Craig G Chang, MD. General and Bariatric Surgery
OBJECTIVE: Our objective was to examine the efficacy and safety outcomes for sleeve gastrectomy (SG) with concurrent laparoscopic hiatal hernia repair (LHHR) utilizing a biologic mesh [VERITAS Collagen Matrix, Baxter Healthcare, Deerfield, IL] for reinforcement.
DESCRIPTION/METHOD OF APPLICATION: Gastroesophageal reflux disease (GERD) after SG is a troublesome problem occurring in 22-49% of patients. SG may produce de novo reflux or aggravate existing GERD. The typical medical treatments for GERD after SG are antacids, H2 blockers and proton pump inhibitors. These medications have variable success for relief of symptoms. The typical surgical treatments are redo SG if the sleeve fundus is too large, dilation of strictures and conversion to Roux-en-Y gastric bypass (RYGB).
Hiatal hernia repair 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 repair of hiatal hernias at the time of the SG. To determine the efficacy and safety of the combined procedure, we reviewed the records of patients who underwent laparoscopic hiatal hernia repair (LHHR) with biologic mesh at SG. The primary efficacy outcome measures were: 1) 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) and 2) hiatal hernia recurrence. A secondary outcome measure was overall safety of the combined procedure.
PRELIMINARY RESULTS: From July, 2009 to October, 2014, a total of 87 patients underwent LHHR with biologic mesh reinforcement with SG. The average hernia size was 2.1±0.8 cm. The majority of patients presented with a type I hernia (98.8%) . The study included 81 females (93.1%) and 6 males (6.9%). All of the patients were obese or morbidly obese with an average BMI of 39.6±6.5. Approximately 87.4% (76/87) of the hiatal hernias were diagnosed intraoperatively, while 12.6% (11/87) were diagnosed preoperatively. The average age was 49.6±10.3 years.
At baseline (preoperative), the mean GERD-HRQL score was 12.3±11.9. At follow-up (> 3 months), the score showed a statistically significant decline to a mean of 2.6±4.3 (p < 0.0001). To date, our preliminary findings indicate no evidence of hiatal hernia recurrence. It is important to note that the hiatal hernia was reinforced with biologic mesh as an onlay following a posterior and anterior cruroplasty. Complications included one death from hemorrhage and three leaks in our early experience. Remaining complications were minor and included nausea, vomiting and abdominal pain that fully resolved over time.
CONCLUSIONS: LHHR with biologic mesh as an onlay reinforcement with SG is efficacious for relief of existing GERD symptoms and prevention of de novo GERD symptoms, essentially rendering reliance on long-term anti-reflux medications and/or conversion to RYGB unnecessary. Leaks can be avoided in this patient population by slowing the diet progression, use of a 40 F bougie and oversewing the upper staple line.
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