Background
Treatment options for hiatal hernias include repair with or without mesh. However, hernia repairs can have high recurrence rates and mesh-related complications. We compared Phasix™ ST mesh to biological mesh and primary repair to assess recurrence rates and mesh-related complications.

Methods
PubMed was searched from 2011 to 2023 using terms hiatal hernia, mesh, and cruroplasty. Randomized controlled trials, non-randomized controlled trials, prospective, retrospective studies, and observational studies were included. Two authors screened studies based on endpoints focusing on patients who underwent hiatal hernia repair with biological mesh, bioabsorbable mesh (Phasix™ ST mesh), or primary repair cruroplasty. They analyzed recurrence rates, reoperation rates and mesh-related complications with patient subgroups based on BMI and follow-up time. Mantel-Haenszel random-effects model was used to pool recurrence and reoperation data, reporting odds ratios (OR) and 95% confidence intervals (95% CI). Heterogeneity was assessed using I² statistics. For single-arm meta-analysis, proportions were transformed to a suitable quantity for synthesis, and the pooled proportion was calculated using the random-effects model with 95% CIs. p-value < 0.05 was considered significant.

Results
Nine studies were included with 700 patients who received different types of mesh (211 Phasix™, 375 biological, 114 cruroplasty). Two-arm meta-analysis with three studies comparing biological mesh and cruroplasty found no significant difference in recurrence (OR 0.50, 95% CI 0.21-1.19) or reoperation rates (OR 0.35, 95% CI 0.05-2.37).

Single-arm meta-analysis was conducted for each mesh type, showing that Phasix™ ST had the lowest recurrence rate (ES 0.05, 95% CI 0.01-0.10), followed by biological mesh (ES 0.16, 95% CI 0.05-0.32), and cruroplasty (ES 0.28, 95% CI 0.09-0.51). No reoperations were reported with Phasix™ ST. Both biological mesh and cruroplasty had similar reoperation rates, with an ES of 0.06 (95% CI 0.01-0.12) and 0.06 (95% CI 0.01-0.13), respectively.

Patients with BMI > 30 in the cruroplasty group had a higher recurrence rate of 51% (95% CI 0.35-0.68) compared to 17% (95% CI 0.09-0.27) in BMI of 25-29 (p=0.000). Increased follow-up time was associated with higher recurrence rates in the biological and cruroplasty groups (p=0.000 vs. 0.001, respectively). During the 24 to 30-month follow-up period, the lowest recurrence rate was observed in the Phasix mesh group at 9% (95% CI 0.03-0.18), compared to 18% (95% CI 0.08-0.31) in the biological mesh group and 19% (95% CI 0.08-0.33) in the cruroplasty group.

Conclusion
Phasix™ ST showed the lowest recurrence and reoperation rates compared to biologic mesh or cruroplasty alone in our study. Further long-term studies are needed to validate these findings.

Emily Coughlin

Appearances