Laparoscopic Nissen fundoplication with prosthetic hiatal closure reduces postoperative intrathoracic wrap herniation - Preliminary results of a prospective randomized functional and clinical study

Background: Postoperative intrathoracic wrap migration is the most frequent morphological complication after laparoscopic antireflux surgery. Previous authors have studied the use of prosthetic materials for hiatal closure to prevent recurrence of hiatal hernia and/or postoperative intrathoracic wrap herniation. Hypothesis: Patients with prosthetic hiatal closure have a higher rate of short-term dysphagia but a significantly lower rate of postoperative intrathoracic wrap herniation at follow-up. Design: Prospective randomized trial. We compared patients who under-went laparoscopic Nissen fundoplication with simple sutured hiatoplasty with those who underwent laparoscopic Nissen fundoplication with prosthetic hiatal closure. Setting: Universtity-affiliated community hospital. Patients: One hundred consecutive patients undergoing laparoscopic Nissen fundoplication for gastroesophageal reflux disease and hiatal hernia repair. Intervention: Laparoscopic Nissen fundoplication with simple sutured crural closure (n=50 [group 1]) vs laparoscopic Nissen fundoplication with simple sutured cruroplasty and onlay of a polypropylene mesh (n=50 [group 2]). Main Outcome Measures: Recurrences; complications; results of esophageal manometry, 24-hour pH monitoring, esophagogastroduodenoscopy, and barium swallow test; and symptomatic outcome. Results: Patients in both groups had similar preoperative values in esophageal manometry, 24-hour pH monitoring, and symptom scoring. At the 3-month and 1-year follow-ups, functional outcome variables (lower esophageal sphincter pressure and DeMeester score) improved significantly compared with the preoperative values. A higher postoperative dysphagia rate could be evaluated in group 2. An intrathoracic wrap migration occurred in 13 patients (26%) in group 1 vs 4 (8%) in group 2 (P<.001). Conclusion: Laparoscopic Nissen fundoplication with prosthetic cruroplasty is an effective procedure to reduce the incidence of postoperative hiatal hernia recurrence and intrathoracic wrap herniation.