BIO-A versus Phasix biosynthetic mesh in minimally invasive hiatal hernia repair: systematic review and meta-analysis

Although surgical repair is the standard treatment for symptomatic large hiatal hernias, recurrence rates remain high. Biosynthetic meshes have been designed to reinforce the crural closure while minimizing mesh-related complications. The aim of this study was to compare surgical outcomes between two widely adopted biosynthetic prostheses for hiatal hernia repair (BIO-A and Phasix).

A systematic review of literature from January 1990 to July 2025 was conducted according to PRISMA guidelines. Studies reporting outcomes of minimally invasive hiatal hernia repair (HHR) with either BIO-A or Phasix were included. Main outcomes were symptom improvement, GERD-HRQL scores, proton pump inhibitor (PPI) use, and hernia recurrence. Secondary outcomes included mesh-related complications, overall and major morbidity, reoperation, and mortality. A meta-analysis of proportions and paired t-tests were performed.

A total of 20 studies comprising 1,880 HHR procedures (BIO-A: n = 1,171 versus Phasix: n = 709) were analyzed. Mean follow-up was 26.5 and 29.6 months for BIO-A and Phasix studies, respectively. Both groups significantly improved symptoms (BIO-A: 65% to 16%, p = 0.003 vs. Phasix: 70% to 12%, p = 0.01), GERD-HRQL scores (BIO-A: 14.83 to 2.67 vs. Phasix: 18.40 to 4.40; p = 0.45), and reduced PPI use (BIO-A: 82% to 15% vs. Phasix: 84% to 10%; p = 0.75). Recurrence rates were similar between groups (BIO-A 9% vs. Phasix 7%, p = 0.63). Overall and major morbidity were also similar between groups (BIO-A: 10% and 0.7% vs. Phasix: 8% and 1.1%, respectively).

Both prostheses were associated with favorable GERD-related outcomes, low surgical morbidity, and low recurrence rates after HHR. However, these findings should be interpreted cautiously, as between-group comparisons are exploratory and based on indirect evidence.