The incidence of hiatal hernia and technical feasibility of repair during bariatric surgery

doi:10.1016/j.surg.2015.06.036

Surgery

Volume 158, Issue 4, October 2015, Pages 911-918

https://doi.org/10.1016/j.surg.2015.06.036 Get rights and content

Purpose

To evaluate the incidence and outcomes of hiatal hernias (HH) that are repaired concomitantly during bariatric surgery.

Methods

We identified patients who had concomitant HH repair during bariatric surgery from 2010 to 2014. Data collected included baseline demographics, perioperative parameters, type of HH repair, and postoperative outcomes.

Results

A total of 83 underwent concomitant HH during study period. The male-to-female ratio was 1:8, mean age was 57.2 ± 10.0 years, and mean body mass index was 44.5 ± 7.9 kg/m². A total of 61 patients had laparoscopic Roux-en-Y gastric bypass, and 22 had laparoscopic sleeve gastrectomy. HH was diagnosed before bariatric surgery in 32 (39%) subjects, whereas 51 (61%) were diagnosed intraoperatively. Primary hernia repair was performed with anterior reconstruction in 45 (54%) patients, posterior in 21 (25%), and additional mesh placement in 7 (8%). A total of 24 early minor postoperative symptoms were reported. At 12 month follow-up, mean body mass index improved to 30.0 ± 6.2 kg/m², and anti-reflux medication was decreased from 84% preoperatively to 52%. Late postoperative complications were observed in 3 patients. A comparative analysis with a matched 1:1 control group displayed no significant differences in operative time (P = .07), duration of stay (P = .9), intraoperative complications, or early (P = .09) and late post-operative symptoms (P = .3). In addition, no differences were noted in terms of weight-loss outcomes.

Conclusion

The true incidence of HH may be underestimated before bariatric surgery. Combined repair of HH during bariatric surgery appears safe and feasible.

Section snippets

Methods

After approval by our institutional review board, charts were reviewed to identify patients who had concomitant HH repair during bariatric surgery between 2010 and 2014. Patients included in the study were either diagnosed preoperatively (upper endoscopy, upper gastrointestinal studies, or barium esophagram) with HH (mildly symptomatic or asymptomatic patients), or the HH was discovered intraoperatively. Patients presenting with severe or obstructive symptoms from HHs were treated primarily as

Results

We identified 83 (3.2%) patients with concomitant repair of HH during the 4-year study period from a total of 2,623 patients undergoing bariatric surgery. The cohort included 9 men (11%) and 74 women (89%) with a mean age of 57.2 and mean BMI of 44.5 ± 7.9 kg/m² (Table I); 61 (74%) had LRYGB and 22 (27%) had LSG. HH was diagnosed before bariatric surgery in 32 (39%) subjects, whereas 51 (61%) asymptomatic patients were diagnosed intraoperatively. Seventy (84%) patients were taking anti-reflux

Discussion

We present satisfactory results in 83 patients with concomitant HH repair during bariatric surgery. Controversy still exists, however, concerning whether to perform a HH repair during weight loss surgery. Several authors advocate for a stand-alone procedure (mainly RYGB) as the preferred treatment option and to avoid repair to the hiatus.10, 11, 12 This approach is supported by studies showing that HH-related symptoms improve after weight-loss surgery, therefore making it unnecessary to repair

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Cited by (39)

Laparoscopic sleeve gastrectomy vs one-anastomosis gastric bypass 5-year follow-up: a single-blinded randomized controlled trial
2024, Journal of Gastrointestinal Surgery
Laparoscopic sleeve gastrectomy (LSG) is the most performed bariatric procedure worldwide, whereas one-anastomosis gastric bypass (OAGB) is the third most performed procedure. Both procedures have reported good weight loss (WL) and low complications. However, should both have differences in the durability of WL and malnutrition?
A single-blinded, randomized controlled trial of 300 patients was conducted to compare the outcomes of LSG and OAGB over a 5-year follow-up. The primary endpoint was WL in percentages of total WL (%TWL) and excess WL (%EWL). The secondary endpoints were complications, gastroesophageal reflux disease (GERD), associated medical problems, bariatric analysis and reporting outcome system (BAROS) assessment, and weight recurrence (WR).
Overall, 201 patients (96 in the LSG group and 105 in the OAGB group) completed 5 years of follow-up. OAGB had significantly higher %TWL and %EWL than those of LSG throughout the follow-up. LSG had significantly higher WR and GERD. Both procedures had significant improvement in associated medical problems and BAROS scores compared with baseline, with no significant difference. WR was associated with higher relapse of associated medical conditions after initial remission and with lower BAROS scores regarding WL scores.
OAGB had significantly higher WL, less WR, and less GERD. However, it had a higher incidence of bile reflux. Both procedures had comparable complication rates, excellent remissions in associated medical problems, and improved quality of life. WR was associated with significantly more relapse of associated medical problems and significantly lower BAROS scores.
Hiatal hernia repair after previous laparoscopic Roux-en-Y gastric bypass
2024, Surgery for Obesity and Related Diseases
Symptomatic hiatal hernia (HH) with pouch migration after previous laparoscopic Roux-en-Y gastric bypass (RYGB) is an uncommon complication, with limited extant evidence for the utility of surgical repair.
To evaluate the presentation and resolution of symptoms in patients with HH repair after previous RYGB.
Multicenter University Hospital.
A retrospective review was conducted from 2010 to 2022. Patients with prior RYGB who were undergoing subsequent isolated HH repair were included. Patients undergoing incidental HH repair during concomitant revisional bariatric surgery were excluded. Baseline characteristics and surgical outcomes were evaluated and presented as medians (25th–75th percentile).
Forty-four patients met the inclusion criteria. The time from RYGB to HH repair was 59 months (39–88). Body mass index at HH repair was 31 kg/m² (27–39). The most common presenting symptoms of hernia were dysphagia (52%), gastric reflux (39%), and abdominal pain (36%). All HH repairs were completed with a minimally invasive approach (98% laparoscopic, 2% robotic). Nonabsorbable suture was used in 98% of patients, with bioabsorbable mesh in 30%. At a median 28-day (12–117) follow-up, 70% of patients reported full symptom resolution and 23% partial resolution. At follow-up, 2 patients had radiologic HH recurrence, with 1 requiring reoperation.
This is the largest series of isolated HH repair for symptomatic pouch migration after previous RYGB. Common presenting symptoms are dysphagia and reflux, and surgical repair yields a high rate of symptom resolution in the short term. Longer follow-up is needed to evaluate the durability of this intervention.
Does the use of bioabsorbable mesh for hiatal hernia repair at the time of bariatric surgery reduce recurrence rates? A meta-analysis
2022, Surgery for Obesity and Related Diseases
Citation Excerpt :
Four studies included an MG and an NM group [20,21,23,25]. There were 6 studies that were NM only [7,26–30]. Seven of the studies were from Italy and 4 from the United States.
Anywhere from 16% to 37% of patients undergoing bariatric and metabolic surgery are estimated to have a hiatal hernia. To address the lack of long-term data showing the efficacy of bioabsorbable mesh in reducing the recurrence of hiatal hernia in patients who undergo bariatric surgery, we evaluated the world literature and performed a meta-analysis.
To evaluate hiatal hernia recurrence rates after placement of bioabsorbable mesh in bariatric patients.
Meta-analysis of world literature.
We performed a literature search using PubMed and MEDLINE with search terms including “hiatal hernia recurrence,” “bariatric surgery,” “bioabsorbable mesh,” “Gore BIO-A,” and “trimethylene carbonate.” Analysis was conducted to compare surgical time, length of stay, recurrence rate, hernia size, and changes in body mass index before and after surgery between mesh-group (MG) and nonmesh (NM) patients. The meta-analysis was described using standardized mean difference, weighted mean difference, effect size, and 95% confidence interval (CI). An I² statistic was computed to assess heterogeneity.
Twelve studies with 1351 patients were included in our meta-analysis. Four studies had both an MG and an NM group. There were 668 patients in the MG and 683 patients in the NM group. Hernia size noted in the NM group (7 cm²) was compared with that in the MG (6.5 cm²) (95% CI: 3.89–9.14; P = .86). The MG had fewer recurrences than the NM group (effect size, 2% versus 14%; 95% CI: –.26 to –.02; P = .027). The average follow-up was 28.8 months for the MG and 32.8 months for the NM group.
Repair with bioabsorbable mesh at the time of the index bariatric surgery is more effective at reducing the recurrence rate of hiatal hernia than suture cruroplasty. Further studies investigating the long-term outcomes of bioabsorbable mesh placed at the time of bariatric surgery are needed.
Long-term comparative effectiveness of gastric bypass and sleeve gastrectomy on use of antireflux medication: a difference-in-differences analysis
2022, Surgery for Obesity and Related Diseases
Citation Excerpt :
This limitation motivated the exclusion of patients with Barrett’s esophagus and marginal ulcer disease, as well as the additional sensitivity analysis performed among patients with a corresponding diagnosis of GERD that strongly corroborated the overall findings of this study. Another limitation of this study is the lack of detail or analysis regarding concurrent hiatal hernia repair, which is not uncommon in patients undergoing bariatric surgery [32]. Because hiatal hernia repair is considered an incidental rather than a separate procedure, claims for this procedure are denied, and therefore, many surgeons do not submit a separate claim, limiting our ability to accurately identify these cases [33].
Gastroesophageal reflux (GERD) is common among patients with obesity who undergo bariatric surgery. Although gastric bypass and sleeve gastrectomy are the most common bariatric operations performed in the United States, their long-term comparative effectiveness on GERD medication use is unknown.
To compare the long-term effectiveness of gastric bypass and sleeve gastrectomy on use of antireflux medication.
Setting: National cohort undergoing inpatient bariatric surgery.
This is a retrospective study of Medicare beneficiaries undergoing gastric bypass and sleeve gastrectomy between January 1, 2012, and December 31, 2017. A difference-in-differences analysis was conducted to evaluate the differential change in antireflux medication use between groups before and after surgery.
A total of 16,640 patients underwent gastric bypass, and 26,724 patients underwent sleeve gastrectomy. Before surgery, GERD medication use was higher among patients who underwent gastric bypass (62.4%; 95% confidence interval [CI]: 62.0%–63.7%) compared with patients who underwent sleeve gastrectomy (60.1%; 95% CI: 59.3%–60.9%). Five years after surgery, GERD medication use was lower in patients who underwent gastric bypass (47.8%; 95% CI: 46.3%–49.3%) compared with patients who underwent sleeve gastrectomy (53.7%; 95% CI: 50.5%–56.9%). The differential decrease from baseline GERD medication use was greater for patients who underwent gastric bypass at 2 years (–4.1 percentage points [pp]; 95% CI: –1.7 to –6.5 pp), 3 years (–4.3 pp; 95% CI: –1.6 to –7.0 pp), 4 years (–6.9 pp; 95% CI: –4.1 to –9.6 pp), and 5 years (–8.3 pp; 95% CI: –3.7 to 12.8 pp) after surgery.
Though use of antireflux medication decreased following both procedures, gastric bypass was associated with a greater reduction in antireflux medication use 5 years after surgery compared with sleeve gastrectomy. Understanding the long-term comparative effectiveness of these common bariatric operations may better inform treatment decisions among patients and surgeons.
Obesity and impact on gastroesophageal reflux disease
2022, Obesity and Esophageal Disorders
Gastroesophageal reflux disease (GERD) is often seen in obese patients. Many studies reported a positive association between GERD and obesity.^1–11 A recent meta-analysis showed that obesity (BMI≥30 kg/m²) is one of the risk factors for GERD together with age, smoking, and nonsteroidal antiinflammation drug/aspirin use. Its odds ratio was 1.73 (95% CI: 1.46–2.06) compared to nonobese individuals. A dose-dependent association was shown between reflux symptoms and BMI (i.e., larger BMI more frequent or severe reflux symptoms),^1–4,10 and two longitudinal studies found that weight gain during approximately 10 years increased the risk of developing reflux symptoms.^3,8 Complications of GERD such as reflux esophagitis, Barrett’s esophagus, and esophageal adenocarcinoma are also related to obesity.^7,10,12 The mechanisms by which obesity causes GERD can be explained by its effects on structural and physiological functions of the gastroesophageal antireflux barrier.
Repair of post–bariatric surgery, recurrent, and de novo hiatal hernias improves bloating, abdominal pain, regurgitation, and food intolerance
2021, Surgery for Obesity and Related Diseases
Citation Excerpt :
BARF II post-RYGB patients mostly have de novo hernias that present years later than those in patients classified with BARF I (SG). These differences may be related to the higher frequency of exposure and dissection of the hiatus anatomy during SG [2] and the relative infrequency of hiatal hernia diagnosis and repair during RYGB [2–4]. Nonetheless, de novo BARF I hiatal hernias are common in our cohort, which may reflect a referral bias.
Post–bariatric surgery hiatal hernias are associated with a cluster of symptoms, including bloating (nausea/vomiting or fullness), abdominal pain, regurgitation, and food intolerance or dysphagia (BARF).
To report the short-term outcomes of repairing post–bariatric surgery hiatal hernias in patients with BARF.
Large, multispecialty group practice with university affiliation.
We reviewed the records of all consecutive patients who underwent repair of post–bariatric surgery hiatal hernias (2012–2020). Data are shown as means ± standard deviations.
We repaired hiatal hernias in 52 patients (age, 57 ± 10 yr), 4 ± 3 years post sleeve gastrectomy (SG; n = 27), 11 ± 6 years following Roux-en-Y gastric bypass (RYGB; n = 24), and 11 years post duodenal switch with SG (DS-SG; n = 1). Diagnoses were made by upper gastrointestinal contrast study (80%), computed tomography (70%), and/or endoscopy (56%). Hernias in patients with SG were repaired by a posterior cruroplasty after reducing the neo-stomach into the abdomen (n = 11 SG patients; n = 1 DS-SG patient) or converting the SG to RYGB (n = 16). All 24 RYGB patients underwent hernia repair similarly. At 12 ± 10 months of follow-up, dysphagia or regurgitation improved in >80% of patients; nausea, vomiting, or abdominal pain improved in 70% of patients; and heartburn persisted in 56% of patients. Subsequent recurrent hernias that required operative repair developed in 3 patients.
Hiatal hernias containing the neo-stomach present earlier after SG than RYGB. The diagnosis can be made with a combination of imaging studies and endoscopy. Repair of post–bariatric surgery hiatal hernias markedly improves symptoms of BARF in most patients.

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Central Surgical AssociationThe incidence of hiatal hernia and technical feasibility of repair during bariatric surgery

Purpose

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

J Gastrointest Surg

J Am Coll Surg

Initial experience with laparoscopic crural closure in the management of hiatal hernia in obese patients undergoing sleeve gastrectomy

Obes Surg

Radiologic and endoscopic evaluation for laparoscopic adjustable gastric banding: preoperative and follow-up

Obes Surg

Is routine preoperative upper endoscopy in gastric banding patients really necessary?

Obes Surg

Upper gastrointestinal symptoms and associated disorders in morbidly obese patients: a prospective study

Dig Dis Sci

Morbid obesity causes chronic increase of intraabdominal pressure

Dig Dis Sci

Central Surgical Association
The incidence of hiatal hernia and technical feasibility of repair during bariatric surgery