Original articleSleeve gastrectomy and crural repair in obese patients with gastroesophageal reflux disease and/or hiatal hernia
Section snippets
Patients
From July 2009 to December 2011, 378 SGs were performed in our department. All patients underwent a preoperative workup, including history and physical examination, routine laboratory evaluation, esophagogastroduodenoscopy, abdominal ultrasonography, a nutritional and psychiatric evaluation, and additional examinations (upper gastrointestinal contrast study) and/or consultations, as indicated. Manometry and 24-hour pH recording were performed when GERD symptoms were present.
The severity of GERD
Results
From July 2009 to December 2011, 378 morbidly obese patients (body mass index 44 ± 3.5 kg/m2) underwent the preoperative workup for SG. A total of 60 patients (15.8%) presented with symptomatic GERD and 42 patients (11.1%) with an endoscopic diagnosis of HH. At surgery, HH was confirmed in all cases, and, in 55 patients (14.5%), it was diagnosed intraoperatively. The groups with a preoperative and intraoperative diagnosis of HH underwent SG and crural repair for a total of 97 patients (Fig. 1),
Discussion
Bariatric surgery has been demonstrated to be the treatment of choice compared with antireflux surgery for the management of GERD and/or HH in morbidly obese patients. Its effectiveness is due, not only to the significant weight loss, but also to specific changes in the anatomy and in the functional configuration of the crural complex [18], [19]. RYGB appears to have a very favorable effect on GERD symptoms, possibly related to the limited acid production in the small (15–30 mL) gastric pouch
Conclusion
In morbidly obese patients, the presence of a crural defect should not be considered a contraindication to SG. It requires surgical repair in conjunction with SG. Preoperative endoscopic and radiologic assessments cannot ensure a sufficiently correct diagnosis of HH; thus, a complete and careful examination of the crura is always recommended in patients undergoing SG. Extensive dissection of the hiatal area ensures more radical fundusectomy, and it is of importance for a more accurate diagnosis
Disclosures
The authors have no commercial associations that might be a conflict of interest in relation to this article.
References (50)
- et al.
Association of obesity with hiatal hernia and esophagitis
Am J Gastroenterol
(1999) - et al.
Indications for sleeve gastrectomy as a primary procedure for weight loss in the morbidly obese
J Gastrointest Surg
(2008) - et al.
Effect of sleeve gastrectomy on gastroesophageal reflux disease: a systematic review
Surg Obes Relat Dis
(2011) - et al.
The Second International Consensus Summit for Sleeve Gastrectomy, March 19–21, 2009
Surg Obes Relat Dis
(2009) - et al.
Gastroesophageal reflux disease and obesity
Rev Gastroenterol Disord
(2008) - et al.
Gastroesophageal reflux in the massively obese
Int Surg
(1987) - et al.
Does massive obesity promote abnormal gastroesophageal reflux?
Dig Dis Sci
(1995) - et al.
Meta-analysis: obesity and the risk for gastroesophageal reflux disease and its complications
Ann Intern Med
(2005) - et al.
Body mass index and gastroesophageal reflux disease: a systematic review and meta-analysis
Am J Gastroenterol
(2006) - et al.
Systematic review: the effects of conservative and surgical treatment for obesity on gastro-oesophageal reflux disease
Aliment Pharmacol Ther
(2009)
Gastro-oesophageal reflux disease in obesity: pathophysiological and therapeutic considerations
Obes Rev
Lower esophageal sphincter pressure and gastroesophageal pressure gradients in excessively obese patients
J Med
Elevated body mass disrupts the barrier to gastroesophageal reflux
Arch Surg
High prevalence of asymptomatic esophageal motility disorders among morbidly obese patients
Obes Surg
Intra-abdominal pressure in the morbidly obese
Obes Surg
Gastroesophageal pressure gradients in gastroesophageal reflux disease: relations with hiatal hernia, body mass index and esophageal acid exposure
Am J Gastroenterol
Gastrointestinal disorders and symptoms: does body mass index matter?
Neth J Med
Obesity is a major cause of failure for both abdominal and transthoracic antireflux operations
Gastroenterology
Obesity and its effect on outcome of laparoscopic Nissen fundoplication
Dis Esophagus
Obesity adversely affects the outcome of antireflux operations
Surg Endosc
Surgical management of gastroesophageal reflux disease in obesity
Dig Dis Sci
Gastroesophageal reflux disease and severe obesity: fundoplication or bariatric surgery?
World J Gastroenterol
Laparoscopic Roux-en-Y gastric bypass for recalcitrant gastroesophageal reflux disease in morbidly obese patients
JSLS
Treatment of morbid obesity and hiatal paraesophageal hernia by laparoscopic Roux-en-Y gastric bypass
Obes Surg
Symptomatic improvement in gastroesophageal reflux disease (GERD) following laparoscopic Roux-en-Y gastric bypass
Surg Endosc
Cited by (174)
Gastroesophageal reflux management after vertical sleeve gastrectomy
2023, Cirugia EspanolaReflux and Barrett's esophagus after sleeve gastrectomy: analysis of a statewide database
2023, Surgery for Obesity and Related DiseasesComparison of upper gastrointestinal series and symptom questionnaires with intraoperative diagnosis of hiatal hernia during sleeve gastrectomy
2023, Surgery for Obesity and Related DiseasesImpact of concurrent hiatal hernia repair during laparoscopic sleeve gastrectomy on patient-reported gastroesophageal reflux symptoms: a state-wide analysis
2023, Surgery for Obesity and Related DiseasesImpacts of sleeve gastrectomy on gastroesophageal reflux disease in severely obese Korean patients
2023, Asian Journal of SurgeryCitation Excerpt :We do not believe that hiatal hernia repair procedure affected GERD improvement. Soricelli et al15,31 and Daes et al32 reported that hiatal hernia repair with LSG had a beneficial effect on improving GERD symptoms, while Santonicola et al16 reported that it did not help improve GERD symptoms. Our study showed that if the size of the hiatal hernia is small and incidentally found and the patients have mild esophagitis (LA classification A), repairing it did not help improve postoperative GERD.