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Impact of concurrent hiatal hernia repair during laparoscopic sleeve gastrectomy on patient-reported gastroesophageal reflux symptoms: a state-wide analysis

Published:December 11, 2022DOI:https://doi.org/10.1016/j.soard.2022.12.021

      Abstract

      Background

      Concurrent hiatal hernia repair (HHR) during laparoscopic sleeve gastrectomy (LSG) may improve gastroesophageal reflux disease (GERD) symptoms. However, patient-reported outcomes are limited, and the influence of surgeon technique remains unclear.

      Objectives

      To assess patient-reported GERD severity before and after LSG with and without concomitant HHR.

      Setting

      Teaching and non-teaching hospitals participating in a state-wide quality improvement collaborative.

      Methods

      Using a state-wide bariatric-specific data registry, all patients who underwent a primary LSG between 2015 and 2019 who completed a baseline and 1 year validated GERD health related quality of life (GERD-HRQL) survey were identified (n = 11,742). GERD severity at 1 year as well as 30-day risk-adjusted adverse events was compared between patients who underwent LSG with or without HHR. Results were also stratified by anterior versus posterior HHR.

      Results

      A total of 4015 patients underwent a LSG-HHR (34%). Compared to patients who underwent LSG without HHR, LSG-HHR patients were older (47.8 yr versus 44.6 yr; P < .0001), had a lower preoperative body mass index (BMI) (45.8 kg/m2 versus 48 kg/m2; P < .0001) and more likely to be female (85.2% versus 77.6%, P < .0001). Patients who underwent a posterior HHR (n = 3205) experienced higher rates of symptom improvement (69.5% versus 64.0%, P = .0014) and lower rates of new onset symptoms at 1 year (28.2% versus 30.2%, P = .0500). Patients who underwent an anterior HHR (n = 496) experienced higher rates of hemorrhage and readmissions with no significant difference in symptom improvement.

      Conclusions

      Concurrent posterior hiatal HHR at the time of sleeve gastrectomy can improve reflux symptoms. Patients undergoing anterior repair derive no benefit and should be avoided.

      Keywords

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      References

        • Ng A.C.T.
        • Delgado V.
        • Borlaug B.A.
        • Bax J.J.
        Diabesity: the combined burden of obesity and diabetes on heart disease and the role of imaging.
        Nat Rev Cardiol. 2021; 18: 291-304
        • Lallemand L.
        • Duchalais E.
        • Musquer N.
        • et al.
        Does sleeve gastrectomy increase the risk of barret's esophagus?.
        Obes Surg. 2021; 31: 101-110
        • Palermo M.
        • Nedelcu M.
        Complications in bariatric surgery.
        J Laparoendosc Adv Surg Tech A. 2021; 31: 139-140
        • Znamirowski P.
        • Bryk P.
        • Lewitowicz P.
        • Kozieł D.
        • Głuszek S.
        GERD-A burning problem after sleeve gastrectomy?.
        Int J Environ Res Public Health. 2021; 18: 10829
        • Kraljević M.
        • Cordasco V.
        • Schneider R.
        • et al.
        Long-term effects of laparoscopic sleeve gastrectomy: what are the results beyond 10 Years?.
        Obes Surg. 2021; 31: 3427-3433
        • Davrieux C.F.
        • Palermo M.
        • Nedelcu M.
        • Nocca D.
        Reflux after sleeve gastrectomy: an update.
        J Laparoendosc Adv Surg Tech A. 2021; 31: 978-982
        • Aleman R.
        • Lo Menzo E.
        • Szomstein S.
        • Rosenthal R.J.
        De novo gastroesophageal reflux disease esophageal surgery in bariatrics: a literature review and analysis of the current treatment options.
        Ann Transl Med. 2021; 9: 899
        • Wilson L.J.
        • Ma W.
        • Hirschowitz B.I.
        Association of obesity with hiatal hernia and esophagitis.
        Am J Gastroenterol. 1999; 94: 2840-2844
        • Soricelli E.
        • Iossa A.
        • Casella G.
        • Abbatini F.
        • Calì B.
        • Basso N.
        Sleeve gastrectomy and crural repair in obese patients with gastroesophageal reflux disease and/or hiatal hernia.
        Surg Obes Relat Dis. 2013; 9: 356-361
        • Kindel T.L.
        • Oleynikov D.
        The improvement of gastroesophageal reflux disease and barrett's after bariatric surgery.
        Obes Surg. 2016; 26: 718-720
        • Varban O.A.
        • Niemann A.
        • Stricklen A.
        • et al.
        Far from standardized: using surgical videos to identify variation in technique for laparoscopic sleeve gastrectomy.
        J Laparoendosc Adv Surg Tech A. 2017; 27: 761-767
        • Ehlers A.P.
        • Thumma J.R.
        • Finks J.F.
        • Carlin A.M.
        • Ghaferi A.A.
        • Varban O.A.
        Evaluation of patient reported gastroesophageal reflux severity at baseline and at one-year after bariatric surgery.
        Ann Surg. 2020; 275: 1143-1148
        • Velanovich V.
        The development of the GERD-HRQL symptom severity instrument.
        Dis Esophagus. 2007; 20: 130-134
        • Chang P.C.
        • Chen K.H.
        • Jhou H.J.
        • et al.
        Promising effects of 33 to 36 Fr. bougie calibration for laparoscopic sleeve gastrectomy: a systematic review and network meta-analysis.
        Sci Rep. 2021; 11: 15217
        • Savas N.
        • Dagli U.
        • Sahin B.
        The effect of hiatal hernia on gastroesophageal reflux disease and influence on proximal and distal esophageal reflux.
        Dig Dis Sci. 2015; 53: 2380-2386
        • Kahrilas P.J.
        • Kim H.C.
        • Pandolfino J.E.
        Approaches to the diagnosis and grading of hiatal hernia.
        Best Pract Res Clin Gastroenterol. 2015; 22: 601-616
        • Dakour Aridi H.
        • Asali M.
        • Fouani T.
        • Alami R.S.
        • Safadi B.Y.
        Gastroesophageal reflux disease after laparoscopic sleeve gastrectomy with concomitant hiatal hernia repair: an unresolved question.
        Obes Surg. 2017; 27: 2898-2904
        • Rawlins L.
        • Rawlins M.P.
        • Brown C.C.
        • Schumacher D.L.
        Sleeve gastrectomy: 5-year outcomes of a single institution.
        Surg Obes Relat Dis. 2013; 9: 21-25
        • Samakar K.
        • McKenzie T.J.
        • Tavakkoli A.
        • Vernon A.H.
        • Robinson M.K.
        • Shikora S.A.
        The effect of laparoscopic sleeve gastrectomy with concomitant hiatal hernia repair on gastroesophageal reflux disease in the morbidly obese.
        Obes Surg. 2016; 26: 61-66
        • Dakour Aridi H.N.
        • Tamim H.
        • Mailhac A.
        • Safadi B.Y.
        Concomitant hiatal hernia repair with laparoscopic sleeve gastrectomy is safe: analysis of the ACS-NSQIP database.
        Surg Obes Relat Dis. 2017; 13: 379-384
        • Ehlers A.P.
        • Chhabra K.
        • Thumma J.R.
        • Dimick J.B.
        • Varban O.
        In the eye of the beholder: surgeon variation in intra-operative perceptions of hiatal hernia and reflux outcomes after sleeve gastrectomy.
        Surg Endosc. 2021; 35: 2537-2542
        • Felinska E.
        • Billeter A.
        • Nickel F.
        • et al.
        Do we understand the pathophysiology of GERD after sleeve gastrectomy?.
        Ann N Y Acad Sci. 2020; 1482: 26-35
        • Keidar A.
        • Appelbaum L.
        • Schweiger C.
        • Elazary R.
        • Baltasar A.
        Dilated upper sleeve can be associated with severe postoperative gastroesophageal dysmotility and reflux.
        Obes Surg. 2010; 20: 140-147
        • King K.
        • Sudan R.
        • Bardaro S.
        • et al.
        Assessment and management of gastroesophageal reflux disease following bariatric surgery.
        Surg Obes Relat Dis. 2021; 17: 1919-1925

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      • Comment on: Impact of concurrent hiatal hernia repair during laparoscopic sleeve gastrectomy on patient-reported gastroesophageal reflux symptoms
        Surgery for Obesity and Related Diseases
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          As laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric surgery in the US, much attention has been on better understanding the technical conduct of the operation and patient selection. Since its widespread adoption, changes in technique have focused on important aspects of sleeve construction, including proximity to the antrum, luminal diameter, attention to fundus resection, staple heights, and staple-line reinforcement, among other considerations. One particular area of the operation that still remains under active investigation is the identification of, and repair of, hiatal hernia at the time of the operation.
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