The Effect of Laparoscopic Sleeve Gastrectomy with Concomitant Hiatal Hernia Repair on Gastroesophageal Reflux Disease in the Morbidly Obese

Kamran Samakar, MD, MA, Travis J Mckenzie, MD, Ali Tavakkoli, MD, Scott A Shikora, MD. Brigham and Women’s Hospital, Harvard Medical School.

Background: The effect of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) is controversial. Although concomitant hiatal hernia repair (HHR) at the time of LSG is common, there is little data on the outcomes of GERD symptoms in these patients. The aim of this study was to evaluate the effect of concomitant HHR on GERD symptoms in morbidly obese patients undergoing LSG.

Methods: A single institution prospectively maintained database was examined to identify patients who underwent LSG and concomitant HHR from December 2010 to April 2013. Patient characteristics, operative details, and postoperative outcomes were analyzed. Standardized patient questionnaires administered both pre- and postoperatively were utilized. Primary endpoints included the presence of subjective GERD and the need for antisecretory therapy.

Results: Forty patients were identified meeting inclusion criteria, with a mean follow-up of 17 months (range 6-35 months). The mean age of the cohort was 47.4 years, with 82% being female. Mean preoperative body mass index was 44.4 kg/m². All patients were evaluated preoperatively with upper gastrointestinal contrast series (UGI). Hiatal hernia was diagnosed on UGI in 25% of cases, with the remainder being diagnosed intra-operatively. Gastroesophageal reflux was demonstrated in 23% of symptomatic patients by UGI. Preoperatively, 75% of patients reported subjective symptoms of GERD and/or required daily antisecretory therapy. After surgery, previously symptomatic patients remained symptomatic and/or continued to require daily antisecretory therapy in 67% of cases. New onset of GERD requiring daily antisecretory therapy was seen in 30% of patients who were previously asymptomatic.

Conclusion: Based on our data, LSG with concomitant HHR may not improve GERD symptoms or the need for daily antisecretory therapy in symptomatic patients. Furthermore, LSG with HHR may induce de-novo GERD in a subset of previously asymptomatic patients. The role of HHR with LSG remains controversial.

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