• Muhammed Ashraf Memon, Breda Memon, Rossita Mohamad Yunus, and Shahjahan Khan.
• *South East Queensland Surgery (SEQS) and Sunnybank Obesity Centre, Sunnybank, Queensland, Australia †Mayne Medical School, School of Medicine, University of Queensland, Brisbane, Queensland, Australia ‡Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia §Faculty of Health and Social Science, Bolton University, Bolton, Lancashire, UK ¶Institute of Mathematical Sciences, University of Malaya, Kuala Lumpur, Malaysia ||School of Agricultural, Computing and Environmental Sciences, International Centre for Applied Climate Sciences and Centre for Health Sciences Research, University of Southern Queensland, Toowoomba, Queensland, Australia.
• Ann. Surg. 2016 Feb 1; 263 (2): 258-66.

ObjectiveThe aim was to conduct a meta-analysis of randomized controlled trials (RCTs) comparing 2 methods of hiatal closure for large hiatal hernia and to evaluate their strengths and flaws.MethodsProspective RCTs comparing suture cruroplasty versus prosthetic hiatal herniorrhaphy for large hiatal hernia were selected by searching PubMed, Medline, Embase, Science Citation Index, Current Contents, and the Cochrane Central Register of Controlled Trials published between January 1991 and October 2014. The outcome variables analyzed included operating time, complications, recurrence of hiatal hernia or wrap migration, and reoperation. These outcomes were unanimously decided to be important because they influence the practical approach toward patient management. Random effects model was used to calculate the effect size of both dichotomous and continuous data. Heterogeneity among the outcome variables of these trials was determined by the Cochran's Q statistic and I index. The meta-analysis was prepared in accordance with Preferred Reporting of Systematic Reviews and Meta-Analyses guidelines.ResultsFour RCTs were analyzed totaling 406 patients (Suture = 186, Prosthesis = 220). For only 1 of the 4 outcomes, ie, reoperation rate (OR 3.73, 95% CI 1.18, 11.82, P = 0.03), the pooled effect size favored prosthetic hiatal herniorrhaphy over suture cruroplasty. For other outcomes, comparable effect sizes were noted for both groups which included recurrence of hiatal hernia or wrap migration (OR 2.01, 95% CI 0.92, 4.39, P = 0.07), operating time (SMD -0.46, 95% CI -1.16, -0.24, P = 0.19) and complication rates (OR 1.06, 95% CI 0.45, 2.50, P = 0.90).ConclusionsOn the basis of our meta-analysis and its limitations, we believe that the prosthetic hiatal herniorrhaphy and suture cruroplasty produces comparable results for repair of large hiatal hernias. In the future, a number of issues need to be addressed to determine the clinical outcomes, safety, and effectiveness of these 2 methods for elective surgical treatment of large hiatal hernias. Presently, the use of prosthetic hiatal herniorrhaphy for large hiatal hernia cannot be endorsed routinely and the decision for the placement of mesh needs to be individualized based on the operative findings and the surgeon's recommendation.

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