A. Shada1, M. Stem2, L. Funk1, D. C. Jackson1, J. Greenberg1, A. Stroud1, A. O. Lidor1 1University Of Wisconsin,General Surgery, School Of Medicine And Public Health,Madison, WI, USA 2Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA
Introduction:
Nearly 200,000 bariatric operations are performed annually in the US. Paraesophageal hernia (PEH) is a relatively rare subset of hiatal hernia, but is associated with morbid obesity and is a fairly common condition that bariatric surgeons encounter. There is no consensus on the management of PEH at the time of bariatric surgery. We sought to examine short term outcomes following concomitant PEH repair at the time of bariatric surgery. We also investigated whether there were differences in 30 day outcomes between those who underwent a PEH repair and either a laparoscopic sleeve gastrectomy (LSG) or gastric roux-en-y bypass (LRGB).
Methods:
Using the American College of Surgeons National Surgical Quality Improvement Program database (2011-2014), patients who underwent bariatric surgery (laparoscopic gastric bypass or laparoscopic sleeve gastrectomy) with or without PEH repair were identified. A propensity score matching analysis was used to compare 30-day outcomes between these two groups. The primary outcome variable was overall morbidity; secondary outcome variables included mortality, readmissions, and reoperations. An additional propensity matched subgroup analysis compared LSG and LRGB in only those patients who received concurrent PEH repair.
Results:
Of the 76,343 bariatric surgery patients included in this study, 7.80%(n=5,958) underwent concurrent PEH repair. The proportion of bariatric cases that involved a concurrent PEH repair increased during the study period (2.14% in 2010 vs. 12.17% in 2014, p<0.001) with rate of concomitant PEH/LSG noted to be over 2.5 times higher than PEH/LRGB in 2014 (8.90% vs. 3.20%). After initial propensity score matching, 5,952 bariatric surgery patients who underwent a PEH repair were matched with 11,904 bariatric surgery patients who did not undergo a PEH repair. There were no significant differences in 30-day outcomes between the cohorts. However, the subgroup analysis demonstrated that among all patients with concurrent PEH repair, LRGB patients experienced greater rates of morbidity (6.20% vs. 2.69%, p<0.001), readmission (6.33% vs. 3.06%, p<0.001), and reoperation (3.00% vs. 1.05%, p<0.001) when compared to LSG patients.
Conclusion:
This study found that paraesophageal hernia repair at the time of bariatric surgery appears to be safe in the short-term and therefore strengthens the argument for a concurrent approach to the morbidly obese patient with PEH. In patients with PEH who are equivalent candidates for gastric bypass or sleeve gastrectomy, a sleeve gastrectomy may be preferable given that it is associated with a lower rate of postoperative morbidity.
