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, Flagstaff, aZ, 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/m 2 , hSa mean size 3.4±2 cm 2 . 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 cm 2 . 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.