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“BARF Syndrome:” Hiatal Hernias as a cause of bloating, abdominal pain, regurgitation or reflux, and food intolerance in the post-bariatric surgery cohort.

Adam A Golas, MD, MPH, Shadi Al-Bahri, MD, Juaquito Jorge, Michel M Murr, MD, FACS, John P Gonzalvo. University of South Florida

Background:  The risk of developing a hiatal hernia in the obese population is 4.2 fold compared to patients with a BMI <30.  Most hiatal hernias after bariatric surgery are asymptomatic and when symptoms are present they may be difficult to differentiate from overeating or maladaptive eating habits.  The aim of this study was to define the risk and symptoms associated with a hiatal hernia in the post-bariatric surgery cohort. 

Methods: A retrospective review of prospectively collected data for patients who underwent laparoscopic hiatal hernia repair who previously had primary Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG).  Data collection spanned a five-year interval (7/2012-6/2017). Preoperative and follow up data were collected from medical records and questionnaires in the clinic or by telephone.  Variables obtained include age, gender, psychiatric history, pre-index procedure BMI, pre-hiatal hernia repair BMI, post-hernia repair BMI, pre and post operative symptoms, and associated morbidity.  All hiatal hernia repairs were done laparoscopically, with posterior cruroplasty after circumferential hiatal dissection.

Results:  We identified 30 patients with a symptomatic hiatal hernia who had previously (range: 1-23 years) underwent bariatric surgery.   Fourteen RYGB patients presented at a mean of 10.7 years compared to 16 SG patients who presented at a mean of 3.4 years after index procedure.  Diagnosis was by  a combination of UGI (67%), CT scan (50%) and EGD (27 % ).  Mean follow up was 8.6 months (range: 1-32 months).  Laparoscopic hiatal hernia repair was successfully performed in all 30 patients with 0% mortality.  Dysphagia and regurgitative symptoms markedly improved in >85% of patients however, nausea, vomiting and abdominal pain were not changed in 20-30% of patients (Figure).

Conclusion:  Hiatal hernia following bariatric surgery is a rare but important cause of Bloating manifested as nausea and vomiting, Abdominal pain, Regurgitation or Reflux, and Food intolerance or dysphagia (BARF) – and should be further evaluated with imaging or endoscopy when present.  Laparoscopic repair of hiatal hernia is warranted and results in resolution of symptoms in the majority of symptomatic patients.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 87883

Program Number: P654

Presentation Session: iPoster Session (Non CME)

Presentation Type: Poster

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