Matt Pfister, MD, Abby Navratil, MD, Andrea Schwoerer, MD, Keith Gersin, MD, Timothy Kuwada, MD. Carolina Medical Center
Introduction: Hiatal hernia (HH) is common in the morbidly obese. SAGES guidelines recommend hiatal hernia (HH) repair during bariatric surgery. The optimal technique for HH repair is controversial. Mesh reinforcement may improve the high recurrence rate associated with HH repair. Although a wide variety of mesh materials have been described, the risk of esophageal injury from permanent synthetic mesh at the hiatus has swayed surgeons towards resorbable Bio mesh materials. There is a paucity of studies that examine HH repairs with mesh in the setting of bariatric surgery. The aim of this study was to evaluate the effectiveness and safety of preforming hiatal hernia repair using BIO-A mesh (synthetic absorbable mesh) with concurrent laparoscopic Rouxen-Y gastric bypass (RYGB) or sleeve gastrectomy SG.
Methods: IRB approved retrospective review of prospectively collected database of a single surgeon’s consecutive series (2009 to 2016) of laparoscopic RYGB and SG with concurrent hiatal hernia repair. Hiatal laxities (dimpling) and small type 1 HH, which were repaired with a figure of eight anterior cruroplasty, were excluded. The study group consisted of all larger HH’s repaired with a posterior cruroplasty and U-configured polyglycolic acid trimethylene carbonate mesh (Bio-A®, W.L. Gore). All procedures were preformed laparoscopically. Primary outcomes included peri-operative complications, recurrence (radiographic or endoscopic) and GERD symptomatology. Resolution of GERD was defined as the absence of “heartburn” or regurgitation without the use of acid reducing medications (PPI or H2 blocker). Recurrence was defined as >2cm of vertical migration of the GE junction into the chest on imaging or EGD.
Result: 921 RYGB and SG were preformed between 2009 and 2016. 37(4%) had concurrent posterior HH repair with BIO-A mesh. 19/37 (51%) were RYGB. Mean follow up was 23.8 months (2 weeks to 74 months). 17/37 (46%) had clinical GERD prior to bariatric surgery with 15/17 (95%) experiencing complete resolution of GERD after surgery. 38% of patients had postoperative endoscopy, CT or UGI. 2/37 (5%) had radiographic or endoscopic evidence of HH recurrence post operatively. No major complications or morbidity occurred within 90 days of surgery. There were no mesh related complications.
Conclusions: Concurrent HH repair with a synthetic absorbable mesh (Bio-A) during RYGB or SG is feasible and safe and appears to yield favorable rates of GERD resolution and a relatively low risk of recurrence. Further studies are required to evaluate the outcomes of hiatal hernia repair with and without mesh reinforcement.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80139
Program Number: S021
Presentation Session: Bariatric and Metabolic Surgery
Presentation Type: Podium