Management of Paraesophageal Hernia in the Morbidly Obese Patient

Full esophageal mobilization during hiatal hernia repair with concomitant sleeve gastrectomy improves postoperative reflux symptoms for patients with preexisting reflux

BACKGROUND

Hiatal hernia repair (HHR) performed concurrently with vertical sleeve gastrectomy (VSG) has been shown to improve postoperative gastroesophageal reflux disease (GERD). However, data on the optimal extent of esophageal mobilization during repair are lacking. Mobilization techniques for HHR during VSG include partial (PM) or full (FM) mobilization of the esophagus. We hypothesize that patients who undergo full mobilization will be less likely to develop postoperative reflux.

METHODS

A single-institution retrospective review of all patients who underwent a VSG with a HHR between 2014 and 2021 was conducted. The primary outcome was postoperative reflux symptoms defined by diagnosis in the medical record, utilization of anti-reflux medications, and GERD health-related quality of life (GERD-HRQL) scores obtained via patient surveys.

RESULTS

There were 190 patients included with 80 patients (42.1%) undergoing PM and 110 (57.9%) undergoing FM. Rates of preoperative reflux were similar between the two groups (47.5% vs. 51.8%; p = 0.55). During the GERD-HRQL survey, there were 114 patients (60.0%) contacted with a participation rate of 91.2% (104 patients). Patients with preoperative reflux who underwent PM were found to have a higher rate of reported postoperative reflux (90.0% vs. 62.5%; p = 0.03) and higher GERD-HRQL scores (16.40 ± 9.95 vs. 10.84 ± 9.01; p = 0.04). Patients without preoperative reflux did not have a significant difference in reported reflux (55.0% vs. 51.7%; p = 0.82) or GERD-HRQL scores (12.35 ± 14.14 vs. 9.93 ± 9.46; p = 0.25).

CONCLUSION

Our study found that postoperative GERD was higher in patients with preexisting reflux who underwent partial esophageal mobilization during concurrent hiatal hernia repair with vertical sleeve gastrectomy. In patients without preoperative GERD, our data suggest that postoperative reflux symptoms are not dependent on the extent of esophageal mobilization during hiatal hernia repair with vertical sleeve gastrectomy.

American society for metabolic and bariatric surgery: intra-operative care pathway for minimally invasive Roux-en-Y gastric bypass

BACKGROUND

Clinical care pathways help guide and provide structure to clinicians and providers to improve healthcare delivery and quality. The Quality Improvement and Patient Safety Committee (QIPS) of the American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published care pathways for the performance of laparoscopic sleeve gastrectomy (LSG) and pre-operative care of patients undergoing Roux-en-Y gastric bypass (RYGB).

OBJECTIVE

This current RYGB care pathway was created to address intraoperative care, defined as care occurring on the day of surgery from the preoperative holding area, through the operating room, and into the postanesthesia care unit (PACU).

METHODS

PubMed queries were performed from January 2001 to December 2019 and reviewed according to Level of Evidence regarding specific key questions developed by the committee.

RESULTS

Evidence-based recommendations are made for care of patients undergoing RYGB including the pre-operative holding area, intra-operative management and performance of RYGB, and concurrent procedures.

CONCLUSIONS

This document may provide guidance based on recent evidence to bariatric surgeons and providers for the intra-operative care for minimally invasive RYGB.

Does the Repair of an Accidentally Discovered Hiatal Hernia and Gastropexy Affect the Incidence of De Novo Postoperative GERD Symptoms After Laparoscopic Sleeve Gastrectomy?

Background

The relationship between laparoscopic sleeve gastrectomy (LSG) and gastroesophageal reflux disease (GERD) is intricate. Hiatal hernia repair or gastropexy can have an impact on postoperative GERD.

Aim

To assess the effect of the repair of an accidentally discovered HH and/or gastropexy on the development of de novo postoperative GERD symptoms after LSG.

Methods

This retrospective study included all obese patients who underwent LSG at our hospital from January 2018 to June 2022. The data retrieved from patients' files comprised demographic and clinical data, including BMI, GERD symptoms, and comorbidities. Hiatal hernias, surgical technique, gastropexy, duration, and intraoperative complications were recorded. Postoperative data included early and late postoperative complications, weight loss, de novo GERD, and medication use.

Results

The study included 253 patients, 89 males (35.2%) and 164 females (64.8%), with a mean age of 33.3±10.04 years. De novo GERD was detected in 94 individuals (37.15%). HH was accidentally found and repaired in 29 patients (11.5%). Only 10.3% of LSG and HH repair patients had de novo GERD symptoms, compared to 40.6% of non-HH patients. 149 patients (58.9%) had gastropexy with LSG. Postoperative de novo GERD symptoms were comparable for LSG with gastropexy (40.5%) and LSG alone (40.9%).

Conclusion

After one year, concurrent hiatal hernia repair and LSG seem to be safe and beneficial in lowering postoperative de novo GERD symptoms. The inclusion of gastropexy with LSG had no significant impact on postoperative de novo GERD. Both HH repair and gastropexy lengthened the operation but did not increase its complications.

Propensity score matched analysis of laparoscopic revisional and conversional sleeve gastrectomy with concurrent hiatal hernia repair

INTRODUCTION

The primary aim of this study was to evaluate outcomes associated with concurrent hiatal hernia repair (CHHR) when performing a conversional or revisional vertical sleeve gastrectomy (VSG). CHHR is often necessary during VSG due to potential gastroesophageal reflux disease (GERD) development or obstructive symptoms.

METHODS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement (MBSAQIP) participant use file was assessed for the years 2015-2020 for revisional/conversional VSG procedures. The presence of CHHR was used to create two groups. Propensity score matching (PSM) was performed with E-analysis.

RESULTS

There were 33,909 patients available, with 5986 undergoing the VSG procedure with CHHR. In the unmatched analysis, there was an increased frequency of patients being female (85.72 vs 83.30%; p < 0.001), having a history of GERD (38.01 vs 31.25%; p < 0.001), and being of older age (49.59 ± 10.97 vs 48.70 ± 10.83; p < 0.001). Patients undergoing VSG with CHHR experienced decreased sleep apnea (25.00 vs 28.84%; p < 0.001) and diabetes (14.27 vs 17.80%; p < 0.001). PSM yielded 5986 patient pairs. Matched patients with CHHR experienced increased operative time (115 min ± 53 vs 103 min ± 51; p < 0.001), increased risk of postoperative pneumonia (0.45 vs 0.15%; p = 0.005) and readmission (4.69 vs 3.58%; p = 0.002) within thirty days. However, patients undergoing CHHR with revisional or conversional VSG did not experience increased risk of death, postoperative bleeding, postoperative leak, or reoperations.

CONCLUSION

Despite a small association with increased postoperative pneumonia, the rate of complications in patients undergoing laparoscopic revisional/conversional VSG and CHHR are low. CHHR is a safe option when combined with the laparoscopic revisional/conversional VSG procedure in the early postoperative period.

Risk factors for adverse outcomes following paraesophageal hernia repair among obese patients

BACKGROUND

Although obesity is an established risk factor for adverse outcomes after paraesophageal hernia repair (PEHR), many obese patients nonetheless receive PEHR. The purpose of this study was to explore risk factors for adverse outcomes of PEHR among this high-risk cohort. We hypothesized that obese patients may have other risk factors for adverse outcomes following PEHR.

METHODS

A retrospective study of adult obese patients who underwent minimally invasive PEHR from 2017 to 2019 was performed. Patients were excluded for BMI < 30 or if they had concomitant bariatric surgery at time of PEHR. The primary outcome of interest was a composite adverse outcome (CAO) defined as having any of the four following outcomes after PEHR: persistent GERD > 30 d, persistent dysphagia > 30 d, recurrence, or reoperation. Chi-square and t-test analysis was used to compare demographic and clinical characteristics. Multivariable logistic regression analysis was used to evaluate independent predictors of CAO.

RESULTS

In total, 139 patients met inclusion criteria with a median follow-up of 19.7 months (IQR 8.8-81). Among them, 51/139 (36.7%) patients had a CAO: 31/139 (22.4%) had persistent GERD, 20/139 (14.4%) had persistent dysphagia, 24/139 (17.3%) had recurrence, and 6/139 (4.3%) required reoperation. On unadjusted analysis, patients with a CAO were more likely to have a history of prior abdominal surgery (86.3% vs 70.5%, p = 0.04) and were less likely to have undergone a preoperative CT scan (27.5% vs 45.5%, p = 0.04). On multivariable analysis, previous abdominal surgery was independently associated with an increased likelihood of CAO whereas age and preoperative CT scan had a decreased likelihood of CAO.

CONCLUSIONS

Although there were adverse outcomes among obese patients, minimally invasive PEHR may be feasible in a subset of patients at specialized centers. These findings may help guide the appropriate selection of obese patients for PEHR.

What works best in hiatus hernia repair, sutures alone, absorbable mesh or non-absorbable mesh? A systematic review and network meta-analysis of randomized clinical trials

Laparoscopic hiatal hernia repair (HHR) and fundoplication is a common low risk procedure providing excellent control of gastro-oesophageal reflux disease and restoring of normal anatomy at the hiatus. HHR may fail, however, resulting in hiatus hernia (HH) recurrence, and the use of tension-free mesh-augmented hernioplasty has been proposed to reduce recurrence. Previous research on this topic has been heterogeneous, including study methods, mesh type used and technique performed. A systematic review and network meta-analysis were carried out. An electronic systematic research was carried out using 'PUBMED', 'EMBASE', 'Medline (OVID)' and 'Web of Science', of articles identifying HHR with suture cruroplasty, non-absorbable mesh (NAM) and absorbable mesh (AM) reinforcement. Eight RCTs with 766 patients were evaluated. NAM had significantly (P < 0.05) lower early recurrence rates (OR: 0.225, 95% CI 0.0342, 0.871) compared with suture repair alone; however, no differences in late recurrences were evident. For AM, no difference in early (0.508, 95% CI 0.0605, 4.81) or late (1.07. 95% CI 0.116, 11.4) recurrence rates were evident compared with the suture only group. Major complication rates were similar in all groups. NAM reinforcement significantly reduced early HH recurrence when compared with sutured cruroplasty alone; however, late recurrence rates were similar with all techniques. Given the limited data in comparing AM with NAM, this study was unable to conclude which composition was significant. We emphasize caution when interpreting small sample size RCTs, and recommend more research with larger randomized studies.

Defining benchmarks for fellowship training in foregut surgery: a 10-year review of fellowship council index cases

INTRODUCTION

Surgical treatment of foregut disease is a complex field that demands advanced expertise to ensure favorable outcomes for patients. To address the growing need for foregut surgeons, leaders within several national societies have become interested in developing a foregut fellowship. The aim of this study was to develop data-driven benchmarks that will aid in defining appropriate accreditation criteria for these fellowships.

METHODS

We obtained case log data for Fellowship Council fellows trained from 2009-2019. We identified 78 complex foregut (non-bariatric) case codes and divided them into 5 index case categories including (1) hiatal/paraoesophageal hernia repair, (2) fundoplication, (3) esophageal myotomy, (4) major organ resection, and (5) minor organ resection. Median volumes in each index category were compared over time using Kruskall-Wallis tests. The share of cases done using open, laparoscopic, or robotic approaches were analyzed using linear regression analysis.

RESULTS

For the 10 years analyzed, 1362 fellows logged 82,889 operations and 111,799 endoscopies. Median foregut cases per fellow grew significantly from 42 (IQR = 24-74) cases in 2010 to 69 (IQR = 33-106) cases in 2019. Median endoscopy volumes also grew significantly from 42 (IQR = 7-88) in 2010 to 69 (IQR 32-123) in 2019.The volume of hiatal/paraoesophageal hernia repairs increased significantly over time while volumes in the remaining 4 index categories remained stable. The share of robotic cases exhibited near perfect linear growth from 2.2% of all foregut cases in 2010 to 14.4% in 2019 (R = 0.99, p < 0.0001). Open cases exhibited linear decay from 7.2% of cases in 2010 to 4.7% of cases in 2019 (R = 0.92, p = 0.0001). Laparoscopic/thoracoscopic cases also exhibited linear decay from 90.6% of cases in 2010 to 80.9% of cases in 2019 (R = 0.98, p < 0.00001).

CONCLUSIONS

FC fellows are exposed to robust volumes of foregut cases. This rich data set provides an evidence-based guide for establishing criteria for potential foregut fellowships.

Management of Recurrent Paraesophageal Hernia

Introduction: Recurrent paraesophageal hernias (rPEH) represent a clinical and surgical challenge. Even with a relatively high incidence, most of them are minimally symptomatic, and the need for reoperation is low. For those patients who are candidates for surgery, laparoscopic revision is a feasible and safe technique although there are other treatment options available. Methods: This article provides an overview of the definition, mechanisms of recurrence, epidemiology, clinical presentation, and indications for treatment of rPEH, as well as an overview of the surgical management options and a description of the technical principles of the repair and/or resection. Results: Surgeons should consider multiple factors when deciding the appropriate treatment of patients with rPEH, and all of them require a complete and comprehensive evaluation. The surgical options need to be individualized and include a redo PEH repair and revisional fundoplication, a partial or total gastrectomy with Roux-en-Y reconstruction, or an esophagectomy. There are key steps during the surgical repair that contribute to a successful operation and also auxiliary techniques that can improve postoperative outcomes. After laparoscopic redo most patients have improvement of their symptoms and an acceptable rate of perioperative complications when they are performed by experienced foregut surgeons. In obese patients with rPEH, bariatric surgery can be the best treatment option. Conclusions: Laparoscopic reoperative management should be considered in symptomatic patients who are not controlled with maximal nonoperative therapy, after a thorough work-up and appropriate counseling. In cases with multiple hernia repairs, it is important to consider alternative operations.

Robotic Transgastric Reconstruction of the Double Lumen Esophagus

Double lumen esophagus is an extremely rare condition, developing in most cases as a complication of antireflux procedures or gastroesophageal reflux itself secondary to the severe inflammatory process in and around the lower esophagus. We describe a case of iatrogenic double lumen esophagus after multiple previous Nissen fundoplications for chronic gastroesophageal reflux disease. There is no standard surgical intervention for the management of this complication. We present a first report of successful robot-assisted surgical reconstruction of a double lumen esophagus.

When should we use mesh in laparoscopic hiatal hernia repair? A systematic review

The use of mesh in laparoscopic hiatal hernia repair (LHHR) remains controversial. The aim of this systematic review was to determine the usefulness of mesh in patients with large hiatal hernia (HH), obesity, recurrent HH, and complicated HH. We performed a systematic review of the current literature regarding the outcomes of LHHR with mesh reinforcement. All articles between 2000 and 2020 describing LHHR with primary suturing, mesh reinforcement, or those comparing both techniques were included. Symptom improvement, quality of life (QoL) improvement, and recurrence rates were evaluated in patients with large HH, obesity, recurrent HH, and complicated HH. Reported outcomes of the use of mesh in patients with large HH had wide variability and heterogeneity. Morbidly obese patients with HH should undergo a weight-loss procedure. However, the benefits of HH repair with mesh are unclear in these patients. Mesh reinforcement during redo LHHR may be beneficial in terms of QoL improvement and hernia recurrence. There is scarce evidence supporting the use of mesh in patients undergoing LHHR for complicated HH. Current data are heterogeneous and have failed to find significant differences when comparing primary suturing with mesh reinforcement. Further research is needed to determine in which patients undergoing LHHR mesh placement would be beneficial.

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.

Concurrent hiatal hernia repair and bariatric surgery: outcomes after sleeve gastrectomy and Roux-en-Y gastric bypass

BACKGROUND

Hiatal hernias are often repaired concurrently with bariatric surgery to reduce risk of gastroesophageal reflux disease-related complications.

OBJECTIVES

To examine the association between concurrent hiatal hernia repair (HHR) and bariatric outcomes.

SETTING

A 2010-2017 U.S. commercial insurance claims data set.

METHODS

We conducted a retrospective cohort study. We identified adults who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) alone or had bariatric surgery concurrently with HHR. We matched patients with and without HHR and followed patients up to 3 years for incident abdominal operative interventions, bariatric revisions/conversions, and endoscopy. Time to first event for each outcome was compared using multivariable Cox proportional hazards modeling.

RESULTS

We matched 1546 SG patients with HHR to 3170 SG patients without HHR, and we matched 457 RYGB patients with HHR to 1156 RYGB patients without HHR. A total of 73% had a full year of postoperative enrollment. Patients who underwent concurrent SG and HHR were more likely to have additional abdominal operations (adjusted hazard ratio [aHR], 2.1; 95% CI, 1.5-3.1) and endoscopies (aHR, 1.5; 95% CI, 1.2-1.8) but not bariatric revisions/conversions (aHR, 1.7; 95% CI, .6-4.6) by 1 year after surgery, a pattern maintained at 3 years of follow-up. Among RYGB patients, concurrent HHR was associated only with an increased risk of endoscopy (aHR, 1.4; 95% CI, 1.1-1.8)) at 1 year of follow-up, persisting at 3 years.

CONCLUSIONS

Concurrent SG/HHR was associated with increased risk of some subsequent operative and nonoperative interventions, a pattern that was not consistently observed for RYGB. Additional studies could examine whether changes to concurrent HHR technique could reduce risk.

Simultaneous surgeries in bariatric surgery (literature review)

Based on the available publications, the article presents an analysis of the studies on the simultaneous implementation of cholecystectomy, ventral and paraesophageal hernia repair during a bariatric intervention. If there is a clinical picture of chronic calculous cholecystitis, simultaneous cholecystectomy is justified and does not lead to a significant increase in the number of complications. In the case of asymptomatic gallstones, the optimal tactics remains controversial, both a surgical treatment and observation are possible. In the absence of gallstone disease, all patients after the surgical correction of the excess weight are prescribed ursodeoxycholic acid, while performing preventive cholecystectomy is not recommended. A simultaneous ventral hernia repair is justified only for small defects ( 10 cm) of the anterior abdominal wall. If a paraesophageal hernia is detected in patients with morbid obesity, bariatric surgery may be combined with cruroraphy.