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Treating Hiatal hernias

Treating Hiatal hernia in bariatric and metabolic surgery candidates

Image - GORE® BIO-A® Tissue Reinforcement
Closure of the mesenteric defects is mandatory at his centre in order to avoid the most important long-term complications after bypass procedures, namely internal hernia
The GORE® BIO-A® Tissue Reinforcement is a unique biosynthetic web scaffold made of 67% polyglycolic acid (PGA) and 33% trimethylene carbonate (TMC) designed for soft tissue reinforcement procedures

Obesity is a known independent risk factor for the development of Hiatal hernia (HH) and symptomatic HH occurs in about 15-20% of patients who are candidates to bariatric and metabolic surgery, with or without reflux symptoms. Bariatric News talked to Professor Gianfranco Silecchia, Professor of Surgery at Sapienza University of Rome, Rome Italy, about the causes of HH, treatment strategies and outcomes.

“The timing of diagnosis of hiatal defect in bariatric patients is very important: it should be examined pre-operatively during the work up and treated intra-operatively,” explained Professor Silecchia. “However, more than 40% of the hiatal hernia/hiatal defect in my practise, confirmed by the literature data, are diagnosed during bariatric surgery, so the exploration of the hiatal area is a crucial step to avoid missing hernias, which can cause postoperative reflux or other upper gastro-intestinal symptoms.” (1)

Professor Gianfranco Silecchia

According to Professor Silecchia, the causes of the hiatus defects are multiple and is the consequence of a very complex interaction of high intrabdominal pressure, a weakness of the pillars, an anatomical distortion of the hiatal surface area due to obesity, as well as changes in the connective tissue related to the obesity. He added that the closure of the mesenteric defects is mandatory at his centre in order to avoid the most important long-term complications after bypass procedures, namely internal hernia. “This is a very important step supported by the wider literature evidence and it is part of the procedure, not just an ‘option’ based on the surgeon’s feeling or opinion.”

With regard to laparoscopic sleeve gastrectomy, Professor Silecchia noted that size of the hiatal hernia per se is not the single driver to offer sleeve and concomitant hiatoplasty and said the following points should be considered in the decision-making process:

  • GERD symptoms
  • Severity of the symptoms
  • PPI treatment
  •  Upper GI endoscopy findings (severity of oesophagitis)
  • Barrett oesophagus
  • Primary sleeve or revisional sleeve
  • Type of hiatal hernia

In his own practice, Professor Silecchia offers his patients a sleeve gastrectomy with concomitant HH repair up to 8cm2 HH Surface evaluated by a pre-operative by computed tomography (CT) scan or intraoperative measurement (2, 3), when:

  • There is a sliding hernia (type 1)
  • There is no severe esophagitis (only Los Angels A grade)
  • It is a primary sleeve procedure
  • There is no long term of PPI treatment; and
  • There is no severe reflux at pHmetry

Mesh material

With several different types of mesh material on the market for HH repair, he explained that there are several papers in the literature, including his own research, which strongly support the use of mesh to reinforce the posterior cruroplasty in the obese population to prevent/reduce the recurrence rate (1, 4). He added that during the last few years the use of a synthetic permanent mesh has been abandoned due to the disappointing results related to the permanent presence of non-absorbable material on the hiatus near the oesophagus.

“More recently, bioabsorbable biologic and synthetic meshes have been proposed as alternative to maintaining the concept of ‘reinforcement’,” added Professor Silecchia. “However, in my opinion, the biologic meshes are too expensive, difficult to handle and there is no evidence to support their long-term effectiveness. I believe the synthetic bioabsorbable mesh is very promising with a high safety profile with no concerns over complications related to the presence of the material on the hiatus, which is completely absorbed within one year. There is only one brand of mesh with a devoted shape facilitating the onlay positioning on the hiatus after posterior or anterior cruroplasty - the GORE® BIO-A® Tissue Reinforcement.”

The GORE® BIO-A® Tissue Reinforcement is a unique biosynthetic web scaffold made of 67% polyglycolic acid (PGA) and 33% trimethylene carbonate (TMC) designed for soft tissue reinforcement procedures. It is a uniquely designed web of biocompatible synthetic polymers that is gradually absorbed by the body and as a biosynthetic tissue-building scaffold - not derived from human or animal tissue but engineered for uniformity, consistency, and versatility - it is an alternative to biologics products. The material is absorbed within six to seven months, facilitating rapid cellular infiltration and vascularisation, leaving no permanent material behind in the body at one year.“

"In more than 120 consecutive cases, we have not observed any major complications related to the mesh in normal weight patients who underwent hiatal hernia repair plus 360° fundoplication or in obese candidates who underwent any bariatric procedure plus concomitant hiatal hernia repair.”

“I have been using the GORE® BIO-A® Tissue Reinforcement for the reinforcement of posterior cruroplasty in normal weight, as well obese patients covering all the hiatal surface area for five years. The product shape is fantastic for the onlay position, it can be rolled like a cigarette and introduced through a 10mmm trocar and fixed with non-absorbable tool, such as a fibrin glue. In my opinion, there are no other comparable mesh products in the market at the moment in terms of size, shape, easy handling, simple fixation with non-absorbable material, and importantly, long-term effectiveness.” (2)

For example, in his practice of using the GORE® BIO-A® Tissue Reinforcement, Professor Silecchia has not experienced a single intra-operative or peri-operative complication related to the product. Moreover, he has had no long-term complications such as oesophagus stenosis, dysphagia, anatomical distortion of the hiatal surface area, leak etc, and the product is completely absorbed within one-year.

“In more than 120 consecutive cases, we have not observed any major complications related to the mesh in normal weight patients who underwent hiatal hernia repair plus 360° fundoplication or in obese candidates who underwent any bariatric procedure plus concomitant hiatal hernia repair,” he added. “We have submitted our five-year follow up data to a top-ranking journal and the results confirm the high safety profile of the GORE® BIO-A® Tissue Reinforcement at five years.”

Professor Silecchia noted that his HH technique has changed and has become more refined as his experience with GORE® BIO-A® Tissue Reinforcement has grown over the years. Again, he emphasised the importance of a pre-operative evaluation and measurement by means of CT scan of the Hiatus defect, so the surgeon can discuss the procedure with the patient and plan the correct technique for the HH repair.

“Furthermore, intra-operative measurements of the hiatal surface area (HSA) and careful evaluation of the weakness of the pillars, abdominalisation of the distal oesophagus of at least 4-5cm, use of synthetic non-absorbable stitches to obtain an effective posterior cruroplasty, calibration of the cruroplasty by means of an orogastric bougie 40-42Fr, onlay position of the GORE® BIO-A® Tissue Reinforcement covering all the HAS, are all key operative components in achieving a successful outcome,” he stressed.

“I can remember at least three cases when the GORE® BIO-A® Tissue Reinforcement was extremely useful with unexpected long-term results. For example, one case involved a sleeve migration after three years with symptomatic reflux, no severe esophagitis or no dysphagia. The young women refused my recommendation to convert the sleeve to a bypass and asked me to perform a ‘restoration of the sleeve’ and repair the defect. The patient was enrolled in a prospective study, in co-operation with our radiologist, to evaluate the size of the reinforced HSA by CT scan at three years. At two years, she is fine and symptom free, despite my opinion before surgery.”

“The concept of reinforcement should be considered in our everyday practise. The mesh is not a substitute for a proper oesophageal technique with well-established steps. However, the mesh is a valuable and safe support to ameliorate our clinical results in selected cases to reduce the recurrence rate,” concluded Professor Silecchia. “The GORE® BIO-A® Tissue Reinforcement is a synthetic, absorbable material regularly used in open and laparoscopic surgery with a large number of studies reporting the safety profile of the material in open, as well in laparoscopic surgery. At the moment, in my opinion, there is no competitor.”

References

  1. Ruscio, S., Abdelgawad, M., Badiali, D., Iorio, O., Rizzello, M., Cavallaro, G., Severi, C., Silecchia, G.Simple versus reinforced cruroplasty in patients submitted to concomitant laparoscopic sleeve gastrectomy: prospective evaluation in a bariatric center of excellence. (2016) Surgical Endoscopy and Other Interventional Techniques, 30 (6), pp. 2374-2381.. DOI: 10.1007/s00464-015-4487-0 SOURCE: Scopus
  2. Silecchia, G., Iossa, A., Cavallaro, G., Rizzello, M., Longo, F. Reinforcement of hiatal defect repair with absorbable mesh fixed with non-permanent devices (2014) Minimally Invasive Therapy and Allied Technologies, 23 (5), pp. 302-308. DOI: 10.3109/13645706.2014.909853 SOURCE: Scopus
  3. Rengo, M., Bellini, D., Iorio, O., De Cecco, C.N., Rizzello, M., Cavallaro, G., Carabotti, M., Laghi, A., Silecchia, G. :Role of preoperative imaging with multidetector computed tomography in the management of patients with gastroesophageal reflux disease symptoms after laparoscopic sleeve gastrectomy (2013) Obesity Surgery, 23 (12), pp. 1981-1986. (Cite https://www.scopus.com/inward/record.uri?eid=2-s2.0-84889089671&partnerI...)
  4. Soricelli E, Casella G, Rizzello M, et al. Initial experience with laparoscopic crural closure in the management of hiatal hernia in obese patients undergoing sleeve gastrectomy. Obes Surg. 2010;20(8):1149–1153

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