Paraesophageal Hernia Repair With Partial Longitudinal Gastrectomy in Obese Patients

Outcomes of Bariatric Surgery With Concomitant Hiatal Hernia Repair Using an Absorbable Tissue Matrix

BACKGROUND

Hiatal hernias are a common finding in patients who undergo bariatric surgery with an incidence of about 20% of all bariatric patients. Controversy exists on the utility of a biosynthetic tissue matrix (BTM) usage in combination with crural repair. This study was designed to explore the safety and benefits of the use of a BTM during concomitant hiatal hernia repair with bariatric surgical procedures.

METHODS

This was a retrospective chart review of bariatric surgical patients who underwent a concomitant hiatal hernia repair at a single practice at a tertiary academic medical center from January 2014 to February 2019.

RESULTS

A total of 420 patients were reviewed. Hiatal BTM reinforcement, recurrence, and postoperative proton pump inhibitor use were reported by type of operation. Recurrence was higher in gastric bypass patients who underwent hiatal hernia repair with suture cruroplasty alone vs. those who also underwent hiatal BTM reinforcement (7.1% vs. 3.7%, P = .52) and significantly higher in gastric sleeve patients who underwent hiatal hernia repair with suture cruroplasty alone vs. those who also underwent hiatal BTM reinforcement (7.1% vs. .5%, P = .01). No patient required reoperation for hiatal hernia recurrence.

DISCUSSION

Performing Roux-en-Y gastric bypass or vertical sleeve gastrectomy with concomitant hiatal hernia repair is safe and durable. Employing crural reinforcement with BTM may be of benefit in reducing recurrence rates of hiatal hernia, particularly in sleeve gastrectomy patients.

Mesh Repair of a Giant Para-Esophageal Hernia + Sleeve Gastrectomy. Combined Treatment of Intra-Thoracic Stomach and Morbid Obesity: a Video Case Presentation

Concurrent surgical treatment of an intra-gastric stomach + morbid obesity is demonstrated. Video footage on diagnosis (gastroscopy and upper GI series) and surgical steps, as well as 2-year outcome (upper GI series), is presented. Although controversy exists regarding the best bariatric option when concomitantly repairing a giant para-esophageal hernia, in the light of recent reports and our own experience, sleeve gastrectomy may be the procedure of choice if reflux is no issue.

Gastroesophageal reflux disease complicating laparoscopic sleeve gastrectomy: current knowledge and surgical therapies

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is currently the most commonly performed bariatric procedure worldwide. However, the incidence of gastroesophageal reflux disease (GERD) after LSG is high.

OBJECTIVES

The aim of this systematic review was to identify the optimal surgical strategy for treating GERD after LSG.

SETTING

West China Hospital, Sichuan University, Chengdu, China.

METHODS

A systematic literature search was performed to identify studies on surgical treatments for GERD after LSG. The effectiveness and safety profile of surgical management on GERD after LSG were analyzed.

RESULTS

A total of 40 articles enrolling 2049 patients were included in this review. Surgical strategies to prevent GERD after LSG were mainly of 2 types: concomitant LSG + antireflux procedures (hiatal hernia repair or fundoplication) and secondary procedures (conversion to Roux-en-Y gastric bypass [RYGB] or repeat sleeve gastrectomy). The short-term remission or improvement rate of GERD was 34.6%-100% after concomitant LSG + antireflux procedures. The postoperative complication rate was the same (3.0%) for both LSG + antireflux procedures and LSG alone. The remission or improvement rate of GERD was 57.1%-100% after conversion to RYGB and 100% after repeat sleeve gastrectomy.

CONCLUSIONS

The effectiveness and safety profile of concomitant LSG + antireflux procedures is uncertain. However, secondary operations after LSG, such as conversion to RYGB, appear to provide good results. The data overall are heterogeneous, with imprecise methods of documenting and defining GERD complicating LSG. More cohort studies or RCT studies of high quality with long-term follow-up are needed in the future.

Outcomes of Laparoscopic Hiatal Hernia Repair in Nine Bariatric Patients with Prior Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) may exacerbate gastroesophageal reflux disease (GERD) in patients with a hiatal hernia (HH). Surgical repair may be needed, however prior LSG precludes standard HH repair with fundoplication.

METHODS

We retrospectively reviewed our experience with bariatric patients with prior LSG undergoing laparoscopic HH repair from August 2010 to July 2016. Patient demographics and outcomes including mortality, length of stay (LOS), readmission rates, reoperation, and complications were described. A validated 13-point questionnaire was used to determine symptomatic relief, weight loss, and overall satisfaction.

RESULTS

A total of nine consecutive patients with prior LSG underwent HH repair and were included in the analysis. Repair was performed using Bio-A Gore® mesh (W.L Gore Inc., Newark, DE) in six (66.7%) cases and posterior cruroplasty in three (33.3%) patients. Heartburn was significantly decreased at 1 year (1.4 ± 0.9 vs. 2.6 ± 0.9, p = 0.031), and 78% of patients reported some degree of symptomatic relief after HH repair.

CONCLUSIONS

Laparoscopic HH repair offers a safe and feasible approach in the management of persistent GERD after LSG in well-selected bariatric patients. Larger prospective studies are warranted to investigate the effectiveness of HH repair in this population as 22% of our patients did not demonstrate postoperative symptomatic improvement.

Paraesophageal Hernia Repair: Techniques for Success

With the introduction of laparoscopy, the outcomes of patients undergoing paraesophageal hernia repair have improved dramatically. When the fundamentals of a proper repair are followed, patients can expect to have improvement in gastroesophageal reflux symptoms, including heartburn, regurgitation, chest pain, dysphagia, and dyspnea. Adhering to these principles will alleviate patients' symptoms and avoid reoperation. This article describes the approach to paraesophageal hernia repair, including patient evaluation, operative technique, and postoperative management. Esophageal lengthening and crural reinforcement with mesh are addressed as well. Adhering to the basic techniques outlined in this article should lead to successful and durable patient outcomes following a paraesophageal hernia repair.

Surgical Treatment of Paraesophageal Hernias: A Review

The management of paraesophageal hernia (PEH) can be challenging due to the lack of consensus regarding indications and principles of operative treatment. In addition, data about the pathophysiology of the hernias are scant. Therefore, the goal of this review is to shed light and describe the classification, pathophysiology, clinical presentation, and indications for treatment of PEHs, and provide an overview of the surgical management and a description of the technical principles of the repair.