Background: GERD is a known complication of bariatric banding procedures. Recently the sleeve gastrectomy (SG) has emerged as a viable bariatric procedure, which is being increasingly performed. The long-term complications of this procedure are not well described. This study reviewed our experience with symptomatic hiatal hernias (HH) and its management in patients after SG as part of their bariatric procedure.
Methods:A retrospective review was performed on the records of 755 patient who underwent bariatric procedures from 6/20/02 to 8/20/06 in our practice. 194 patients underwent vertical banded gastroplasty (VBG) with SG, 186-SG alone and 375-SG as part of duodenal switch procedure. Patients with severe reflux or documented complications of GERD underwent either gastric bypass and or HH repair at the time of their bariatric procedure. Those were excluded from this study.
Results: In the VBG-SG group, 36% of patients required resumption of medical treatment for symptoms after stopping the post-operative 6 months protocol regimen of proton pump inhibitors (PPI). The patients who required further intervention for persistent nausea and vomiting were 12.6 %. These presented with chronic cough in one and nausea and vomiting in 7. Interestingly, pain and heartburn were not the primary complaints. The other two groups which included SG alone and SG with duodenal switch did not show any persistent symptoms needing any intervention. Measures for the symptomatic group included metoclopramide, dietary adjustments and doubling of PPI dosages. Symptoms persisted in 8 patients, who eventually received omental wrap procedure. All of these were females with 35-50 years age range. These symptoms appeared after an average of one year following the bariatric procedure and persisted for 2-3 months. Pre-operative EGD, upper GI with swallow and pH studies showed 5 cm HH and significant reflux in all 8 patients. Two of these 8 patients had a 2 cm HH which was found on EGD before the bariatric procedure. The pH studies showed a mean demister score of 26. After the omental wrap procedure, the mean demister score dropped to 12 with significant symptomatic improvement. There was one recurrence of HH in a patient who became pregnant.The prevalence of HH in VBG-SG group as a whole was 26% (51/194) diagnosed pre-operatively.
Conclusions: Omental sling wrap is an effective procedure for management of HH in the absence of gastric fundus. Presenting symptoms in our series were mainly nausea, vomiting and cough with notable absence of heartburn. The pH studies and demister score are still a reliable way in the diagnosis and follow-up of theses patients.