Comparison of upper gastrointestinal series and symptom questionnaires with intraoperative diagnosis of hiatal hernia during sleeve gastrectomy

Published:January 09, 2023DOI:


      • Hiatal hernias are highly prevalent in sleeve gastrectomy patients.
      • Low sensitivity of UGI, GerdQ, and BEDQ limit the utility of these tests for preoperative hiatal hernia diagnosis.



      Hiatal hernias are common in bariatric surgery patients; however, the utility of preoperative hiatal hernia diagnosis prior to sleeve gastrectomy (SG) is debated.


      This study compares preoperative and intraoperative hiatal hernia detection rates in patients undergoing laparoscopic SG.


      University Hospital, United States


      As part of a randomized trial evaluating the role of routine crural inspection during SG, an initial cohort was prospectively studied to assess the correlation between preoperative upper gastrointestinal series (UGI), reflux and dysphagia symptoms, and intraoperative hiatal hernia diagnosis. Preoperatively, patients completed the Gastroesophageal Reflux Disease Questionnaire (GerdQ), Brief Esophageal Dysphagia Questionnaire (BEDQ), and UGI. Intraoperatively, patients with an anteriorly visible defect underwent hiatal hernia repair followed by SG. All others were randomized to standalone SG or posterior crural inspection with repair of any hiatal hernia identified prior to SG.


      Between November 2019 and June 2020, 100 patients (72 female) were enrolled. Preoperative UGI identified hiatal hernia in 28% (26/93) of patients. Intraoperatively, hiatal hernia was diagnosed during initial inspection in 35 patients. Diagnosis was associated with older age, lower body mass index, and Black race, but did not correlate with GerdQ or BEDQ. Using the standard conservative approach, compared to intraoperative diagnosis, sensitivity and specificity of UGI were 35.3% and 80.7%, respectively. Hiatal hernia was identified in an additional 34% (10/29) of patients randomized to posterior crural inspection.


      Hiatal hernias are highly prevalent in SG patients. However, GerdQ, BEDQ, and UGI unreliably identify hiatal hernia in the preoperative setting and should not influence intraoperative evaluation of the hiatus during SG.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery for Obesity and Related Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Eusebi L.H.
        • Ratnakumaran R.
        • Yuan Y.
        • Solaymani-Dodaran M.
        • Bazzoli F.
        • Ford A.C.
        Global prevalence of, and risk factors for, gastro-oesophageal reflux symptoms: A meta-analysis.
        Gut. 2018; 67: 430-440
        • Santonicola A.
        • Angrisani L.
        • Cutolo P.
        • Formisano G.
        • Iovino P.
        The effect of laparoscopic sleeve gastrectomy with or without hiatal hernia repair on gastroesophageal reflux disease in obese patients.
        Surg Obes Relat Dis. 2014; 10: 250-255
        • Daes J.
        • Jimenez M.E.
        • Said N.
        • Dennis R.
        Improvement of gastroesophageal reflux symptoms after standardized laparoscopic sleeve gastrectomy.
        Obes Surg. 2014; 24: 536-540
        • Roman S.
        • Kahrilas P.J.
        The diagnosis and management of hiatus hernia.
        Br Med J. 2014; 349
        • Kim J.
        • Hiura G.T.
        • Oelsner E.C.
        • Yin X.
        • Barr R.G.
        • Smith B.M.
        • et al.
        Hiatal hernia prevalence and natural history on non-contrast CT in the Multi-Ethnic Study of Atherosclerosis (MESA).
        BMJ Open Gastroenterol. 2021; 8: 1-9
        • Che F.
        • Nguyen B.
        • Cohen A.
        • Nguyen N.T.
        Prevalence of hiatal hernia in the morbidly obese.
        Surg Obes Relat Dis. 2013; 9: 920-924
        • Suter M.
        • Dorta G.
        • Giusti V.
        • Calmes J.M.
        Gastro-esophageal reflux and esophageal motility disorders in morbidly obese patients.
        Obes Surg. 2004; 14: 959-966
        • Ghassemian A.J.
        • MacDonald K.G.
        • Cunningham P.G.
        • Swanson M.
        • Brown B.M.
        • Morris P.G.
        • et al.
        The workup for bariatric surgery does not require a routine upper gastrointestinal series.
        Obes Surg. 1997; 7: 16-18
        • Carabotti M.
        • Avallone M.
        • Cereatti F.
        • Paganini A.
        • Greco F.
        • Scirocco A.
        • et al.
        Usefulness of Upper Gastrointestinal Symptoms as a Driver to Prescribe Gastroscopy in Obese Patients Candidate to Bariatric Surgery. A Prospective Study.
        Obes Surg. 2016; 26: 1075-1080
        • Melissas J.
        • Braghetto I.
        • Molina J.C.
        • Silecchia G.
        • Iossa A.
        • Iannelli A.
        • et al.
        Gastroesophageal Reflux Disease and Sleeve Gastrectomy.
        Obes Surg. 2015; 25: 2430-2435
        • Richter J.E.
        • Rubenstein J.H.
        Presentation and Epidemiology of Gastroesophageal Reflux Disease.
        Gastroenterology. 2018; 154: 267-276
        • Popescu A.L.
        • Ioniţa-Radu F.
        • Jinga M.
        • Gavrilă A.I.
        • Săvulescu F.A.
        • Fierbinţeanu-Braticevici C.
        Laparoscopic sleeve gastrectomy and gastroesophageal reflux.
        Romanian J Intern Med Rev Roum Med Interne. 2018; 56: 227-232
        • Ashrafi D.
        • Osland E.
        • Memon M.A.
        Bariatric surgery and gastroesophageal reflux disease.
        Ann Transl Med. 2020; 8: S11
        • de Vries D.R.
        • van Herwaarden M.A.
        • Smout A.J.P.M.
        • Samsom M.
        Gastroesophageal pressure gradients in gastroesophageal reflux disease: relations with hiatal hernia, body mass index, and esophageal acid exposure.
        Am J Gastroenterol. 2008; 103: 1349-1354
        • Angrisani L.
        • Santonicola A.
        • Borrelli V.
        • Iovino P.
        Sleeve gastrectomy with concomitant hiatal hernia repair in obese patients: long-term results on gastroesophageal reflux disease.
        Surg Obes Relat Dis. 2020; 16: 1171-1177
        • Kohn G.P.
        • Price R.R.
        • Demeester S.R.
        • Zehetner J.
        • Muensterer O.J.
        • Awad Z.
        • et al.
        Guidelines for the management of hiatal hernia.
        Surg Endosc. 2013; 27: 4409-4428
        • Gagner M.
        • Hutchinson C.
        • Rosenthal R.
        Fifth International Consensus Conference: Current status of sleeve gastrectomy.
        Surg Obes Relat Dis. 2016; 12: 750-756
        • Dempsey D.T.
        Barium upper GI series in adults: a surgeon’s perspective.
        Abdom Radiol. 2018; 43: 1323-1328
        • Mani V.R.
        • Kalabin A.
        • Nwakanama C.
        • Suman P.
        • Ahmed L.
        Preoperative versus intraoperative diagnosis of hiatal hernia in bariatric population.
        Surg Obes Relat Dis. 2019; 15 (–55): 1949
        • Heacock L.
        • Parikh M.
        • Jain R.
        • Balthazar E.
        • Hindman N.
        Improving the diagnostic accuracy of hiatal hernia in patients undergoing bariatric surgery.
        Obes Surg. 2012; 22: 1730-1733
      1. Jones R, Junghard O, Dent J, Vakil N, Halling K, Wernersson B, et al. Development of the GerdQ, a tool for the diagnosis and management of gastro-oesophageal reflux disease in primary care. Aliment Pharmacol Ther 2009;30:1030–1038.

        • Taft T.H.
        • Riehl M.
        • Sodikoff J.B.
        • Kahrilas P.J.
        • Keefer L.
        • Doerfler B.
        • et al.
        Development and validation of the brief esophageal dysphagia questionnaire.
        Neurogastroenterol Motil. 2016; 28: 1854-1860
        • Mizrahi I.
        • Abubeih A.
        • Rachmuth J.
        • Plotkin Y.
        • Beglaibter N.
        • Grinbaum R.
        • et al.
        Routine Upper Gastrointestinal Fluoroscopy Before Laparoscopic Sleeve Gastrectomy: Is It Necessary?.
        Obes Surg. 2019; 29: 1704-1708
        • Goitein D.
        • Sakran N.
        • Rayman S.
        • Szold A.
        • Goitein O.
        • Raziel A.
        Barium swallow for hiatal hernia detection is unnecessary prior to primary sleeve gastrectomy.
        Surg Obes Relat Dis. 2017; 13: 138-142
        • Schneider R.
        • Lazaridis I.
        • Kraljević M.
        • Beglinger C.
        • Wölnerhanssen B.
        • Peterli R.
        The impact of preoperative investigations on the management of bariatric patients; results of a cohort of more than 1200 cases.
        Surg Obes Relat Dis. 2018; 14: 693-699
        • 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
        • Telem D.A.
        • Gould J.
        • Pesta C.
        • Powers K.
        • Majid S.
        • Greenberg J.A.
        • et al.
        American Society for Metabolic and Bariatric Surgery: care pathway for laparoscopic sleeve gastrectomy.
        Surg Obes Relat Dis. 2017; 13: 742-749
        • 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
        • Mani V.R.
        • Kalabin A.
        • Nwakanama C.
        • Suman P.
        • Ahmed L.
        Preoperative versus intraoperative diagnosis of hiatal hernia in bariatric population.
        Surg Obes Relat Dis. 2019; 15 (–55): 1949
        • Weber C.
        • Davis C.S.
        • Shankaran V.
        • Fisichella P.M.
        Hiatal hernias: a review of the pathophysiologic theories and implication for research.
        Surg Endosc. 2011; 25: 3149-3153