Hiatal reconstruction is safe and effective for control of reflux after laparoscopic sleeve gastrectomy

Abstract

Background Gastroesophageal reflux is a known complication following laparoscopic sleeve gastrectomy (LSG) as anatomical changes predispose to reduced lower esophageal sphincter pressure and development of hiatus hernia. The mainstay of surgical management has been Roux-en-Y gastric bypass (RYGB) which is not without risk. Hiatus hernia repair (HHR) with surgical reattachment of the oesophagus to the crura, recreating the phreno-esophageal ligament is a simple procedure specifically targeting a number of anatomical changes responsible for reflux in this population. Methods We conducted a single centre retrospective analysis of adult patients with post-sleeve reflux refractory to medical treatment, managed with either HHR, RYGB or One-anastomosis Duodenal switch (OADS). PPI use and symptoms of reflux were assessed at early and mid-term time points via validated questionnaires. Results 99 patients were included, of these the surgical procedure was HHR alone in 58, RYGB in 29 and OADS in 12. At early follow-up control of reflux symptoms was achieved in 72.4% after HHR, 82.1% after RYGB and 100% after OADS with no significant difference between groups (p = 0.09). At mid-term followup (median 10 months IQR 7–21) there was no significant difference in the presence of symptomatic reflux as determined by post-op Visick score nor a difference in PPI use. The GerdQ score was significantly lower after OADS as compared to HHR and RYGB (4.6 ± 2.3 vs 7.7 ± 2.2 vs 8.7 ± 3.5, p = 0.006). Conclusion HHR with reconstruction of the phreno-esophageal ligament is a safe and effective procedure for patients with reflux after LSG, that avoids more complex operations such as RYGB and OADS and their associated long-term sequelae.

Ligamentum Teres Augmentation for Hiatus Hernia Repair After Bariatric Surgery: A Systematic Review and Meta-analysis

“…HH and symptomatic GERD are frequent long-term issues encountered after MBS, but the optimal surgical solution for them has yet to be agreed upon. 31,32 Autologous biological tissue has been used to buttress the hiatus in nonbariatric scenarios. [33][34][35] The primary aim of this metaanalysis was to evaluate the safety and efficacy of LTA to buttress the repair of HH and treat GERD in the management of patients who previously underwent MBS.…”

“…HH and symptomatic GERD are frequent long-term issues encountered after MBS, but the optimal surgical solution for them has yet to be agreed upon 31,32 . Autologous biological tissue has been used to buttress the hiatus in non-bariatric scenarios 33–35 .…”