Tammy L Kindel, MD, PhD, Jennifer Jolley, MD, Corrigan McBride, MD, Vishal Kothari, MD, Dmitry Oleynikov, MD. UNMC
Introduction: The presence of a hiatal hernia (HH) is a well-known risk factor for symptomatic gastro-esophageal reflux disease (GERD). Morbidly obese patients have a risk of developing a HH approaching nearly 40%; however, classic surgical repair of a HH including crural closure and fundoplication is generally avoided in patients with a BMI>35 due to unacceptably high failure rates. It has been advocated that a HH found at the time of bariatric surgery should be repaired as failure to do so may worsen GERD symptoms over time. We have previously published that concomitant HH repair at the time of Roux-en-y gastric bypass (RYGB) is safe, well-tolerated, and with minimal additional cost. However, there are few studies examining the radiographic recurrence of HH after bariatric surgery.
Methods: A retrospective chart review was conducted of all bariatric procedures involving a concomitant HH repair performed at a single, academic institution from 2004-2014. The operative technique was documented as either an anterior or circumferential dissection with or without biologic mesh used as crural reinforcement. Charts were reviewed for radiographic documentation of HH recurrence by either CT or upper gastrointestinal series occurring at least three months post-operatively. Body mass index (BMI) loss was calculated at one year post-operatively from the patient’s preoperative BMI.
Results: Forty-one patients were found to have a bariatric procedure and concomitant HH repair (17 Lap Band, 9 Sleeve Gastrectomy, 15 RYGB). There were 12 radiographically-confirmed hiatal hernia recurrences (31.7%) at an average of 1.9 years post-operatively. This included 4 Bands (23.5%), 2 Sleeves (22%) and 6 RYGBs (40%) with no statistically significant differences between the recurrence rate among any specific type of bariatric surgery performed (p=0.63). There was no difference in pre-operative BMI between patients with and without HH recurrence. There was a similar distribution among patients with and without recurrence regarding HH repair technique. For patients with a recurrence, 50% had an anterior dissection only and 50% had a circumferential dissection and crural closure. The use of biologic mesh onlay with the crural closure (n=10) did not significantly impact recurrence risk (p=0.43). At one year post-operatively, patients with a HH recurrence had a decrease in their BMI of 8.5, similar to patients without a recurrence (8.1, p=0.82).
Conclusions: Patients undergoing bariatric surgery with a concomitant HH repair are at high risk of recurrence, over 30%. The type of crural dissection or the use of biologic mesh did not impact the rate of radiographic HH recurrence. The extent of post-operative weight loss did not correlate with recurrence suggesting that the pre-operative morbidly obese state is the dominant factor for HH recurrence after bariatric surgery.
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