Concomitant hiatal hernia repair during bariatric surgery: does the reinforcement make the difference?

Abstract

BACKGROUND Hiatal hernia repair (HHR) is still controversial during bariatric procedures, especially in case of laparoscopic sleeve gastrectomy (LSG). AIMS to report the long-term results of concomitant HHR, evaluating the safety and efficacy of posterior cruroplasty (PC), simple or reinforced with biosynthetic, absorbable Bio-A® mesh (Gore, USA). Primary endpoint: PC's failure, defined as symptomatic HH recurrence, nonresponding to medical treatment and requiring revisional surgery. METHODS the prospective database of 1876 bariatric operations performed in a center of excellence between 2011-2019 was searched for concomitant HHR. Intraoperative measurement of the hiatal surface area (HSA) was performed routinely. RESULTS A total of 250 patients undergone bariatric surgery and concomitant HHR (13%). Simple PC (group A, 151 patients) was performed during 130 LSG, 5 re-sleeves and 16 gastric bypasses; mean BMI 43.4 ± 5.8 kg/m2, HSA mean size 3.4 ± 2 cm2. Reinforced PC (group B) was performed in 99 cases: 62 primary LSG, 22 LGB and 15 revisions of LSG; mean BMI 44.6 ± 7.7 kg/m2, HSA mean size 6.7 ± 2 cm2. PC's failure, with intrathoracic migration (ITM) of the LSG was encountered in 12 cases (8%) of simple vs. only 4 cases (4%) of reinforced PC (p=0.23); hence, a repeat, reinforced PC and R-en-Y gastric bypass (LRYGB) was performed laparoscopically in all cases. No mesh-related complications were registered perioperatively or after long-term follow-up (mean 50 months). One case of cardiac metaplasia without goblet cells was detected 4 years postoperatively; conversion to LRYGB, with reinforced redo of the PC was performed. The Cox hazard analysis showed that the use of more than four stitches for cruroplasty represents a negative factor on recurrence (HR = 8; p < 0.05). CONCLUSIONS An aggressive search for and repair of HH during any bariatric procedure seems advisable, allowing a low HH recurrence rates. Additional measures, like mesh reinforcement of crural closure with biosynthetic, absorbable mesh, seem to improve results on long term follow-up, especially in case of larger hiatal defects. In our experience, reinforcement of even smaller defects seems advisable in obese population.