M. S. Sultany1, M. Mendez2, C. Kim3, Z. Zheng4, S. M. Ahmed1, S. Kapadia1, H. Shamseddeen1, M. Ali1, V. Lyo1 4University Of California – Davis, Sacramento, CA, USA 1University of California Davis, Surgery, Sacramento, CA, USA 2Dartmouth Hitchcock Medical Center, Surgery, Lebanon, NH, USA 3OSF HealthCare, Surgery, Peoria, IL, USA
Introduction: Roux-en-Y gastric bypass (RYGB) is the optimal operation for patients with obesity and concomitant gastroesophageal reflux disease (GERD). However, patients may develop de novo or recurrent hiatal hernias after RYGB leading to GERD symptoms. Predictors and outcomes of hiatal hernia repair (HHR) following RYGB are not well described. We sought to review the indications for, work-up of, and outcomes after HHR performed after RYGB at our institution.
Methods: A retrospective review of patients with prior RYGB who underwent subsequent laparoscopic HHR at our academic, tertiary care center from 2008-2022 was performed. Demographic data, surgical history, symptomatology, workup, HHR techniques, and outcomes were analyzed.
Results: Forty-four patients (93.2% female) with mean age of 55±9.2 years and BMI of 31.4±6.7 kg/m2 underwent HHR on average 9.4±5.9 years after RYGB. Five (11.4%) had recurrent HHR. Twenty-one (47.7%) patients underwent primary RYGB at our institution. Mean BMI 45.7±8.3 kg/m2 prior to RYGB. HH was confirmed on esophagram or CT imaging in 35 patients and by upper endoscopy in 29 (3 with Barrett’s esophagus). Of 20 patients who had pH testing, 50% had elevated DeMeester scores, and 19 had preoperative manometry. Bile reflux was found in 10 patients by HIDA, endoscopy, or impedance testing. GERD or bile-reflux symptoms were the main indication for surgery in 33 (75%) of patients with various preoperative complaints, while the remaining 11 patients underwent surgery for other indications (Table 1).
All patients underwent suture HHR, with 10 including mesh reinforcement. Concurrent operations were performed in 39 patients: 17 truncal vagotomies, 7 GJ revisions, 6 gastrogastric fistula takedowns, 5 Roux lengthening, 3 cholecystectomies, 2 blind limb resections, 3 hernia repairs, and 6 gastrostomy tube placements. Four patients (9.1%) had significant complication including 2 significant bleeds, 1 peritonitis, and 1 pulmonary embolism. Two patients were lost to follow up. At a mean follow-up of 24.3±37.7 months, 75% had improvement in their symptoms, but 63.6% remained on or restarted antacid therapy. Of the 14 with postop imaging or endoscopy, 5 (11.4%) had HH recurrence and 2 with persistent, 2 de novo, and 1 resolved Barrett’s esophagus.
Conclusion: This study is the largest series to date documenting post-RYGB HHR outcomes. Our patients had complex symptomatology and HHR was often accompanied by additional procedures. While most patients had improved GERD symptoms, most patients resumed postoperative antacid therapy. Adequate preoperative work up and careful patient selection and counseling are important given the variability of symptom resolution after surgery.
