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

Published:December 11, 2022DOI:



      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.


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


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


      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.


      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.


      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.


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        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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