Comparison of upper gastrointestinal series and symptom questionnaires with intraoperative diagnosis of hiatal hernia during sleeve gastrectomy

Risk factors associated with hiatal hernia: a retrospective study and two-sample Mendelian randomization

OBJECTIVES

The existing literature has demonstrated that variables such as gender, body mass index (BMI), and age play a significant role in the risk assessment of hiatal hernia. This study aims to comprehensively investigate the association between these risk factors and hiatal hernia through a retrospective analysis and Mendelian randomization (MR) analysis.

METHODS

In this study, the examination results and basic information of 685 patients who underwent routine esophagogastroduodenoscopy (EGD) at the gastroesophageal Reflux Center of Xuanwu Hospital from 2018 to 2024 were retrospectively collected. logistic regression was used to analyze the potential risk factors. Meanwhile, a two-sample MR analysis was used to further validate and supplement these risk factors.

RESULTS

A retrospective study showed that the incidence of hiatal hernia diagnosed by endoscopy was 28.7%, in the population without GERD, the incidence was 22.8%In the multivariate logistic regression analysis, male sex (P = 0.033), age (P < 0.001), heavy physical labor (P < 0.001), and gastroesophageal reflux disease (GERD) (P < 0.001) were independent risk factors for hiatal hernia, while an increase in BMI, smoking, alcohol consumption, and the number of pregnancies and deliveries in women were not statistically significant. The inverse variance weighting (IVW) results of the MR analysis showed that an increased waist-hip ratio (ORIVW = 2.57, CI 1.32-5.01, P = 0.0057), trunk fat (ORIVW = 3.53, CI 1.76-7.07, P = 0.0004), smoke initiation (ORIVW = 1.47, CI 1.02-2.13, P = 0.0408), and alcohol intake frequency (ORIVW = 2.23, CI 1.18-4.20, P = 0.0134) were associated with hiatal hernia, but the causal relationship between alcohol intake frequency and hiatal hernia was not established.

CONCLUSION

This study showed that male gender, age, heavy physical labor, and GERD were independent risk factors for hiatal hernia. MR analysis showed that abdominal obesity and smoking may be genetically associated with hiatal hernia. However, there was no statistical significance between increased BMI and hiatal hernia in multivariate analysis and MR analysis.

Surgeon variability in repair of hiatal hernia at the time of bariatric surgery

BACKGROUND

Hiatal hernia (HH) is estimated to affect between 20 and 50% of patients undergoing bariatric surgery. However, there is no consensus regarding the preoperative assessment and intraoperative repair of HH. The aim of this study was to evaluate the variation in surgeon assessment and repair of HH during bariatric surgery across a multi-hospital healthcare system.

METHODS

A retrospective cohort analysis was conducted using data obtained from the metabolic and bariatric accreditation quality improvement program (MBSAQIP) and institutional medical records. All adult patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were included. Preoperative assessment of HH was defined as either EGD or upper GI/Esophagram (UGI) within one year of surgery. Surgeons were evaluated individually and by hospital. Chi-square analysis and ANOVA were performed.

RESULTS

From January 2018 to February 2023, 3,487 bariatric surgeries were performed across 4 hospitals and 11 surgeons (2481 SG and 1006 RYGB). HH were concurrently repaired during 24% of operations. The rate of HH repair in SG was 25 and 22% in RYGB (p = 0.06). Preoperatively, 41% of patients underwent EGD and 23% had an UGI. HH was diagnosed in 22% of EGDs. Patients who underwent preoperative EGD had higher rates of HH repair than those without a preop EGD (33% vs. 17%; p < 0.001). The rate of preoperative EGD utilization by surgeon varied significantly from 3 to 92% (p < 0.001) as did HH repair rates between surgeons (range 8-57%; p < 0.001). Even among patients with a preoperatively diagnosed HH, the repair rate ranged 20-91% between individual surgeons (p < 0.001).

CONCLUSION

Within a healthcare system there was significant heterogeneity in approach to assessment and repair of HH during bariatric surgery. This appears to be mediated by multiple factors, including utilization of preoperative studies, individual surgeon differences, and differences between hospitals.

Physiological Archetypes of de novo Gastroesophageal Reflux Disease After Laparoscopic Sleeve Gastrectomy

Laparoscopic Sleeve Gastrectomy (LSG) is the most common bariatric surgery in the world. While clinically effective, recent studies have shown increasingly higher rates of gastroesophageal reflux disease (GERD) and esophageal motility disorders. We reviewed all the literature and unraveled the underlying mechanism of post-LSG GERD. Finally, we propose a new classification to help us understand the disease and guide work-up, treatment, and future refinements in the surgical technique.