Association between mesh reinforcement and postoperative gastroparesis following paraesophageal and hiatal hernia repair: a propensity-matched analysis

Abstract Background Mesh reinforcement during hiatal hernia repair, including paraesophageal hernia repair, remains controversial because of uncertain long-term durability benefits and concerns regarding mesh-related complications. Its association with postoperative gastric dysmotility remains poorly defined. We evaluated the association between mesh reinforcement and new-onset gastroparesis following hiatal hernia repair. Methods Adults undergoing repair of a hiatal hernia between 2013 and 2023 were identified from a multi-institutional U.S. database and stratified by mesh utilization. Patients with preexisting gastroparesis or prior prokinetic medication use were excluded. The primary outcome was new-onset gastroparesis diagnosed between 1 month and 1 year postoperatively. Secondary outcomes included initiation of prokinetic medications, gastroparesis-related symptoms, and subsequent interventions for gastric dysmotility. Propensity score matching was performed to balance demographic and clinical characteristics. Prespecified subgroup analyses evaluated obesity, diabetes, and revisional repair. Results A total of 29,923 patients were identified, of whom 10,010 (33.5%) underwent mesh-reinforced repair. After propensity matching, mesh reinforcement was associated with a higher incidence of postoperative gastroparesis compared with non-mesh repair (2.04% vs 1.51%; OR 1.36, p = 0.011). The association was more pronounced in patients with obesity, including those with BMI > 30 (2.52% vs 1.53%; OR 1.68, p = 0.013), with the strongest effect observed in patients with BMI > 35 (2.64% vs 0.84%; OR 3.24, p < 0.001). Rates of postoperative prokinetic use, gastroparesis-related symptoms, and subsequent interventions for gastric dysmotility were similar between groups. Among patients undergoing mesh-reinforced repair, revisional operations were associated with higher rates of postoperative gastroparesis than primary repairs after matching (4.32% vs 1.93%; OR 2.31, p = 0.004). Conclusion Mesh reinforcement during hiatal hernia repair was associated with a modest increase in the risk of postoperative gastroparesis, although the absolute risk remained low and there were no corresponding differences in symptom burden. The association was most pronounced among patients with severe obesity, while revisional mesh-reinforced repairs had the highest incidence of postoperative gastroparesis. These findings suggest that patient susceptibility and operative complexity may contribute to postoperative gastric dysmotility in addition to mesh utilization.