OBES SURG (2015) 25:159–166 DOI 10.1007/s11695-014-1470-0
REVIEW ARTICLE
Simultaneous Sleeve Gastrectomy and Hiatus Hernia Repair: a Systematic Review Kamal K. Mahawar & William R. J. Carr & Neil Jennings & Shlok Balupuri & Peter K. Small
Published online: 29 October 2014 # Springer Science+Business Media New York 2014
Abstract Sleeve gastrectomy can exacerbate gastrooesophageal reflux disease in some patients and cause de novo reflux in others. Some surgeons believe Roux-en-Y gastric bypass is the best bariatric surgical procedure for obese patients with hiatus hernia. Others believe that even patients with hiatus hernia can also be safely offered sleeve gastrectomy if combined with a simultaneous hiatus hernia repair. Still, others will offer these patients sleeve gastrectomy without any attempt to diagnose or repair hiatus hernia repair. The effectiveness of concurrent hiatal hernia repair in reducing the incidence of postoperative reflux after sleeve gastrectomy is unclear. This review systematically investigates the results and techniques of simultaneous sleeve gastrectomy and hiatus hernia repair for the treatment of obesity in accordance with PRISMA guidelines.
Keywords Bariatric surgery . Obesity surgery . Sleeve gastrectomy . Hiatus hernia . Para-oesophageal hernia . Sliding hiatus hernia . Crural approximation . Gastro-oesophageal reflux disease . GORD . Reflux
Abbreviations RYGB Roux-en-Y gastric bypass GORD Gastro-oesophageal reflux disease SG Sleeve gastrectomy HH Hiatus hernia PRISMA Preferred reporting items for systematic reviews and meta-analyses PPI Proton pump inhibitor K. K. Mahawar (*) : W. R. J. Carr : N. Jennings : S. Balupuri : P. K. Small Department and Institute: Bariatric Unit, Sunderland Royal Hospital, Sunderland SR4 7TP, UK e-mail: [email protected]
Background Roux-en-Y gastric bypass (RYGB) is considered the gold standard procedure for obese patients with gastro-oesophageal reflux disease (GORD) [1–4]. Although sleeve gastrectomy (SG) can improve GORD [3, 4], some patients undergoing SG experience de novo GORD [5] and others experience worsening of preexisting GORD [6]. The presence of hiatus hernia (HH) is believed to be a risk factor for GORD in the general population and also after SG. HH is present in up to 40 % of morbidly obese patients [7], and its prevalence increases after SG [8]. Most high volume sleeve surgeons recommend aggressively looking for and repairing HH [9] while performing SG. Other surgeons, including our own group, believe that SG should not be offered to obese patients with GORD and/or hiatus hernia, and these patients should preferentially undergo a gastric bypass. However, gastric bypass is not suitable for all patients; there will be patients who cannot undergo a gastric bypass due to Crohn’s disease, significant intra-abdominal adhesions, technical difficulty, patient choice, or surgeon preference. The optimal choice of bariatric procedures for obese patients with GORD and/or HH continues to polarise the bariatric community. It is also unclear if these patients should undergo simultaneous hiatal hernia repair, if they do undergo SG. Many surgeons believe SG is safe in obese patients with HH, only if combined with concurrent closure of hiatal defects [3, 4, 10–13] to reduce the incidence of postoperative reflux. There is, however, currently no consensus [5] that this is helpful and if one does choose to repair the hiatus hernia, on the technique of closure. In the latest survey of SG surgeons [9], significant 31 % surgeons only looked for a HH if shown on preoperative studies or there was a history of GORD. If a HH was found, 11 % surgeons did not repair it. There is no review currently available in literature examining the efficacy of HH repair in obese patients undergoing SG. This review systematically investigates published English language literature in accordance with PRISMA (preferred
160
OBES SURG (2015) 25:159–166
reporting items for systematic reviews and meta-analyses) guidelines to find out the safety, usefulness, and technical aspects of simultaneous SG and hiatal hernia repair for the treatment of obesity complicated by hiatus hernia.
Results
Methods
Basic Demographics
An online search of PubMed, Embase, and Google Scholar was carried out using key words like, “sleeve gastrectomy”, “gastro-oesophageal reflux disease”, “hiatus hernia”, “oesophagitis”, “crural repair”, “crural approximation”. A total of 133 articles were identified. Out of these, 20 articles described simultaneous hiatal defect closure with sleeve gastrectomy. Study by Rodriquez et al. [14], where a simultaneous para-oesophageal hernia repair and a partial longitudinal gastrectomy was carried out, was excluded, as the gastrectomy was not really carried out as a bariatric procedure. The study by Bernante et al. [15] describing emergency sleeve gastrectomy as a rescue treatment for acute gastric necrosis due to para-oesophageal hernia was excluded as the primary intention was not to carry out a bariatric procedure. A further study by Moon et al. [16] was excluded, as authors did not state how many patients underwent hiatal hernia closure in their comparative analysis of revisional SG and RYGB. A total of 17 articles were included in cumulative analysis (Fig. 1).
A total of 737 patients underwent simultaneous SG and hiatal hernia repair in 17 studies. The mean age of patients was 44.1 years (n=134), and 87.8 % (n=123/140) patients were females. The mean BMI was 44 (n=139). The mean followup was 13.9 months. Clear follow-up was stated for only 237 patients. Even where the follow-up was not clearly stated, it was obvious that these were early results and most of these patients were within 2–3 years of surgery.
We included all studies that described concurrent hiatal hernia repair with SG. A total of 17 such studies were identified. Table 1 presents important characteristics of these studies [5, 10–13, 17–28].
Technique of Closure Hiatal hernia repair technique was clearly described in 581 patients in 14 studies. Of these, 285 patients underwent posterior crural approximation, 293 anterior, and a further three only underwent reduction of hernia. All surgeons used nonabsorbable sutures for crural approximation. Additional mesh reinforcement was reported in 31 patients in seven studies [13, 18, 19, 21–23, 28]. All of these surgeons used biological meshes except one group, who used polypropylene mesh [13]. Most of these surgeons closed crura posteriorly [5, 11, 13, 18, 19, 21–23, 25–28]. However, two groups [10, 24] closed crura anteriorly in majority of their patients. It is, however, worth noting that these authors only used anterior crural approximation for hiatal laxities [24], reserving posterior repair for proper hiatal hernia.
Postoperative GORD
Fig. 1 PRISMA flow chart for article selection
All, bar one group, performing concurrent hiatal hernia repair reported favourable results. Santonicola et al. [5] were the only group who were not able to produce satisfactory results. Cumulatively, symptomatic postoperative GORD was seen in 12.6 % (n=54/428) patients. In most patients, it was easily managed on proton pump inhibitor (PPI) with a reduction in need for PPI compared to preoperative status. De novo reflux appears to be particularly reduced with simultaneous HH repair. None of the authors studied postoperative GORD systematically using pH and impedance studies. Though three patients in the study by Angrisani et al. [12] needed conversion to RYGB, this was the only study where the conversion to
OBES SURG (2015) 25:159–166
161
Table 1 Studies that describe simultaneous Sleeve Gastrectomy and Hiatus Hernia Repair Studies
Anterior closure/ posterior closure/ mesh repair
Reflux outcome
Mizrahi et al. [17] Level III No of patients = 14 Mean age = NA Males/females = NA Preoperative BMI = NA Mean follow-up = NA but 5 cm). There was no mortality in this series. After a mean follow-up of 4 months, GORD symptoms resolved in three of the four symptomatic patients and improved considerably in the fourth one. Angrisani et al. [12] These authors reported simultaneous hiatal hernia reduction with cruroplasty in 15 out of 121 patients, who underwent sleeve gastrectomy at their centre between January 2003 and December 2006. Out of these, 16 were planned as two-stage procedures and 105 were planned
as standalone procedures. There was no mortality in this series. Hiatus hernia recurred in three patients in the standalone group. One of these patients had already had a conversion to RYGB when authors published their results and other two were waiting to be converted. Authors do not report a clear follow-up on these patients. Daes et al. [10] In this study, authors described hiatus hernia repair in 34, out of 134 patients, who underwent sleeve gastrectomy between April 2011 to April 2012 and had completed at least 6 months of follow-up. Hiatus hernia was treated by reduction only in three patients, anterior repair in 28, and posterior repair in three. HH was six times more frequent in patients with GORD than those without, and large HH only occurred in patients with GORD. Only two patients had symptoms of GORD at 6–12 months postoperatively; both patients had a small HH without oesophagitis on postoperative endoscopy. These two patients were well treated with proton pump inhibitors and preoperatively both had a large HH. Authors stated that they did not use mesh for large hernias, but since the only two patients with large hiatus hernia had persistent GORD, one wonders if using a mesh for these patients would have yielded different results. Soliman et al. [28] These authors described simultaneous SG and HH repair in 20 patients operated between July 2009 and November 2011. In 18 of these, HH was symptomatic and diagnosed preoperatively. In the other two, HH was asymptomatic and diagnosed intra-operatively. Authors did not report any mortality or complications in these patients. They carried out posterior crural repair using three 2–0 Ethibond interrupted sutures. Prosthetic reinforcement of crural repair was performed in two symptomatic cases with large HH (>5 cm) using polypropylene mesh. Out of the 18 symptomatic patients, 13 reported resolution of GORD symptoms and five reported an improvement (requiring minimal dose of PPI) in their symptoms at a mean follow-up of 7 months.
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Soricelli et al. [11] In this study, authors reported their experience with 97 patients where SG was performed with HH repair between July 2009 and December 2011. HH was diagnosed preoperatively in 42 patients and intra-operatively in 55. Authors considered a fingerprint indentation of the diaphragm just above the oesophagus as suspicious for hiatus hernia. The repair was always carried out posteriorly using two interrupted non-absorbable sutures. Forty-one of these patients suffered with symptomatic GORD preoperatively. Remaining 56 had HH without symptomatic GORD. At a mean follow-up of 18 months, GORD resolved in 33 of 41 symptomatic patients and improved in the remaining eight. Authors did not describe any recurrences of HH. Interestingly, de novo GORD symptoms were noted in 22.9 % of the patients undergoing SG alone compared with 0 % of patients undergoing SG and HH repair. Authors also noted that reflux symptoms always developed within the 6 months of the procedure. Daes et al. [20] These surgeons described simultaneous SG and HH repair in 142 (out of 382) patients who underwent SG between April 2011 and October 2012. Though authors did not clearly state it, it appears that repair was carried out using posterior crural approximation. Authors used non-absorbable monofilament sutures and did not use a mesh in any patient. Eight of these patients suffered with GORD postoperatively. Of the remaining 240 patients, who were not found to have a HH intra-operatively, only two developed GORD postoperatively. They had a minimum follow-up of 6 months on all their patients (range 6–22 months); 119 patients were followed up for 12 months, 124 for 18 months, and 130 for 22 months. Santonicola et al. [5] In this study, all patients with an intraoperative diagnosis of hiatus hernia underwent posterior closure of crura with “0” Ethibond. This group (n=78) was compared with those patients who were not identified to have a HH intra-operatively (n=102) and hence did not undergo crural repair. The incidence of preoperative reflux was 38.4 % (n=30) and 39.2 % (n=40) in the hiatus hernia and no hiatus hernia group, respectively. This is an interesting data considering hiatus hernia is known to predispose to GORD. Mean follow-up was 14.6 months in the sleeve gastrectomy and hiatus hernia repair compared to 17.1 months in the sleeve gastrectomy only group. Authors did not find any significant decrease in GORD symptoms in crural repair group: 30.8 % (24/78) patients had reflux postoperatively as opposed to 38.4 % (30/78) preoperatively. On the other hand, in the no hiatal hernia group, who underwent sleeve gastrectomy without any crural repair, authors found a significant decrease in GORD symptoms; 19.6 % (20/102) patients had postoperative reflux compared to 39.2 % (40/102) preoperatively. Moreover, heartburn and regurgitation frequency scores significantly decreased postoperatively in sleeve gastrectomy only group; no improvement was seen in sleeve gastrectomy with crural
OBES SURG (2015) 25:159–166
repair group. When two groups were compared to each other, crural repair patients had significantly higher heartburn frequency-intensity scores; the regurgitation frequencyintensity scores were also higher but did not reach statistical significance. It is worth noting that this is the only study in literature, which has not shown good results with crural repair. Authors suspected that repair of the hiatus hernia could actually destroy the natural anti-reflux mechanisms thus perpetuating or worsening reflux. They warned against a “very aggressive attitude towards hiatus hernia management”. Pham et al. [19] In this study, authors reported simultaneous SG and para-oesophageal hernia repair in 23 patients between May 2011 and February 2013. Posterior crural repair was carried out, with or without further reinforcement using biological mesh. No patient reported significant GORD on follow-up. The mean follow-up was 6.16 months (range 1 −19 months). Gibson et al. [24] In this study, authors described their experience with 500 SG over a 3-year period. During SG, anterior repair of hiatal laxity was performed in 265 patients and formal posterior repair in 30 patients. The prevalence of GORD reduced from 45 % preoperatively to 6 % (n=30) postoperatively. Postoperative GORD was well controlled in all patients with PPI. Authors do not clearly describe how many of these patients with postoperative GORD underwent HH repair. Mizrahi et al. [17] In this retrospective review of SG performed between 2008 and 2012, authors described concurrent HH repair in 14 patients. They found that older patients (>60 years) had a higher rate of hiatal hernia diagnosed intra-operatively, requiring crural repair (23 % vs. 1.9 %). Authors recommended careful examination and repair of crura intra-operatively. They do not provide any information on technique of crural repair. They simply mention that hiatal hernias were repaired using a “primary repair technique” with a non-absorbable suture. Authors do not clearly state how many patients suffered with GORD postoperatively. These authors reported 100 % follow-up without clearly mentioning the duration of follow-up for patients who had hiatus hernia repair. Their mean follow-up for older and younger patient groups was 17 and 22 months, respectively.
Discussion To the best of our knowledge, this is the first systematic review examining efficacy and technical aspects of simultaneous SG and HH repair in obese patients with HH. There is considerable debate amongst bariatric surgeons regarding the best bariatric procedure for such patients. Many surgeons, including our group,
OBES SURG (2015) 25:159–166
believe that gastric bypass is the best option for obese patients with GORD and/or HH, but despite this approach, we need to manage patients from time to time, who cannot or will not have a gastric bypass for one reason or another. This review demonstrates safety of SG with hiatal hernia repair, in obese subjects, with acceptable postoperative GORD rates. Of all the studies examined in this review, there was only one study [5] that reported poor results from this approach and did not recommend it. It is undeniable that there is a definite prevalence of postoperative GORD in these patients, which in this review was found out to be at 12.6 %. At the same time, it is worth recognising that postoperative GORD is also reported in patients undergoing gastric bypass or those without hiatus hernia/GORD, undergoing SG [4]. The exact rate of postoperative GORD in obese patients with HH, if SG was carried out without HH repair, is currently unclear from scientific literature, and studies with direct comparison of these two approaches are lacking. However, very few surgeons will actually recommend this approach. As was also evident from the latest consensus statement issued by SG surgeons [9], most surgeons recommend aggressive identification and repair of any hiatal hernia during performance of SG. With regards to techniques of closure, most authors advocate posterior crural approximation. Numbers in this review have become somewhat inflated in favour of anterior hiatal closure due to the article by Gibson et al. [24] where they performed anterior repair for hiatal laxity in 265 out of 500 (53 %) patients. Authors say that they carried out a formal posterior repair in 30 patients. This gives the impression that anything more than a slight hiatal laxity needs a posterior repair. Posterior repair is known to be superior for antireflux mechanism, as it restores the normal anti-reflux gastro-oesophageal angle. It is hardly surprising that every single author recommended use of non-absorbable sutures, though a variety of suture materials like Ethibond, silk, prolene, Ticron, etc. were used. Large defects were reinforced with a biological mesh with satisfactory outcomes. The obvious weakness of this review is that it only includes those studies where surgeons have specifically talked about concurrent hiatal hernia repairs during performance of SG. Many other surgeons also carry out hiatal hernia repairs routinely with SG, but in absence of clear published numbers, it is difficult to include that data for the purposes of a review. The retrospective nature of the majority of these reports and potential discrepancies in the diagnosis and classification of hiatal hernia are other weaknesses of this paper.
Conclusion This review demonstrates safety of simultaneous SG and HH repair in published English language scientific literature. It
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can hence be recommended as an acceptable management strategy for obese patients with hiatus hernia with acceptable postoperative GORD rates. There is a need for studies with longer follow-up and direct comparison of this approach with other surgical approaches.
Conflict of Interest The authors declare that they have no conflict of interest. Statement of Human and Animal Rights Not applicable Statement of Informed Consent Not applicable
References 1. Pagé MP, Kastenmeier A, Goldblatt M, Frelich M, Bosler M, Wallace J, Gould J. Medically refractory gastroesophageal reflux disease in the obese: what is the best surgical approach? Surg Endosc. 2013 Dec 6. 2. Li JF, Lai DD, Lin ZH, Jiang TY, Zhang AM, Dai JF. Comparison of the long-term results of Roux-en-Y gastric bypass and sleeve gastrectomy for morbid obesity: a systematic review and meta-analysis of randomized and nonrandomized trials. Surg Laparosc Endosc Percutan Tech. 2014 3. Peterli R, Borbély Y, Kern B, et al. Early results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): a prospective randomized trial comparing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. Ann Surg. 2013;258(5):690–4. 4. Pallati PK, Shaligram A, Shostrom VK, et al. Improvement in gastroesophageal reflux disease symptoms after various bariatric procedures: review of the Bariatric Outcomes Longitudinal Database. Surg Obes Relat Dis. 2013. doi:10.1016/j.soard.2013.07.018. 5. Santonicola A, Angrisani L, Cutolo P, et al. The effect of laparoscopic sleeve gastrectomy with or without hiatal hernia repair on gastroesophageal reflux disease in obese patients. Surg Obes Relat Dis. 2013. doi:10.1016/j.soard.2013.09.006. 6. Dupree CE, Blair K, Steele SR, et al. Laparoscopic sleeve gastrectomy in patients with preexisting gastroesophageal reflux disease: a national analysis. JAMA Surg. 2014. doi:10.1001/jamasurg.2013. 4323. 7. Che F, Nguyen B, Cohen A, et al. Prevalence of hiatal hernia in the morbidly obese. Surg Obes Relat Dis. 2013;9(6):920–4. 8. Tai CM, Huang CK, Lee YC, et al. Increase in gastroesophageal reflux disease symptoms and erosive esophagitis 1 year after laparoscopic sleeve gastrectomy among obese adults. Surg Endosc. 2013;27(4):1260–6. 9. Gagner M, Deitel M, Erickson AL, et al. Survey on laparoscopic sleeve gastrectomy (LSG) at the Fourth International Consensus Summit on Sleeve Gastrectomy. Obes Surg. 2013;23:2013–7. 10. Daes J, Jimenez ME, Said N, et al. Laparoscopic sleeve gastrectomy: symptoms of gastroesophageal reflux can be reduced by changes in surgical technique. Obes Surg. 2012;22(12):1874–9. 11. Soricelli E, Iossa A, Casella G, et al. Sleeve gastrectomy and crural repair in obese patients with gastroesophageal reflux disease and/or hiatal hernia. Surg Obes Relat Dis. 2013;9(3):356–61. 12. Angrisani L, Cutolo PP, Buchwald JN, et al. Laparoscopic reinforced sleeve gastrectomy: early results and complications. Obes Surg. 2011;21(6):783–93. 13. Soricelli E, Casella G, Rizzello M, et al. Initial experience with laparoscopic crural closure in the management of hiatal hernia in
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OBES SURG (2015) 25:159–166 obese patients undergoing sleeve gastrectomy. Obes Surg. 2010;20(8):1149–53. Rodriguez JH, Kroh M, El-Hayek K, et al. Combined paraesophageal hernia repair and partial longitudinal gastrectomy in obese patients with symptomatic paraesophageal hernias. Surg Endosc. 2012;26(12):3382–90. Bernante P, Breda C, Zangrandi F, et al. Emergency sleeve gastrectomy as rescue treatment for acute gastric necrosis due to type II paraesophageal hernia in an obese woman with gastric banding. Obes Surg. 2008;18(6):737–41. doi:10.1007/s11695-007-9374-x. Moon RC, Teixeira AF, Jawad MA. Conversion of failed laparoscopic adjustable gastric banding: sleeve gastrectomy or Roux-en-Y gastric bypass? Surg Obes Relat Dis. 2013;9(6):901–7. doi:10.1016/j. soard.2013.04.003. Mizrahi I, Alkurd A, Ghanem M, Zugayar D, Mazeh H, Eid A, Beglaibter N, Grinbaum R. Outcomes of laparoscopic sleeve gastrectomy in patients older than 60 years. Obes Surg. 2014 Jan 19. Clapp B. Prosthetic bioabsorbable mesh for hiatal hernia repair during sleeve gastrectomy. SLS. 2013;17(4):641–4. doi:10.4293/ 108680813X13693422520008. Pham DV, Protyniak B, Binenbaum SJ, et al. Simultaneous laparoscopic paraesophageal hernia repair and sleeve gastrectomy in the morbidly obese. Surg Obes Relat Dis. 2013. doi:10.1016/j.soard. 2013.08.003. Daes J, Jimenez ME, Said N, Dennis R. Improvement of gastroesophageal reflux symptoms after standardized laparoscopic sleeve gastrectomy. Obes Surg. 2013 Nov 8.
21. Korwar V, Peters M, Adjepong S, et al. Laparoscopic hiatus hernia repair and simultaneous sleeve gastrectomy: a novel approach in the treatment of gastroesophageal reflux disease associated with morbid obesity. J Laparoendosc Adv Surg Technol A. 2009;19(6):761–3. 22. Merchant AM, Cook MW, Srinivasan J, et al. Comparison between laparoscopic paraesophageal hernia repair with sleeve gastrectomy and paraesophageal hernia repair alone in morbidly obese patients. Am Surg. 2009;75(7):620–5. 23. Varela JE. Laparoscopic biomesh hiatoplasty and sleeve gastrectomy in a morbidly obese patient with hiatal hernia. Surg Obes Relat Dis. 2009;5(6):707–9. doi:10.1016/j.soard.2009.02.003. 24. Gibson SC, Le Page PA, Taylor CJ. Laparoscopic sleeve gastrectomy: review of 500 cases in single surgeon Australian practice. ANZ J Surg. 2013. doi:10.1111/ans.12483. 25. Cuenca-Abente F, Parra JD, Oelschlager BK. Laparoscopic sleeve gastrectomy: an alternative for recurrent paraesophageal hernias in obese patients. JSLS. 2006;10(1):86–9. 26. Kotak R, Murr M. Recurrent hiatal hernia repair after sleeve gastrectomy. Surg Obes Relat Dis. 2013;9(6):1027–8. doi:10.1016/j.soard. 2013.06.016. 27. Parikh M, Gagner M. Laparoscopic hiatal hernia repair and repeat sleeve gastrectomy for gastroesophageal reflux disease after duodenal switch. Surg Obes Relat Dis. 2008;4(1):73–5. 28. Soliman AM, Maged H, Awad AM, et al. Laparoscopic crural repair with simultaneous sleeve gastrectomy: a way in gastroesophageal reflux disease treatment associated with morbid obesity. J Minim Invasive Surg Sci. 2012;1(2):67–73.
REVIEW ARTICLE
Simultaneous Sleeve Gastrectomy and Hiatus Hernia Repair: a Systematic Review Kamal K. Mahawar & William R. J. Carr & Neil Jennings & Shlok Balupuri & Peter K. Small
Published online: 29 October 2014 # Springer Science+Business Media New York 2014
Abstract Sleeve gastrectomy can exacerbate gastrooesophageal reflux disease in some patients and cause de novo reflux in others. Some surgeons believe Roux-en-Y gastric bypass is the best bariatric surgical procedure for obese patients with hiatus hernia. Others believe that even patients with hiatus hernia can also be safely offered sleeve gastrectomy if combined with a simultaneous hiatus hernia repair. Still, others will offer these patients sleeve gastrectomy without any attempt to diagnose or repair hiatus hernia repair. The effectiveness of concurrent hiatal hernia repair in reducing the incidence of postoperative reflux after sleeve gastrectomy is unclear. This review systematically investigates the results and techniques of simultaneous sleeve gastrectomy and hiatus hernia repair for the treatment of obesity in accordance with PRISMA guidelines.
Keywords Bariatric surgery . Obesity surgery . Sleeve gastrectomy . Hiatus hernia . Para-oesophageal hernia . Sliding hiatus hernia . Crural approximation . Gastro-oesophageal reflux disease . GORD . Reflux
Abbreviations RYGB Roux-en-Y gastric bypass GORD Gastro-oesophageal reflux disease SG Sleeve gastrectomy HH Hiatus hernia PRISMA Preferred reporting items for systematic reviews and meta-analyses PPI Proton pump inhibitor K. K. Mahawar (*) : W. R. J. Carr : N. Jennings : S. Balupuri : P. K. Small Department and Institute: Bariatric Unit, Sunderland Royal Hospital, Sunderland SR4 7TP, UK e-mail: [email protected]
Background Roux-en-Y gastric bypass (RYGB) is considered the gold standard procedure for obese patients with gastro-oesophageal reflux disease (GORD) [1–4]. Although sleeve gastrectomy (SG) can improve GORD [3, 4], some patients undergoing SG experience de novo GORD [5] and others experience worsening of preexisting GORD [6]. The presence of hiatus hernia (HH) is believed to be a risk factor for GORD in the general population and also after SG. HH is present in up to 40 % of morbidly obese patients [7], and its prevalence increases after SG [8]. Most high volume sleeve surgeons recommend aggressively looking for and repairing HH [9] while performing SG. Other surgeons, including our own group, believe that SG should not be offered to obese patients with GORD and/or hiatus hernia, and these patients should preferentially undergo a gastric bypass. However, gastric bypass is not suitable for all patients; there will be patients who cannot undergo a gastric bypass due to Crohn’s disease, significant intra-abdominal adhesions, technical difficulty, patient choice, or surgeon preference. The optimal choice of bariatric procedures for obese patients with GORD and/or HH continues to polarise the bariatric community. It is also unclear if these patients should undergo simultaneous hiatal hernia repair, if they do undergo SG. Many surgeons believe SG is safe in obese patients with HH, only if combined with concurrent closure of hiatal defects [3, 4, 10–13] to reduce the incidence of postoperative reflux. There is, however, currently no consensus [5] that this is helpful and if one does choose to repair the hiatus hernia, on the technique of closure. In the latest survey of SG surgeons [9], significant 31 % surgeons only looked for a HH if shown on preoperative studies or there was a history of GORD. If a HH was found, 11 % surgeons did not repair it. There is no review currently available in literature examining the efficacy of HH repair in obese patients undergoing SG. This review systematically investigates published English language literature in accordance with PRISMA (preferred
160
OBES SURG (2015) 25:159–166
reporting items for systematic reviews and meta-analyses) guidelines to find out the safety, usefulness, and technical aspects of simultaneous SG and hiatal hernia repair for the treatment of obesity complicated by hiatus hernia.
Results
Methods
Basic Demographics
An online search of PubMed, Embase, and Google Scholar was carried out using key words like, “sleeve gastrectomy”, “gastro-oesophageal reflux disease”, “hiatus hernia”, “oesophagitis”, “crural repair”, “crural approximation”. A total of 133 articles were identified. Out of these, 20 articles described simultaneous hiatal defect closure with sleeve gastrectomy. Study by Rodriquez et al. [14], where a simultaneous para-oesophageal hernia repair and a partial longitudinal gastrectomy was carried out, was excluded, as the gastrectomy was not really carried out as a bariatric procedure. The study by Bernante et al. [15] describing emergency sleeve gastrectomy as a rescue treatment for acute gastric necrosis due to para-oesophageal hernia was excluded as the primary intention was not to carry out a bariatric procedure. A further study by Moon et al. [16] was excluded, as authors did not state how many patients underwent hiatal hernia closure in their comparative analysis of revisional SG and RYGB. A total of 17 articles were included in cumulative analysis (Fig. 1).
A total of 737 patients underwent simultaneous SG and hiatal hernia repair in 17 studies. The mean age of patients was 44.1 years (n=134), and 87.8 % (n=123/140) patients were females. The mean BMI was 44 (n=139). The mean followup was 13.9 months. Clear follow-up was stated for only 237 patients. Even where the follow-up was not clearly stated, it was obvious that these were early results and most of these patients were within 2–3 years of surgery.
We included all studies that described concurrent hiatal hernia repair with SG. A total of 17 such studies were identified. Table 1 presents important characteristics of these studies [5, 10–13, 17–28].
Technique of Closure Hiatal hernia repair technique was clearly described in 581 patients in 14 studies. Of these, 285 patients underwent posterior crural approximation, 293 anterior, and a further three only underwent reduction of hernia. All surgeons used nonabsorbable sutures for crural approximation. Additional mesh reinforcement was reported in 31 patients in seven studies [13, 18, 19, 21–23, 28]. All of these surgeons used biological meshes except one group, who used polypropylene mesh [13]. Most of these surgeons closed crura posteriorly [5, 11, 13, 18, 19, 21–23, 25–28]. However, two groups [10, 24] closed crura anteriorly in majority of their patients. It is, however, worth noting that these authors only used anterior crural approximation for hiatal laxities [24], reserving posterior repair for proper hiatal hernia.
Postoperative GORD
Fig. 1 PRISMA flow chart for article selection
All, bar one group, performing concurrent hiatal hernia repair reported favourable results. Santonicola et al. [5] were the only group who were not able to produce satisfactory results. Cumulatively, symptomatic postoperative GORD was seen in 12.6 % (n=54/428) patients. In most patients, it was easily managed on proton pump inhibitor (PPI) with a reduction in need for PPI compared to preoperative status. De novo reflux appears to be particularly reduced with simultaneous HH repair. None of the authors studied postoperative GORD systematically using pH and impedance studies. Though three patients in the study by Angrisani et al. [12] needed conversion to RYGB, this was the only study where the conversion to
OBES SURG (2015) 25:159–166
161
Table 1 Studies that describe simultaneous Sleeve Gastrectomy and Hiatus Hernia Repair Studies
Anterior closure/ posterior closure/ mesh repair
Reflux outcome
Mizrahi et al. [17] Level III No of patients = 14 Mean age = NA Males/females = NA Preoperative BMI = NA Mean follow-up = NA but 5 cm). There was no mortality in this series. After a mean follow-up of 4 months, GORD symptoms resolved in three of the four symptomatic patients and improved considerably in the fourth one. Angrisani et al. [12] These authors reported simultaneous hiatal hernia reduction with cruroplasty in 15 out of 121 patients, who underwent sleeve gastrectomy at their centre between January 2003 and December 2006. Out of these, 16 were planned as two-stage procedures and 105 were planned
as standalone procedures. There was no mortality in this series. Hiatus hernia recurred in three patients in the standalone group. One of these patients had already had a conversion to RYGB when authors published their results and other two were waiting to be converted. Authors do not report a clear follow-up on these patients. Daes et al. [10] In this study, authors described hiatus hernia repair in 34, out of 134 patients, who underwent sleeve gastrectomy between April 2011 to April 2012 and had completed at least 6 months of follow-up. Hiatus hernia was treated by reduction only in three patients, anterior repair in 28, and posterior repair in three. HH was six times more frequent in patients with GORD than those without, and large HH only occurred in patients with GORD. Only two patients had symptoms of GORD at 6–12 months postoperatively; both patients had a small HH without oesophagitis on postoperative endoscopy. These two patients were well treated with proton pump inhibitors and preoperatively both had a large HH. Authors stated that they did not use mesh for large hernias, but since the only two patients with large hiatus hernia had persistent GORD, one wonders if using a mesh for these patients would have yielded different results. Soliman et al. [28] These authors described simultaneous SG and HH repair in 20 patients operated between July 2009 and November 2011. In 18 of these, HH was symptomatic and diagnosed preoperatively. In the other two, HH was asymptomatic and diagnosed intra-operatively. Authors did not report any mortality or complications in these patients. They carried out posterior crural repair using three 2–0 Ethibond interrupted sutures. Prosthetic reinforcement of crural repair was performed in two symptomatic cases with large HH (>5 cm) using polypropylene mesh. Out of the 18 symptomatic patients, 13 reported resolution of GORD symptoms and five reported an improvement (requiring minimal dose of PPI) in their symptoms at a mean follow-up of 7 months.
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Soricelli et al. [11] In this study, authors reported their experience with 97 patients where SG was performed with HH repair between July 2009 and December 2011. HH was diagnosed preoperatively in 42 patients and intra-operatively in 55. Authors considered a fingerprint indentation of the diaphragm just above the oesophagus as suspicious for hiatus hernia. The repair was always carried out posteriorly using two interrupted non-absorbable sutures. Forty-one of these patients suffered with symptomatic GORD preoperatively. Remaining 56 had HH without symptomatic GORD. At a mean follow-up of 18 months, GORD resolved in 33 of 41 symptomatic patients and improved in the remaining eight. Authors did not describe any recurrences of HH. Interestingly, de novo GORD symptoms were noted in 22.9 % of the patients undergoing SG alone compared with 0 % of patients undergoing SG and HH repair. Authors also noted that reflux symptoms always developed within the 6 months of the procedure. Daes et al. [20] These surgeons described simultaneous SG and HH repair in 142 (out of 382) patients who underwent SG between April 2011 and October 2012. Though authors did not clearly state it, it appears that repair was carried out using posterior crural approximation. Authors used non-absorbable monofilament sutures and did not use a mesh in any patient. Eight of these patients suffered with GORD postoperatively. Of the remaining 240 patients, who were not found to have a HH intra-operatively, only two developed GORD postoperatively. They had a minimum follow-up of 6 months on all their patients (range 6–22 months); 119 patients were followed up for 12 months, 124 for 18 months, and 130 for 22 months. Santonicola et al. [5] In this study, all patients with an intraoperative diagnosis of hiatus hernia underwent posterior closure of crura with “0” Ethibond. This group (n=78) was compared with those patients who were not identified to have a HH intra-operatively (n=102) and hence did not undergo crural repair. The incidence of preoperative reflux was 38.4 % (n=30) and 39.2 % (n=40) in the hiatus hernia and no hiatus hernia group, respectively. This is an interesting data considering hiatus hernia is known to predispose to GORD. Mean follow-up was 14.6 months in the sleeve gastrectomy and hiatus hernia repair compared to 17.1 months in the sleeve gastrectomy only group. Authors did not find any significant decrease in GORD symptoms in crural repair group: 30.8 % (24/78) patients had reflux postoperatively as opposed to 38.4 % (30/78) preoperatively. On the other hand, in the no hiatal hernia group, who underwent sleeve gastrectomy without any crural repair, authors found a significant decrease in GORD symptoms; 19.6 % (20/102) patients had postoperative reflux compared to 39.2 % (40/102) preoperatively. Moreover, heartburn and regurgitation frequency scores significantly decreased postoperatively in sleeve gastrectomy only group; no improvement was seen in sleeve gastrectomy with crural
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repair group. When two groups were compared to each other, crural repair patients had significantly higher heartburn frequency-intensity scores; the regurgitation frequencyintensity scores were also higher but did not reach statistical significance. It is worth noting that this is the only study in literature, which has not shown good results with crural repair. Authors suspected that repair of the hiatus hernia could actually destroy the natural anti-reflux mechanisms thus perpetuating or worsening reflux. They warned against a “very aggressive attitude towards hiatus hernia management”. Pham et al. [19] In this study, authors reported simultaneous SG and para-oesophageal hernia repair in 23 patients between May 2011 and February 2013. Posterior crural repair was carried out, with or without further reinforcement using biological mesh. No patient reported significant GORD on follow-up. The mean follow-up was 6.16 months (range 1 −19 months). Gibson et al. [24] In this study, authors described their experience with 500 SG over a 3-year period. During SG, anterior repair of hiatal laxity was performed in 265 patients and formal posterior repair in 30 patients. The prevalence of GORD reduced from 45 % preoperatively to 6 % (n=30) postoperatively. Postoperative GORD was well controlled in all patients with PPI. Authors do not clearly describe how many of these patients with postoperative GORD underwent HH repair. Mizrahi et al. [17] In this retrospective review of SG performed between 2008 and 2012, authors described concurrent HH repair in 14 patients. They found that older patients (>60 years) had a higher rate of hiatal hernia diagnosed intra-operatively, requiring crural repair (23 % vs. 1.9 %). Authors recommended careful examination and repair of crura intra-operatively. They do not provide any information on technique of crural repair. They simply mention that hiatal hernias were repaired using a “primary repair technique” with a non-absorbable suture. Authors do not clearly state how many patients suffered with GORD postoperatively. These authors reported 100 % follow-up without clearly mentioning the duration of follow-up for patients who had hiatus hernia repair. Their mean follow-up for older and younger patient groups was 17 and 22 months, respectively.
Discussion To the best of our knowledge, this is the first systematic review examining efficacy and technical aspects of simultaneous SG and HH repair in obese patients with HH. There is considerable debate amongst bariatric surgeons regarding the best bariatric procedure for such patients. Many surgeons, including our group,
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believe that gastric bypass is the best option for obese patients with GORD and/or HH, but despite this approach, we need to manage patients from time to time, who cannot or will not have a gastric bypass for one reason or another. This review demonstrates safety of SG with hiatal hernia repair, in obese subjects, with acceptable postoperative GORD rates. Of all the studies examined in this review, there was only one study [5] that reported poor results from this approach and did not recommend it. It is undeniable that there is a definite prevalence of postoperative GORD in these patients, which in this review was found out to be at 12.6 %. At the same time, it is worth recognising that postoperative GORD is also reported in patients undergoing gastric bypass or those without hiatus hernia/GORD, undergoing SG [4]. The exact rate of postoperative GORD in obese patients with HH, if SG was carried out without HH repair, is currently unclear from scientific literature, and studies with direct comparison of these two approaches are lacking. However, very few surgeons will actually recommend this approach. As was also evident from the latest consensus statement issued by SG surgeons [9], most surgeons recommend aggressive identification and repair of any hiatal hernia during performance of SG. With regards to techniques of closure, most authors advocate posterior crural approximation. Numbers in this review have become somewhat inflated in favour of anterior hiatal closure due to the article by Gibson et al. [24] where they performed anterior repair for hiatal laxity in 265 out of 500 (53 %) patients. Authors say that they carried out a formal posterior repair in 30 patients. This gives the impression that anything more than a slight hiatal laxity needs a posterior repair. Posterior repair is known to be superior for antireflux mechanism, as it restores the normal anti-reflux gastro-oesophageal angle. It is hardly surprising that every single author recommended use of non-absorbable sutures, though a variety of suture materials like Ethibond, silk, prolene, Ticron, etc. were used. Large defects were reinforced with a biological mesh with satisfactory outcomes. The obvious weakness of this review is that it only includes those studies where surgeons have specifically talked about concurrent hiatal hernia repairs during performance of SG. Many other surgeons also carry out hiatal hernia repairs routinely with SG, but in absence of clear published numbers, it is difficult to include that data for the purposes of a review. The retrospective nature of the majority of these reports and potential discrepancies in the diagnosis and classification of hiatal hernia are other weaknesses of this paper.
Conclusion This review demonstrates safety of simultaneous SG and HH repair in published English language scientific literature. It
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can hence be recommended as an acceptable management strategy for obese patients with hiatus hernia with acceptable postoperative GORD rates. There is a need for studies with longer follow-up and direct comparison of this approach with other surgical approaches.
Conflict of Interest The authors declare that they have no conflict of interest. Statement of Human and Animal Rights Not applicable Statement of Informed Consent Not applicable
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