Location and Number of Sutures Placed for Hiatal Hernia Repair During Laparoscopic Adjustable Gastric Banding: Does It Matter?

Nabeel R Obeid, MD, Spencer Deese-Laurent, BA, Bradley F Schwack, MD, Heekoung Youn, RN, CCRC, MA, Marina S Kurian, MD, Christine Ren Fielding, MD, George A Fielding, MD

New York University Medical Center

Introduction:
It has been demonstrated in previous literature that simultaneous hiatal hernia repair (HHR) during laparoscopic adjustable gastric banding (LAGB) decreases the rate of reoperation. However, the technical aspects of how the HHR is performed are not standardized. Specifically, the number of sutures and location of suture placement (anterior hiatus, posterior hiatus, or both) can be quite variable. It is currently unknown whether or not such technical details are associated with rates of reoperation for band-related problems.

Methods:
A retrospective analysis of prospectively-collected date was performed from a single institution (university hospital setting). The database was collected from 2,301 patients undergoing LAGB with HHR from 7/1/2007 to 12/31/2011. The LAGB was performed with a standard pars flaccida technique. The HHR was performed with simple, interrupted Prolene sutures, with the number and location of suture placement left to the judgment of the surgeon. The independent variables were number of sutures and location of sutures. The data collected included demographics, OR time, length of stay (LOS), follow-up time, postop BMI/%EWL at yearly intervals, and rates of readmission and reoperation. Statistical analyses included ANOVA for continuous data and chi-squared tests for categorical data. Kaplan-Meier, log-rank, and Cox regression tests were used for follow-up data, as well as for reoperation rates, in order to account for differential length of follow-up and confounding variables, respectively.

Results:
The total number of patients in our database was 2,301. In comparing groups based on number of sutures used, there was no difference in length of follow-up, with 91-97% follow-up at 1 year, and 66-77% at 4 years. The majority of patients had 1 suture (55%, n = 1,282; 2 sutures = 784, 3 sutures = 188, 4+ sutures = 47; range = 1-6). Patients with fewer sutures had shorter OR time (1 suture 45 min. vs. 4+ sutures 56 min., p-value < 0.0001). LOS, 30-day readmission, band-related reoperation, and postop BMI/%EWL were not statistically significant.

Of the original 2,301 patients, location of suture placement was known for 2,246 (98%), and there was no difference in length of follow-up, with 91-93% follow-up at 1 year, and 50-68% at 4 years. The majority of patients had anterior sutures (61%, n = 1,378; posterior = 735, both = 133). OR time was shorter in those with anterior suture (41 min. vs. posterior 56 min. vs. both 59 min., p-value < 0.0001). Patients with posterior suture had a longer LOS (84% 1 day vs. anterior 74% 1 day vs. both 74% 1 day, p-value < 0.0001). There was no difference in 30-day readmission, band-related reoperation, and postop BMI/%EWL.

Conclusions:
Patients with fewer or anterior sutures have shorter OR times. However, 30-day readmission, band-related reoperation, and postop weight loss are not affected by number or location of suture. The technical aspects of HHR do not appear to be associated with readmission or reoperation, and therefore a standardized approach may be unnecessary.


Session: Podium Presentation

Program Number: S083

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