Hiatal repair during laparoscopic sleeve gastrectomy may limit GERD symptoms

Last Updated: 2018-01-10

By Will Boggs MD

NEW YORK (Reuters Health) - Repair of hiatal laxity and herniation during laparoscopic sleeve gastrectomy (LSG) for obesity improves symptoms of gastroesophageal reflux disease (GERD), according to a new study.

Some studies have shown new or worsening GERD following LSG, and it remains unclear whether specific interventions during LSG can prevent this.

Dr. Himanshu Wadhawan from Queen Elizabeth's University Hospital, in Glasgow, UK, and colleagues examined the effect of surgically treating hiatal weakness on GERD symptoms in a prospective observational study of 100 patients undergoing LSG at a single tertiary referral institution in Sydney, Australia.

Nearly half the patients (47%) reported some degree of reflux at baseline, and 22 patients were on acid suppression treatment. Overall, 48 patients with hiatal laxity, including 26 of those who were symptomatic, underwent hiatal repair.

Reflux-related quality of life improved significantly from a mean 4.5 (on a scale from 0 to 50) preoperatively to 2.0 at early postoperative follow-up and to 0.76 at late postoperative follow-up, the researchers report in Surgical Endoscopy, online December 12.

Mean reflux-only scores followed a similar course, improving significantly from 0.85 (on a scale from 0 to 5) to 0.53 and then to 0.38, respectively.

Among patients who were symptomatic preoperatively, mean reflux-related quality of life scores improved from 8.43 preoperatively to 0.94 at late postoperative follow-up (P<0.0001), whereas patients who were asymptomatic preoperatively experienced a non-significant worsening from 0.88 at baseline to 1.94 at early postoperative follow-up before improving non-significantly to 0.47 at 12 months.

Mean reflux-only scores improved from 1.79 preoperatively to 0.47 at late postoperative follow-up for patients who were symptomatic preoperatively (P=0.0001), whereas patients who were asymptomatic preoperatively experienced increases from 0 at baseline to 0.37 at early postoperative follow-up (P=0.003), with a slight decline to 0.30 at the late postoperative juncture.

Higher preoperative reflux and dysphagia scores, younger age, and lower percentage excess weight loss at 12 months were independently associated with larger reductions in reflux score at 12 months, and all but younger age also predicted lower overall reflux score at 12 months.

"Contrary to popular belief those with heartburn, even moderate to severe, improve and those without pre-operative reflux do not develop clinically significant symptomatology," the researchers conclude. "The specific importance of repairing hiatal weakness cannot be definitively concluded due to the study design; however, given the overall reflux related outcomes demonstrated this approach can be recommended."

Dr. Franco Signorini from Hospital Privado Centro Medico de Cordoba, in Cordoba, Argentina, who recently reported an increased prevalence of GERD symptoms and hiatal hernia following LSG, told Reuters Health by email, "After (our) study, we have changed our indication for obese patients with hiatal hernia from sleeve gastrectomy with hiatal repair to gastric bypass, because we are sure that there is no technical problems with the repair; it is just not effective, probably because of some nausea/vomiting or the fact that the sleeve can migrate through the crura more easily."

"We should not indicate LSG to patients with hiatal hernia," concluded Dr, Signorini, who was not involved in the new study.

Dr. Wadhawan did not respond to a request for comment.

SOURCE: http://bit.ly/2Fm6G5F

Surg Endosc 2017.