In particular, hernia recurrence is the Achilles’ heel of PEH repair, for which objective rates in excess of 50% at 5 years have been reported.1 and 2 Mesh reinforcement of the crural closure has been advocated in an effort to reduce hernia recurrence. Although synthetic mesh has been shown to be beneficial, the risk of mesh erosion into the esophagus has kept many esophageal surgeons from adopting synthetic mesh for routine use at the hiatus. Absorbable or biologic mesh at the hiatus would be less likely to

erode, but long-term follow-up of a randomized multicenter trial of PEH repair using Surgisis mesh (Surgisis, Cook Biotech Inc) found no reduction in hernia recurrence compared with primary crural closure without mesh.2 Following the results of this trial we abandoned Surgisis and used a new biologic mesh (AlloMax Surgical Graft, Davol Inc) for Ruxolitinib solubility dmso crural reinforcement during antireflux surgery or

PEH repair. AlloMax graft is a sterile, non–cross-linked human collagen matrix that supports cellular ingrowth and revascularization. We also were concerned that hernia recurrence may be related to underappreciated tension on the crural closure or a foreshortened esophagus. Therefore we adopted adjunct techniques including crural relaxing incisions and the wedge-fundectomy Collis gastroplasty to address tension when encountered intraoperatively. The aim of this study was to evaluate our results with the use of AlloMax graft reinforcement of the primary crural closure along with adjunct techniques to reduce tension when necessary in patients undergoing antireflux surgery or PEH repair. A retrospective chart review was performed to identify all patients Nutlin-3a ic50 who had an AlloMax graft placed at the hiatus during repair of a sliding or paraesophageal hiatal hernia. The first use of this mesh at our center was in January 2011, and we included all patients who had their operation before January 22, 2013 in this study. Preoperative evaluation included upper endoscopy, videoesophagram, high resolution esophageal motility, and, when indicated, esophageal selleckchem pH monitoring. Paraesophageal hernias

were defined as the presence of at least 50% of the stomach in the chest, with the gastric fundus located above the gastroesophageal junction. Postoperative follow-up was scheduled at 3 months and annually in all patients and included physical examination and videoesophagram. Upper endoscopy was performed selectively to evaluate patients with symptoms or an abnormal videoesophagram, after Collis gastroplasty to rule out esophagitis related to acid production by the gastric tube above the fundoplication, and for surveillance in patients with Barrett’s esophagus. Recurrence was defined as any size hernia seen on videoesophagram or on upper endoscopy. This study was approved by the IRB of the University of Southern California. The surgical technique was similar in all patients and has been previously described.