Sleeve Gastrectomy with Hiatal Hernia Repair for Relief of Gastroesophageal Reflux Disease: Long-term Outcomes

Craig G Chang, MD1, Lisa Thackeray, MS2. 1Advanced Bariatric Surgical Specialists, 2NAMSA

OBJECTIVE:  To examine the long-term efficacy outcomes for sleeve gastrectomy (SG) with hiatal hernia repair (HHR) reinforced with a biologic mesh [VERITAS Collagen Matrix, Baxter Healthcare, Deefield, IL] for long-term relief of gastroesophageal reflux disease (GERD) symptoms. 

DESCRIPTION/METHOD OF APPLICATION:  GERD after SG is a troublesome problem occurring in 22-49% of patients. SG may produce de novo reflux or aggravate existing GERD.  HHR at the time of SG has been shown to reduce the incidence of postoperative GERD.  Therefore, in our practice, we’ve taken a very aggressive approach at HHR at the time of the SG as recommended by the International Sleeve Gastrectomy Expert Panel Consensus Statement.  Our specific technique includes reinforcement of the hiatal hernia with biologic mesh as an onlay following a posterior and anterior cruroplasty. 

Short-term efficacy of SG with reinfored HHR to relieve GERD symptoms has been documented.  However, long-term efficacy is questionable, and the few studies performed have focused on larger, paraesophageal hernias.  Our study was designed to capture data as to the efficacy of the combined procedure to reduce and/or alleviate GERD symptoms at long-term follow-up (> 2 years) for smaller (< 5 cm, type I and III) hiatal hernias.  The primary efficacy outcome measure was relief from GERD symptoms as measured using a validated survey instrument, the GERD–Health-Related Quality-of-Life Scale (GERD-HRQL)(scale of 0: no symptoms to 50: debilitating symptoms)

PRELIMINARY RESULTS:  From July, 2009 to September, 2013, a total of 55 patients underwent SG with HHR.   The average hernia size was 2.3±1.5 cm.   The majority of patients presented with a type I hernia (96.2%).  The study included 51 females (92.7%) and 4 males (7.3%).  All of the patients were obese or morbidly obese with an average BMI of 40.6±7.1.  Approximately 90.9% (50/55) of the hiatal hernias were diagnosed intraoperatively, while  9.1% (5/55) were diagnosed preoperatively. The average age was 48.9±11.3 years. 

At baseline (preoperative), the mean GERD-HRQL score was 13.0±12.6.  At long-term follow-up (median of 34 months), the score showed a statistically significant decline to a mean of 3.1±5.9  (p < 0.0001).  There were no major complications.  Minor complications included nausea, vomiting and fever that resolved over time. 

CONCLUSIONS:  Sleeve gastrectomy with hiatal hernia repair reinforced with biologic mesh provides long-term relief for existing GERD symptoms and prevention of de novo GERD symptoms.

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