Müller-Stich Beat P, Kenngott Hannes G, Gondan Matthias, Stock Christian, Linke Georg R, Fritz Franziska, Nickel Felix, Diener Markus K, Gutt Carsten N, Wente Moritz, Büchler Markus W, Fischer Lars
Department of General, Visceral and Transplant Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
Department of Psychology, University of Copenhagen, Øster Farimagsgade 2A, 1315, København K, Denmark.
PLoS One. 2015 Oct 15;10(10):e0139547. doi: 10.1371/journal.pone.0139547. eCollection 2015.
Mesh augmentation seems to reduce recurrences following laparoscopic paraesophageal hernia repair (LPHR). However, there is an uncertain risk of mesh-associated complications. Risk-benefit analysis might solve the dilemma.
A systematic literature search was performed to identify randomized controlled trials (RCTs) and observational clinical studies (OCSs) comparing laparoscopic mesh-augmented hiatoplasty (LMAH) with laparoscopic mesh-free hiatoplasty (LH) with regard to recurrences and complications. Random effects meta-analyses were performed to determine potential benefits of LMAH. All data regarding LMAH were used to estimate risk of mesh-associated complications. Risk-benefit analysis was performed using a Markov Monte Carlo decision-analytic model.
Meta-analysis of 3 RCTs and 9 OCSs including 915 patients revealed a significantly lower recurrence rate for LMAH compared to LH (pooled proportions, 12.1% vs. 20.5%; odds ratio (OR), 0.55; 95% confidence interval (CI), 0.34 to 0.89; p = 0.04). Complication rates were comparable in both groups (pooled proportions, 15.3% vs. 14.2%; OR, 1.02; 95% CI, 0.63 to 1.65; p = 0.94). The systematic review of LMAH data yielded a mesh-associated complication rate of 1.9% (41/2121; 95% CI, 1.3% to 2.5%) for those series reporting at least one mesh-associated complication. The Markov Monte Carlo decision-analytic model revealed a procedure-related mortality rate of 1.6% for LMAH and 1.8% for LH.
Mesh application should be considered for LPHR because it reduces recurrences at least in the mid-term. Overall procedure-related complications and mortality seem to not be increased despite of potential mesh-associated complications.
在腹腔镜食管旁疝修补术（LPHR）后，使用补片加强似乎可降低复发率。然而，补片相关并发症的风险尚不确定。风险效益分析或许能解决这一困境。
进行系统的文献检索，以确定比较腹腔镜补片加强裂孔成形术（LMAH）与腹腔镜无补片裂孔成形术（LH）在复发率和并发症方面的随机对照试验（RCT）和观察性临床研究（OCS）。采用随机效应荟萃分析来确定LMAH的潜在益处。使用所有关于LMAH的数据来估计补片相关并发症的风险。采用马尔可夫蒙特卡罗决策分析模型进行风险效益分析。
对3项RCT和9项OCS（共915例患者）的荟萃分析显示，与LH相比，LMAH的复发率显著更低（合并比例，12.1%对20.5%；比值比（OR），0.55；95%置信区间（CI），0.34至0.89；p = 0.04）。两组的并发症发生率相当（合并比例，15.3%对14.2%；OR，1.02；95% CI，0.63至1.65；p = 0.94）。对LMAH数据的系统评价显示，在那些报告至少1例补片相关并发症的系列研究中，补片相关并发症发生率为1.9%（41/2121；95% CI，1.3%至2.5%）。马尔可夫蒙特卡罗决策分析模型显示，LMAH的手术相关死亡率为1.6%，LH为1.8%。
LPHR应考虑使用补片，因为至少在中期它能降低复发率。尽管存在潜在的补片相关并发症，但总体手术相关并发症和死亡率似乎并未增加。
