Hiatal Hernias and Repair in Bariatric Surgery Patients: The Impact of Preoperative Imaging

Ashley Mooney, MD1, Stephen S McNatt, MD1, Adam Reid, MD2, Myron S Powell, MD1, Matthew Tufts, MD1. 1Wake Forest School of Medicine, 2Southern Illinois University School of Medicine


Hiatal hernias in obese and morbidly obese patients seeking weight loss surgery have been reported to occur at a rate of nearly 40%. Based on the International Sleeve Gastrectomy Expert Panel Consensus Statement of 2012, our group started routine UGI imaging evaluation for sleeve gastrectomy (SG) patients. Our Roux-en-Y gastric bypass (RYGB) patients were not routinely evaluated with UGI. We aimed to analyze the effect of imaging in both SG and RYGB populations to determine its relevance in the identification and repair of hiatal hernias.


1,141 patients were analyzed by retrospective chart review from July 2008 to August 2014 at our institution. Only first time SG and RYGB operations for the indication of weight loss were included. We assessed for gender, BMI, and UGI evaluation. Prevalence of hiatal hernia was derived. We calculated rates of HHR correlated with UGI findings. Chi square and Fischer exact test were used to compare the two groups.


The groups consisted of 796 RYGB and 345 SG patients. Of the RYGB group, 134 (17%) patients underwent HHR compared to 118 (34%) patients in the SG group, p < 0.001. UGI evaluation was completed in 55 (7%) of the RYGB group and 265 (77%) of the SG group. UGI evaluation identified HH in 50% of those studied. Of the RYGB patients with an UGI, 33 (60%) had positive findings for hiatal hernia (HH) while 127 (48%) of the SG patients with an UGI had positive findings for HH. The rate of HHR in those evaluated with UGI was equal between the two groups, 38% (21of 55 RYGB and 100 of 265 SG, p = 0.9). The rate of HHR by intraoperative identification alone was not different between the two groups, 15% RYGB (113 of 741) and 23% SG (18 of 80), p = 0.1. The false negative rate of UGI was 11% in RYGB and 4% in SG, p < 0.05. The rate of no HHR with a positive UGI was 33 % in RYGB and 14% in SG, p < 0.002. The rate of no HHR with a negative UGI was 29% in RYGB and 48% in SG, p < 0.05. The rate of HHR with a positive UGI was 27% in RYGB and 34% in SG, p = 0.4. A positive UGI lead to a significantly higher rate of HHR than intraoperative assessment alone, 33% vs 19%, p < 0.001, regardless of the type of surgery.


Hiatal hernias are common in patients seeking bariatric surgery. A standard for the preoperative evaluation of weight loss surgery patients has been elusive. Given that hiatal hernia is a risk factor for reflux and that GERD is the most common complication after sleeve gastrectomy, preoperative evaluation for hiatal hernia should be the standard. The significance of hiatal hernia in RYGB is not as clear. We recommend routine UGI in SG patients in order to identify hiatal hernias that will be missed on intraoperative evaluation alone.

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