GASTROESOPHAGEAL REFLUX AFTER HIATAL HERNIA REPAIR: CAN PREOPERATIVE SYMPTOMS HELP PREDICT?
Jessica C. Heard*1, Mira Ibrahim2, Jashwanth Karumuri1, Houssam Osman1, D Rohan Jeyarajah1,2
1Hepatobilary Surgery, Methodist Richardson Medical Center, Richardson, TX; 2University of North Texas Health Science Center, Fort Worth, TX
INTRODUCTION: Gastroesophageal reflux disease (GERD) occurs after hiatal hernia repair (HHR) with fundoplication in up to 30% of cases. While predictors of hernia recurrence have been an intense research focus, little has been done to determine if patient reported symptoms may predict postoperative GERD development among HHR patients.
METHODS: This is a retrospective single-center review of consecutive patients who underwent HHR with intraoperative impedance planimetry between 2020 and 2022. Patients undergoing concurrent weight loss procedures were excluded. A binary logistic regression with bootstrapping to simulate 1,000 observations was performed with postoperative GERD regressed onto preoperative symptoms, body mass index (BMI), and cruroplasty only HHR.
RESULTS: Overall, 63 patients underwent HHR alone (60.3%) or with fundoplication (6.3% Dor, 22.2% Toupet, 9.5% Nissen, 1.6% Hill). There were 13 (20.6%) redo repairs. The mean BMI was 28.9 ± 3.3. The overall median final DI was 2.0 (IQR 1.35) and there was no difference (p = 0.391) based on postoperative GERD status. All but 1 patient with preoperative GERD had improvement or resolution of their preoperative symptoms. Some degree of postoperative GERD was reported in 20 (31.7%) patients during the median 107 (IQR 197) days of follow-up. Table 1 displays the rate of patient reported preoperative symptoms based on postoperative GERD development.
Regression analysis was performed for all 61 patients with complete data. BMI was the only significant factor (p = 0.018) identified that was predictive of postoperative GERD with an odds ratio of 0.77. While not reaching statistical significance, preoperative reported dysphagia (p = 0.089) along with nausea and vomiting (p = 0.055) produced odds ratios of 4.27 and 4.03, respectively. Other non-significant factors included preoperative GERD (OR -3.88, p = 0.825), shortness of breath (OR -3.24, p = 0.521), and cruroplasty only HHR (OR -0.22, p = 0.139).
CONCLUSION: While BMI remains the greatest predictor of postoperative GERD after repair of a symptomatic hiatal hernia, patients with preoperative nausea and vomiting may require additional studies to elucidate occult pathology and prevent postoperative GERD symptoms. While non-specific, preoperative nausea and vomiting may be related to undiagnosed gastric emptying dysfunction, particularly within this study population where diabetes and reoperations were common. Dysfunctional gastric emptying has previously been linked to GERD symptoms. Dysphagia's relationship to postoperative GERD is likely a spurious finding due to preoperative surgeon-patient preference for mild GERD over dysphagia. Interestingly, the results of this study demonstrate cruroplasty only HHR and impedance planimetrydistensibilties were not key factors in postoperative GERD development.
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