HIATAL HERNIA REPAIR IS NON-INFERIOR TO BYPASS IN THE TREATMENT OF POST-SLEEVE REFLUX: EARLY AND LATE FOLLOW-UP
Ben Indja*2, Daniel L. Chan1, Michael Talbot1,2
1Department of Surgery, University of New South Wales, Sydney, New South Wales, Australia; 2St George Hospital, Sydney, New South Wales, Australia
Purpose
Gastroesophageal reflux is a known complication following laparoscopic sleeve gastrectomy (LSG) as the anatomical and physiological changes predispose to reduced lower oesophageal sphincter pressure, increased intragastric pressure and development of hiatus hernia. In patients whose symptoms do not respond to medical therapy, the mainstay of surgical management has been conversion to a Roux-en-Y gastric bypass (RYGB), however this procedure it not without its own risks. Hiatus hernia repair (HHR) is a simple procedure that can specifically target a number of the anatomical changes responsible for reflux in this population. One-anastomosis duodenal switch (OADS) is a less common procedure that targets specific post sleeve anatomical changes which predispose to reflux.
Method
We conducted a single centre retrospective analysis from 2010 to 2020 including adult patients with prior LSG presenting with gastroesophageal reflux refractory to medical therapy. Short term clinic follow-up of 84 patients assessed symptoms of reflux in 4 categories (1) symptom free without PPI therapy, (2) Occasional symptoms, controlled with breakthrough PPI, (3) Symptoms controlled with regular PPI therapy (4) Uncontrolled symptoms not managed with maximal PPI therapy. 33 patients were available for long term follow-up and reflux symptoms were assessed via the Visick score and GerdQ questionnaire.
Results
A total of 84 patients met inclusion criteria with 49 HHR, 26 RYGB and 9 OADS. Early clinic follow-up demonstrated control of reflux symptoms in 67.3% after HHR, 80.4% after RYGB and 100% after OADS with no significant difference demonstrated between groups (X2(2)=4.99, p=0.8)
A total of 33 patients completed long term follow-up (average 47+-33 months) 18 HHR, 10 RYGB and 5 OADS. The mean Visick score for HHR was 2.2, RYGB 2.0 and DS 2.2 with no significant difference demonstrated between groups (F(2,30)=0.166, p=0.85). The mean GerdQ score for HHR was 7.5, RYGB 7.9 and DS 5.0 with no significant difference demonstrated between groups (F(2,30)=3.16, p=0.06). Patients who did not require ongoing PPI therapy included 33.3% for HHR, 30% for RYGB and 20% for OADS with the remainder requiring symptomatic or regular PPI no significant difference demonstrated between groups (X2(3)=2.98, p=0.56)
Conclusion
HHR is a low risk surgical intervention for sleeve related reflux which could be considered as a primary surgical option given similar outcomes when compared to RYGB and OADS without the associated risks and long-term morbidity, whilst also not preventing alternative procedures being performed in the future.
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