CHICAGO – Combining hiatal hernia repair with bariatric surgery is feasible and safe, with no intraoperative complications or deaths reported in a series of 83 patients.
“Concomitant repair of hiatal hernia during these operations can be technically challenging but is a more efficient way of handling this pathology than undergoing separate procedures,” study author Dr. John Rodriguez, from the Cleveland Clinic, said at the annual meeting of the Central Surgical Association.
The presence of a hiatal hernia can play an important role when sizing a pouch or performing a dissection and can make it difficult to have consistent outcomes or gastric sleeves if the complete stomach can’t be visualized, he explained. Hernias can prevent weight gain but also prevent resolution of reflux symptoms.
Prospectively collected data from 83 patients who underwent concomitant hernia repair and bariatric surgery were retrospectively, compared with 83 historic controls who underwent bariatric surgery alone. The two groups were well-matched with regard to age (57.2 years vs. 56.2 years), weight (118.4 kg vs. 119.9 kg), and body mass index (BMI) (44.5 kg/m2vs. 44.6 kg/m2), although diabetes was significantly more common in controls (13.2% vs. 38.5%).
In the study group, hernias were classified as Type I in 47 patients, Type II in 5, Type III in 28, and Type IV in 3. Primary hernia repair was performed in all patients, using anterior reconstruction in 45, posterior reconstruction in 21, posterior reconstruction plus mesh in 7, and an unspecified approach in 10.
Operative time was slightly longer with the addition of hernia repair, but the difference did not reach statistical significance (164.4 minutes vs. 147.5 minutes; P = .07), Dr. Rodriguez said. Average hospital length of stay was nearly identical at 3.5 vs. 3.4 days (P = .09).
In all, 24 patients undergoing concomitant surgery described having early postoperative symptoms such as nausea, dysphagia, abdominal pain, reflux, and dehydration, compared with 15 controls. But, again the difference was not significant (33.7% vs. 18%; P = .09), he said.
Three study patients had late postoperative complications after 1 year requiring esophagogastroduodenoscopy caused by one each of stenosis, hernia recurrence, and marginal ulcer. Among controls, there were four late marginal ulcers and two stenoses (P = .3).
Notably, hiatal hernia was diagnosed intraoperatively in a full 61.4% of the study group. Obesity is an established risk factor for hiatal hernia, although many patients who present for bariatric surgery are asymptomatic, Dr. Rodriguez observed.
At 12 months, patients undergoing bariatric surgery with and without concomitant hernia repair had similar weight loss (80.7 kg vs. 87.4 kg; P = .1) and final BMI (30 kg/m2 vs. 32.5 kg/m2; P = .06).
Use of antireflux medication, however, was significantly higher in those without concomitant surgery (38.5% vs. 43.7%; P = .01), he said. Gastroesophageal reflux disease (GERD) symptoms were present in 84.3% of study patients and 77% of controls at baseline.
Antireflux medication use declined in 66% of patients undergoing laparoscopic Roux en-Y gastric bypass vs. 50% undergoing only laparoscopic sleeve gastrectomy. Surgical approach did not affect weight loss (59.7 kg vs. 51.8 kg) or final BMI (30.3 kg/m2 vs. 32.4 kg/m2).
“The true incidence of hiatal hernia in the obese is likely underestimated,” Dr. Rodriguez said. “Concomitant repair is safe and may prevent further symptoms.”
Limitations of the study were the small, retrospective cohort, a lack of standardized GERD symptom scoring and objective GERD testing, and no uniform hiatal hernia repair. Standardized approaches may improve outcomes during combined procedures, he said.
During a discussion of the results, Dr. Peter T. Hallowell, an audience member from the University of Virginia, Charlottesville, rose to say this is “information we urgently need in bariatric surgery.”
Dr. Rodriguez and his coauthors reported having no financial conflicts.