cost will help surgeons make better informed decisions.

Keywords Paraesophageal hernia · Hiatal hernia repair · Mesh · Cost · Outcomes

Information in this paper was presented as a Poster Presentation at
the SAGES 2016 Annual Meeting, March 16–19, Boston, MA.
The address for Dr. Dmitry Oleynikov reflects the address at the
time the study was performed.
* Priscila R. Armijo
p.rodriguesarmijo@unmc.edu
1
Department of Surgery, University of Nebraska Medical
Center, 986245 Nebraska Medical Center, Omaha,
NE 68198‑6245, USA
2
Center for Advanced Surgical Technology, University
of Nebraska Medical Center, 986246 Nebraska Medical
Center, Omaha, NE 68198‑6246, USA
3
College of Medicine, University of Nebraska Medical Center,
986246 Nebraska Medical Center, Omaha, NE 68198‑6246,
USA
4
College of Public Health, University of Nebraska Medical
Center, 984355 Nebraska Medical Center, Omaha,
NE 68198‑4355, USA
Hiatal hernia (HH) repair has traditionally been performed
using an open transthoracic or transabdominal procedure
with hernia sac reduction, closure of the crus, and fundopli-
cation for the treatment of associated gastroesophageal
reflux disease (GERD) [1]. Laparoscopic HH repair has
become increasingly common, with favorable outcomes [2].
However, hernia recurrence after HH repair, regardless of
surgical approach, has been problematic. Open and laparo-
scopic HH repair have recurrence rates that can range from
approximately 10% up to almost 60% [3, 4]. However, these
hernia recurrence rates can drop significantly with the use
of mesh in the surgical repair [4–7].
Use of absorbable mesh in HH repair has been shown
to decrease recurrence rates in the short term [8]. Biologi-
cal meshes have been shown to reduce hernia recurrence
rates (15–20%) when compared to suture repair without
use of mesh [9]. A recent multicenter trial evaluating the
use of biologic mesh in hiatal repair showed significant

13
Vol.:(0123456789)
 Surgical Endoscopy

symptomatic improvement and a 10% radiographic recur-
rence rate at 2 years [10]. The authors found no significant
difference in symptomatic outcomes between patients with
and without recurrence [10]. The introduction of an absorb-
able biosynthetic mesh in HH has shown similar outcomes to
biologic mesh, increasing its utilization in crural reinforce-
ment [11, 12]. Previously published analysis has shown that
absorbable mesh has a lower radiologic recurrence rate than
primary repair, but recurrence does increase with time in
mesh repair patients [13]. However, symptom resolution is
better maintained in mesh patients, leading to its increased
use for HH repair [14, 15].
The aim of this study was to compare the efficiency
between one synthetic and two biological meshes in relation
to the surgical and clinical outcomes of patients undergoing
hiatal hernia repair and to evaluate which should be deter-
mining factor in the type of mesh used.
Materials and methods
A retrospective analysis of a prospectively collected data-
base at a single institution was performed. Data were col-
lected from patients who underwent HH repair with mesh
by a single surgeon between December 2004 and June 2016.
Our HH repair technique was previously described in 2017
[9]. All patients receive mesh reinforcement, regardless of
hernia size. Each mesh was cut into a U-shape, measuring
4 × 7 cm, and sutured to the hiatus with permanent suture
[16]. Since this study is a retrospective review of data col-
lected over a decade, the type of mesh used was based on
hospital contract and availability. The type of fundoplication
offered (total or partial) was chosen according to preopera-
tive esophageal testing results. Patients with esophageal dys-
motility were offered partial fundoplication. Inclusion crite-
ria included patients 19 years of age or older, with previous
diagnosis of GERD who underwent laparoscopic HH repair
with mesh. Patients with previous history of achalasia were
excluded from this study. Ethical approval and waiver of
informed consent were obtained from the local institutional
review board for this retrospective medical records review.
Outcomes measured
Patient characteristics including age, gender, race, body mass
index, prior repair status, and medical history data were col-
lected. Hernia characteristics were collected preoperatively,
and HH size was categorized into small p< 2.0 cm), mod-
erate (2–4 cm), or large (≥ 5 cm). Pertinent demographic
data are presented in Table 1. The presence of intra-thoracic
stomach was also noted. Preoperative esophageal evaluation
included score of esophageal symptoms, upper gastrointesti-
nal endoscopy (EGD), esophageal manometry, upper barium
swallow, and pH testing. Surgical data included type of mesh
used in the repair, presence of intra-thoracic stomach, surgi-
cal approach, length of hospital stay (LOS), operative room
(OR) time, type of fundoplication, blood loss (BL), and sur-
gical complications. Individual mesh cost and the average
operative cost were also collected.
Three types of mesh were used in this study, one synthetic
and two biologicals. Alloderm® (Life Cell Corporation,
Branchburg, NJ, USA) is a processed cadaveric human tissue
matrix (HTM) mesh. GORE® BIO-A® Tissue Reinforce-
ment (WL Gore & Assoc, Flagstaff, AZ, USA) is a biosyn-
thetic (BIOS) mesh made of 67% polyglycolic acid and 33%
trimethylene carbonate. Strattice™ (LifeCell Corporation;
Branchburg, NJ, USA) is a non-cross linked porcine tissue
matrix (PTM) mesh. Patients were divided into three groups
according to the type of mesh used in the PEH repair: HTM,
BIOS, and PTM, for Alloderm®, GORE® BIO-A®, and
Strattice™, respectively.

Table 1  Patient demographics HTM BIOS PTM p-value

of the three mesh groups N = 162 N = 83 N = 47
(N = 292)
Age—Median (IQR) 60 (49, 69) 57 (48, 66) 62 (58, 74) 0.0322
Gender—N (%)
Male 93 (57%) 46 (55%) 37 (79%) 0.0178
Race—median (%)
Caucasian 138 (99%) 78 (94%) 46 (98%) 0.1458
BMI kg/m2—median (IQR) 29.44 (26.82, 32.30) 28.61 (26.08, 31.16) 29.74 (25.86, 34.43) 0.1864
Hernia size—N (%) < 0.001
Moderate (2–4 cm) 27 (17%) 55 (67%) 2 (5%)
Large (≥ 5 cm) 133 (83%) 27 (33%) 42 (95%)
Primary surgery 133 (83%) 75 (90%) 45 (96%) 0.0372

HTM human tissue matrix, BIOS biosynthetic mesh, PTM porcine tissue matrix, IRQ interquartile range
*Significant at p < 0.05

13
Surgical Endoscopy
Postoperative outcomes were evaluated at 6-mo
(6 months), 12 mo (12-months), and long-term (LT) follow-
up. LT was defined as greater than or equal to 15 months
postoperatively. Outcomes included complications, such as
infection rate, score of esophageal symptoms, medication
usage (proton pump inhibitor, H2-blockers, antacid), and
hernia recurrence. Hernia recurrence was defined as any HH
greater than 2 cm seen in postoperative UGI; this was done
routinely at 12-month follow-up or earlier if symptomatic. A
radiologist was consulted on the specific technique to review
UGI recurrence. The minimally invasive surgeon interpreted
the UGI studies to determine hernia recurrence according to
the criteria. For the LT, both symptomatic and asymptomatic
patients were contacted to perform UGI at regular intervals,
including at the five year mark and at the 10-year mark.
Statistical analysis
Categorical data were analyzed using Chi-square of Fisher’s
exact test when cell counts were low. Continuous data were
analyzed using the nonparametric Kruskal–Wallis test. Data
are presented as frequencies and percentages, or median and
quartiles for categorical and continuous data, respectively.
Chi-square or Fisher’s exact tests were used to examine the
relationship of presence/absence of each symptom at each
time point among mesh types.
Changes of esophageal symptoms from baseline were cal-
culated at 6-mo, 12-mo, and LT follow-up for each group
using the nonparametric sign test, with correction of the
α level for 3 comparisons, to determine whether the num-
ber of patients with improved symptoms was statistically
significant at follow-up. Statistical significance of the test
indicates that there has been a substantial change from base-
line. Subsequently, differences in improvement over time
between mesh groups were compared using Chi-squares
tests, as appropriate. Finally, median scores [interquartile
range] were also reported for each time point. All statistical
analyses were performed using IBM SPSS v26.0.0 and PC
SAS version 9.4, with α = 0.05.
Results
A total of 292 patients met the inclusion criteria and
were enrolled in this study. The majority of patients were
male (60.4%), Caucasian (93.2%), with median age of
59 years [25–90 years], and median BMI of 29.19 kg/m2
[18.9–58.0 kg/m2]. 68.3% had a large HH, and 15.4% had
intra-thoracic stomach. 55.3% (N = 162) of patients had a
repair with HTM mesh, 28.7% (N = 84) with BIOS, and
16% (N = 47) with PTM mesh. Median length of stay was
1 day [1–2 days]. Descriptive information between the three
groups is depicted in Table 1. Median follow-up time was
27 months [1–166 months], and median LT follow-up time
of 4 years [1.5–14 years], with a retention rate of 59.2% at
LT. Overall recurrence rate was 39% (N = 114) and no dif-
ferences were seen between groups (HTM: 44.0%, BIOS:
38.0%, PTM: 40.0%, p = 0.701; Table 2). However, by eval-
uating long-term recurrence only, rates were significantly
lower in the BIOS group (HTM: 31.0%, BIOS: 17.0%, PTM:
19.0%, p = 0.038). No mesh explant or erosion was observed
with the use of any mesh.
Majority of patients received a total fundoplication
(HTM: 92%, BIOS: 64.3%, PTM: 80.9%; p < 0.001).
Median OR time was significantly shorter for the HTM
group (157 min [90–244 min]), when compared to BIOS
(188 min [90–382 min]; p = 0.001), and PTM (198.5 min
[91–439 min]; p < 0.001). BL was minimal (≤ 500 mL) in
majority of patients (HTM: 98.6%, BIOS: 100%, PTM:
100% patients). Overall intra-operative complication rates,
such as pneumothorax, were 9%, 5%, and 8% for HTM,
BIOS, and PTM respectively, p = 0.630. Six patients under-
went EGD with dilation postoperatively (BIOS: N = 4, PTM:
N = 2), with three of them happening within 30 days of the
surgery. Overall postoperative complication rates were also
similar between groups (HTM: 14%, BIOS: 19%, PTM:
13%), p = 0.6647.
There was a significant improvement of all esophageal
symptoms at 6-mo and 12-mo compared to baseline for all
three mesh groups, HTM (Table 3), BIOS (Table 4), and
PTM (Table 5). At LT follow-up, patients in the HTM group
continued to report significant improvement of all esopha-
geal symptoms compared to the baseline (all p < 0.017;
Table 3). However, only heartburn (p < 0.001) and regur-
gitation (p = 0.001) were significantly improved at LT for
patients who underwent HH repair with BIOS (Table 4).
Likewise, PTM patients only reported significant improve-
ment of regurgitation at LT follow-up (p = 0.008; Table 5).
Still, at LT follow-up, median scores for all esophageal
symptoms were 0 in all three mesh groups (Tables 3, 4
Table 2  Hernia recurrence at each time point between the three
groups of mesh
Time point HTM BIOS PTM p-value
Non-cumulative Hernia Recurrence
6 months 3/152 (2%) 7/78 (9%) 3/44 (7%) 0.0402
12 months 17/153 (11%) 10/79 (13%) 6/43 (14%) 0.8597
Long term 47/152 (31%) 13/78 (17%) 8/42 (19%) 0.0383
Hernia recurrence cumulative
6 months 3/152 (2%) 7/78 (9%) 3/44 (7%) 0.0402
12 months 20/153 (13%) 17/79 (22%) 9/43 (21%) 0.1906
Long term 67/152 (44%) 30/78 (38%) 17/42 (40%) 0.7011
HTM human tissue matrix, BIOS biosynthetic mesh, PTM porcine tis-
sue matrix
13
 Surgical Endoscopy

Table 3  Esophageal symptoms improvement over time—HTM

Gastrointestinal symptoms Preop prevalence Number of patients with improved symptom score compared to preoperative baseline—N
(N = 162) (%a), p-value
patients N (%) Median symptom score [IQR]
Median score
[IQR] 6 months (N = 145) 12 months (N = 119) Long-term (N = 104)
p-value p-value p-value

Heartburn 124 (77%) 110/111 (99%) < 0.001 91/92 (99%) < 0.001 80/84 (95%) < 0.001
3 [1–4] 0 [0–0] 0 [0–0] 0 [0–0]
Regurgitation 130 (80%) 112/116 (97%) < 0.001 89/94 (95%) < 0.001 75/84 (89%) < 0.001
2 [1–3] 0 [0–0] 0 [0–0] 0 [0–0]
Solid Dysphagia 91 (56%) 81/84 (96%) < 0.001 65/70 (93%) < 0.001 52/61 (85%) < 0.001
1 [0–2] 0 [0–0] 0 [0–0] 0 [0–0]
Liquid Dysphagia 45 (28%) 42/44 (95%) < 0.001 34/34 (100%) < 0.001 27/30 (90%) < 0.001
0 [0–1] 0 [0–0] 0 [0–0] 0 [0–0]
Abdominal Pain 89/160 (56%) 68/74 (92%) < 0.001 59/64 (92%) < 0.001 50/55 (91%) < 0.001
1 [0–3] 0 [0–1] 0 [0–0] 0 [0–0]
Belching 113/161 (70%) 84/98 (86%) < 0.001 72/79 (91%) < 0.001 65/68 (96%) < 0.001
2 [0–4] 0 [0–1] 0 [0–0] 0 [0–0]
Bloating 104/161 (65%) 80/89 (90%) < 0.001 72/76 (95%) < 0.001 59/63 (94%) < 0.001
2 [0–3] 0 [0–1] 0 [0–1] 0 [0–0]
Nausea 81/161 (50%) 68/68 (100%) < 0.001 59/61 (97%) < 0.001 51/54 (94%) < 0.001
1 [0–3] 0 [0–0] 0 [0–0] 0 [0–0]

Bold values indicate statistically significant p-values

HTM human tissue matrix, preop preoperative, IQR interquartile range
*Significant alpha level cut-off of 0.017 is used instead of 0.05 due to multiple comparisons
a
Percent improved calculated using denominator as number of preoperative symptomatic patients who replied survey at specific time point

and 5). No significant differences were seen between mesh
groups in terms of improvement of symptoms at 6-mo or LT
follow-up compared to preoperative values (Table 6).
Individual mesh costs in 2020, after adjusting for infla-
tion, were as follows: HTM: $1072, BIOS: $548, and PTM:
$1295. Given the historical data available, we were able to
collect additional cost information on BIOS and PTM. The
average total charge was similar between groups (BIOS:
$22,346 ± $4647 vs PTM: $21,333 ± $2380, p = 0.216),
whereas average of total implant cost was significantly
lower for BIOS ($481.16 ± $6.77) when compared to PTM
($1222 ± $123.30), p < 0.001.
Discussion
Our analysis of nearly 300 patients who underwent laparo-
scopic HH repair with mesh with a concurrent anti-reflux
procedure over a 10-year period revealed that the use of
HTM, BIOS, or PTM mesh for crural reinforcement is both
safe and effective, as previous studies evaluating absorbable
mesh have demonstrated [14–17].
The feasibility of HH repair with absorbable mesh has
been demonstrated [14, 17]. HH short-term recurrence rates
have been shown by numerous studies to be lower in repairs
performed with mesh when compared to unreinforced suture
repair. A recent systematic review by Zhang et al., for exam-
ple, demonstrated short- and medium-term (up to 36 months)
symptomatic recurrence rates up to 9.4% without mesh as
against 2.6% where mesh reinforcement was used [14]. Our
data demonstrate an overall recurrence rate of 39%, with
similar rates of recurrence between the three meshes evalu-
ated. Notably, our reported rate reflects asymptomatic recur-
rence, despite being higher than the short-term non-mesh
rate reported by Antiporda et al. where hernia recurrence
was noted at a rate of 34.2%, with a median follow-up of
7 months [18]. Longer-term hernia recurrence rates are still
controversial, especially due to attrition bias affecting sta-
tistical power and analysis. In our prior study, hernia recur-
rence rate at 1 year postoperatively was found to be 27.9%
(24/86) where PTM was used, versus 44.6% (27/61) in the
non-mesh group [9]. Long-term recurrence rates at 5 years
have been reported to be as high as 43–51% irrespective of
mesh use, but as this systematic review notes, long-term data
were only available for one randomized controlled trial [14].
Literature has shown that use of mesh during HH repair can
only slow the progression of an eventual recurrence of the
hernia [8]. As our data suggest, radiographic evidence of
HH increases with time. Still, we believe that mesh protects
from early symptomatic recurrence requiring reparation [8].

13
Surgical Endoscopy

Table 4  Esophageal symptoms improvement over time—BIOS

Gastrointestinal symptoms Preop preva- Number of patients with improved symptom score compared to preoperative baseline—N
lence (N = 81) (%a), p-value
Patients N (%) Median symptom score [IQR]
Median score
[IQR] 6 months, N = 69 12 months, N = 65 Long-term, N = 41
p-value p-value p-value

Heartburn 67/81 (83%) 57/57 (100%) < .0010 52/54 (96%) < .0010 31/33 (94%) < .0010
4 [2–4] 0 [0–0] 0 [0–0] 0 [0–0]
Regurgitation 57/80 (71%) 49/51 (96%) < .0010 50/50 (100%) < .0010 27/28 (96%) .0010
2 [0–4] 0 [0–0] 0 [0–0] 0 [0–0]
Solid dysphagia 39/80 (49%) 28/31 (90%) < .0001 29/29 (100%) < .0001 15/17 (88%) < .0001
0 [0–3] 0 [0–0] 0 [0–0] 0 [0–2]
Liquid dysphagia 22/80 (28%) 16/17 (94%) < .0001 15/15 (100%) < .0001 10/10 (100%) .0020
0 [0–1] 0 [0–0] 0 [0–0] 0 [0–0]
Abdominal pain 38/78 (49%) 29/32 (91%) < .0010 24/28 (86%) < .0010 13/16 (81%) .0051
0 [0–3] 0 [0–1] 0 [0–0] 0 [0–1.5]
Belching 42/78 (54%) 35/39 (90%) < .0001 30/35 (86%) < .0001 19/21 (90%) < .0001
1 [0–3] 0 [0–1] 0 [0–2] 0 [0–0]
Bloating 43/78 (55%) 32/41 (78%) < .0001 29/34 (85%) < .0001 21/23 (91%) < .0001
1 [0–3] 0 [0–3] 0 [0–2] 0 [0–0]
Nausea 32/78 (50%) 27/29 (93%) < .0001 21/22 (95%) < .0001 14/16 (91%) .0006
0 [0–2] 0 [0–0] 0 [0–0] 0 [0–0]

Bold values indicate statistically significant p-values

BIOS biosynthetic mesh, preop preoperative, IQR Interquartile Range
*Significant alpha level cut-off of 0.017 is used instead of 0.05 due to multiple comparisons
a
Percent improved calculated using denominator as number of preoperative symptomatic patients who replied survey at specific time point

We found no significant differences in terms of intra-
operative and immediate postoperative outcomes, irrespec-
tive of the type of mesh used. Perioperative variables, mean
LOS, and intra-operative complication rates were similar to
previous studies [9, 18, 19]. One such study demonstrated a
median LOS of 2 days, and a complication rate of 6% upon
evaluation of 202 patients with giant HH, who underwent
laparoscopic HH repair [18]. Another study found a mean
LOS of 2.45 days in patients under younger than 69 years of
age [19]. Our present study, in keeping with our previously
published data, demonstrated a median LOS of 1 day [9].
With regard to durable postoperative symptom improve-
ment, one study of patients with large HH found a mean
satisfaction score of 9.8 out of 10, at 11 years postopera-
tively [20]. The authors had a 38% follow-up rate at the time.
90% of patients in another study also reported improvement
of symptoms [18]. Likewise, the use of mesh was success-
fully utilized to significantly decrease patients’ symptom
scores through surgical intervention in our study. Notably,
like prior studies, ours was affected by a significant attri-
tion rate, with 16 of 78 patients in the BIOS group, 11 of
42 in the PTM and 66 of 161 in the HTM® groups avail-
able for LT follow-up. This made comparative statistical
analysis of long-term symptom changes challenging but as
demonstrated by Tables 2, 3, and 4, a clear trend towards
long-term esophageal symptom resolution was noted in all
mesh groups with long-term median symptom scores of 0.
Additionally, no statistically significant difference was nota-
ble between the various mesh groups in terms of durable
symptom resolution.
Our study has several limitations, including its retro-
spective nature, and the relatively limited albeit adequately
powered sample. This study evaluated outcomes of patients
who had their surgery performed by a single surgeon at a
single institution. Also, the follow-up rate after HH repairs
is expected to decrease over time, mainly due to resolution of
symptoms, decreasing the power of the long-term outcomes
analysis, as noted above. Our long-term sample size was also
a limitation to perform multivariate analysis to evaluate the
independent association of each type of mesh, such as hernia
size. Further, detailed cost data were limited, especially for
repairs performed before 2012, when our current electronic
medical record was launched. Finally, we did not directly
compare the mesh groups against a similar group of patients
undergoing primary sutured repair, although the benefits of
mesh have been discussed previously.
We did find, as evident in Table 1, that the majority of
patients undergoing reinforced repair with HTM or PTM had
large HH, whereas the use of BIOS was more uniform across
various HH sizes. This may contribute in part to the less than

13
 Surgical Endoscopy

Table 5  Esophageal symptoms improvement over time—PTM

Gastrointestinal symptoms Preop preva- Number of patients with improved symptom score compared to preoperative baseline—N
lence (N = 44) (%a), p-value
Patients N (%) Median symptom score [IQR]
Median score
[IQR] 6 months, N = 43 12 months, N = 38 Long-term, N = 28
p-value p-value p-value

Heartburn 34/44 (77%) 30/32 (94%) < .0010 27/28 (96%) < .0010 18/21 (86%) < .0001
2 [1–3] 0 [0–0] 0 [0–0] 0 [0–1]
Regurgitation 22/43 (51%) 22/22 (100%) < .0010 19/19 (100%) < .0010 14/16 (88%) .0001
1 [0–3] 0 [0–0] 0 [0–0] 0 [0–0.5]
Solid dysphagia 27/41 (66%) 25/26 (96%) < .0010 23/25 (92%) < .0010 12/15 (80%) .0010
2 [0–2] 0 [0–0] 0 [0–0] 0 [0–0]
Liquid dysphagia 17/41 (41%) 17/17 (100%) < .0001 16/17 (94%) .0010 8/10 (80%) .0078
0 [0–2] 0 [0–0] 0 [0–0] 0 [0–0]
Abdominal pain 21/42 (50%) 18/20 (90%) < .0001 19/20 (95%) < .0001 9/13 (69%) .0039
0.5 [0–2] 0 [0–0.5] 0 [0–0] 0 [0–4]
Belching 20/42 (48%) 19/20 (95%) < .0010 16/17 (86%) < .0001 11/14 (79%) .0010
0 [0–3] 0 [0–0] 0 [0–1] 0 [0–0]
Bloating 19/41 (46%) 15/17 (88%) < .0001 13/16 (81%) .0002 8/10 (80%) .0156
2 [0–2] 0 [0–1] 0 [0–1] 0 [0–0]
Nausea 20/42 (48%) 18/19 (95%) < .0010 16/18 (89%) .0003 10/11 (91%) .0020
0 [0–2] 0 [0–0] 0 [0–1] 0 [0–1]

Bold values indicate statistically significant p-values

PTM porcine tissue matrix, Preop preoperative, IQR Interquartile Range
*
Significant alpha level cut-off of 0.017 is used instead of 0.05 due to multiple comparisons
a
Percent improved calculated using denominator as number of preoperative symptomatic patients who replied survey at specific time point

Table 6  Comparison of improved symptom score vs preoperative same time, BIOS had a nearly twofold lower risk of recur-
baseline between the three mesh groups: HTM, BIOS, and PTM rence at long-term with a median LT follow-up of 4 years,
Postoperative follow-up time despite no significant difference in overall recurrence. With
cost being a major factor of healthcare delivery, it seems
Gastrointestinal symptoms 6 months 12 months Long-term
difficult to ignore similar outcomes at a fraction of the price.
p-value p-value p-value

Heartburn 0.0492 0.4822 0.2866

Regurgitation 0.9999 0.2351 0.5889
Solid dysphagia 0.4232 0.3345 0.8297 Conclusion
Liquid dysphagia 0.9999 0.4848 0.3649
Abdominal pain 0.9121 0.5348 0.0771 We found that while medium- and long-term outcomes of
Belching 0.5936 0.6328 0.0622 the three mesh groups were similar, there was a significant
Bloating 0.1957 0.0804 0.2941 difference in the mesh cost, increasing the overall opera-
Nausea 0.0682 0.3555 0.4485 tive cost as well as a difference in long-term recurrence rate
profile. BIOS was found to be the least expensive, thereby
HTM human tissue matrix, BIOS biosynthetic mesh, PTM porcine tis- providing the best cost–benefit ratio. While surgeon and hos-
sue matrix
pital preference play an important role in choosing the type
of mesh used, knowledge of the individual mesh cost and
statistically significant LT symptom outcomes noted in the outcomes will help surgeons make more informed decisions
BIOS group but is difficult to state with certainty given the in the future.
attrition rate and overall excellent symptom scores.
Symptom resolution at short, medium, and LT was found
to be similar among mesh groups in our study. What did Funding Funding for this study was provided by W. L. Gore & Associ-
ates and by the Center for Advanced Surgical Technology at the Uni-
significantly defer, however, was cost and recurrence rates. versity of Nebraska Medical Center.
BIOS was 51% of the cost of HTM and 42% of PTM. At the

13
Surgical Endoscopy
Compliance with ethical standards
Disclosures Dr. Dmitry Oleynikov and Dr. Priscila Rodrigues Armijo
declared conflict of interest directly related to the submitted work and
received a research grant support from W.L. GORE & Associates. Mr.
Tailong Xu, Dr. Crystal Krause, and Ms. Valerie Shostrom have no
conflicts of interest or financial ties to disclose.
References
1. Zehetner J, Demeester SR, Ayazi S, Kilday P, Augustin F, Hagen
JA, Lipham JC, Sohn HJ, Demeester TR (2011) Laparoscopic
versus open repair of paraesophageal hernia: the second decade.
J Am Coll Surg 212:813–820. https:​ //doi.org/10.1016/j.jamcol​ lsur​
g.2011.01.060
2. Lebenthal A, Waterford SD, Fisichella PM (2015) Treatment and
controversies in paraesophageal hernia repair. Front Surg 2:13.
https​://doi.org/10.3389/fsurg​.2015.00013​
3. Petersen LF, McChesney SL, Daly SC, Millikan KW, Myers JA,
Luu MB (2014) Permanent mesh results in long-term symptom
improvement and patient satisfaction without increasing adverse
outcomes in hiatal hernia repair. Am J Surg 207:445–448. https​
://doi.org/10.1016/j.amjsu​rg.2013.09.014
4. Jones R, Simorov A, Lomelin D, Tadaki C, Oleynikov D (2015)
Long-term outcomes of radiologic recurrence after paraesopha-
geal hernia repair with mesh. Surg Endosc 29:425–430. https​://
doi.org/10.1007/s0046​4-014-3690-8
5. Targarona EM, Bendahan G, Balague C, Garriga J, Trias M
(2004) Mesh in the hiatus: a controversial issue. Arch Surg
139:1286–1296
6. Champion JK, Rock D (2003) Laparoscopic mesh cruroplasty for
large paraesophageal hernias. Surg Endosc 17:551–553. https​://
doi.org/10.1007/s0046​4-002-8817-7
7. Lazar DJ, Birkett DH, Brams DM, Ford HA, Williamson C,
Nepomnayshy D (2017) Long-term patient-reported outcomes
of paraesophageal hernia repair. JSLS. https​://doi.org/10.4293/
JSLS.2017.00052​
8. Oelschlager BK, Pellegrini CA, Hunter J, Soper N, Brunt M,
Sheppard B, Jobe B, Polissar N, Mitsumori L, Nelson J, Swan-
strom L (2006) Biologic prosthesis reduces recurrence after
laparoscopic paraesophageal hernia repair: a multicenter, pro-
spective, randomized trial. Ann Surg 244:481–490. https​://doi.
org/10.1097/01.sla.00002​37759​.42831​.03
9. Lomelin D, Smith A, Bills N, Chiruvella A, Crawford C, Krause
C, Bayer R, Oleynikov D (2017) Long-term effectiveness of strat-
tice in the laparoscopic closure of paraesophageal hernias. Surg
Innov 24:259–263. https​://doi.org/10.1177/15533​50617​69352​0
10. Rosen MJ, Borao FJ, Binenbaum SJ, Roth JS, Gillian GK, Gould
J, Heniford BT (2019) A multi-center, prospective clinical trial of
a hepatic derived porcine surgical mesh for the laparoscopic repair
of symptomatic paraesophageal hernias. Am J Surg 218:315–322
11. Olson MT, Singhal S, Panchanathan R, Roy SB, Kang P, Ipsen T,
Mittal SK, Huang JL, Smith MA, Bremner RM (2018) Primary
paraesophageal hernia repair with Gore(R) Bio-A(R) tissue rein-
forcement: long-term outcomes and association of BMI and recur-
rence. Surg Endosc. https​://doi.org/10.1007/s0046​4-018-6200-6
12. Panici Tonucci T, Asti E, Sironi A, Ferrari D, Bonavina L (2020)
Safety and efficacy of crura augmentation with phasix ST mesh
for large hiatal hernia: 3-year single-center experience. J Lapar-
oendosc Adv Surg Tech. https​://doi.org/10.1089/lap.2019.0726
13. Korwar V, Adjepong S, Pattar J, Sigurdsson A (2019) Biologi-
cal mesh repair of paraesophageal hernia: an analysis of our out-
comes. J Laparoendosc Adv Surg Tech 29:1446–1450
14. Zhang C, Liu D, Li F, Watson DI, Gao X, Koetje JH, Luo T, Yan
C, Du X, Wang Z (2017) Systematic review and meta-analysis of
laparoscopic mesh versus suture repair of hiatus hernia: objective
and subjective outcomes. Surg Endosc 31:4913–4922. https:​ //doi.
org/10.1007/s0046​4-017-5586-x
15. Asti E, Lovece A, Bonavina L, Milito P, Sironi A, Bonitta G,
Siboni S (2016) Laparoscopic management of large hiatus her-
nia: five-year cohort study and comparison of mesh-augmented
versus standard crura repair. Surg Endosc 30:5404–5409. https​://
doi.org/10.1007/s0046​4-016-4897-7
16. Ringley CD, Bochkarev V, Ahmed SI, Vitamvas ML, Oleynikov
D (2006) Laparoscopic hiatal hernia repair with human acel-
lular dermal matrix patch: our initial experience. Am J Surg
192(6):767–772
17. Antonino A, Giorgio R, Giuseppe F, de Giovanni V, Silvia DG,
Daniela C, Giuseppe DB, Vincenzo S, Gaspare G (2014) Hiatal
hernia repair with gore bio-a tissue reinforcement: our experience.
Case Rep Surg 2014:851278. https:​ //doi.org/10.1155/2014/85127​
8
18. Antiporda M, Veenstra B, Jackson C, Kandel P, Daniel Smith
C, Bowers SP (2018) Laparoscopic repair of giant paraesopha-
geal hernia: are there factors associated with anatomic recur-
rence? Surg Endosc 32:945–954. https​://doi.org/10.1007/s0046​
4-017-5770-z
19. Parker DM, Rambhajan AA, Horsley RD, Johanson K, Gabrielsen
JD, Petrick AT (2017) Laparoscopic paraesophageal hernia repair
is safe in elderly patients. Surg Endosc 31:1186–1191. https:​ //doi.
org/10.1007/s0046​4-016-5089-1
20. Blake AM, Mittal SK (2018) Long-term clinical outcomes after
intrathoracic stomach surgery: a decade of longitudinal follow-
up. Surg Endosc 32:1954–1962. https​://doi.org/10.1007/s0046​
4-017-5890-5
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
13