Repairing small type I hiatal hernias at the time of RYGB is not necessary to achieve resolution of reflux symptoms,Surgical Endoscopy

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Repairing small type I hiatal hernias at the time of RYGB is not necessary to achieve resolution of reflux symptoms
Surgical Endoscopy ( IF 2.4 ) Pub Date : 2022-09-27 , DOI: 10.1007/s00464-022-09653-5
Ashley Khouri ₁ , Paige Martinez ₂ , Madison Kieffer ₁ , Eric Volckmann ₂ , Jennwood Chen ₂ , Ellen Morrow ₂ , Natalie Turner ₂ , Anna Ibele ₂

Affiliation

Introduction

Roux-en-Y gastric bypass (RYGB) is the gold standard operation for gastroesophageal reflux disease (GERD) in patients with severe obesity, but there is variability in surgeon opinion regarding whether small type I hiatal hernias (HH) require routine repair concurrently with RYGB. We sought to examine whether leaving small type I HHs unrepaired during RYGB affected GERD outcomes.

Methods

Pre-operatively our patients all receive endoscopy, and select patients with reflux symptoms receive esophagram based on attending surgeon practice and preference. We routinely repair paraesophageal hernias (PEH) concurrently with RYGB, but refrain from repairing small type I HH if, intra-operatively, the gastric fat pad and cardia are below the diaphragm with no evidence of retraction into the mediastinum. Records from 268 consecutive patients undergoing primary RYGB between January 2016 and February 2021 who completed pre-operative GERD–HRQL assessments were reviewed for presence of type I HH or PEH. Mann–Whitney U tests examined the pre-operative to post-operative change in GERD–HRQL in patients with type I HH left unrepaired at the time of RYGB (HH group) and patients with no hernia (NH group).

Results

Pre-operatively, GERD–HRQL scores were not statistically different between HH group (median = 7, mean = 8.5, n = 100) and NH group (median = 6.5, mean = 7.2, n = 141) (p > 0.05). Post-operatively, there was no increase in GERD–HRQL scores patients whose hernias were left unrepaired. Neither group had clinically pathologic post-operative GERD–HRQL scores, with median 6 months scores of 1 for HH group (n = 68) versus 1.5 for NH group (n = 90) (p > 0.05), and median 12 months scores of 1.5 for HH group (n = 40) versus 1 for NH group (n = 56) (p > 0.05).

Conclusion

Repair of small type I HH is not necessary to achieve effective, durable resolution of reflux symptoms with RYGB. Omitting repair reduces operative time, cost, and potential risk without adverse impact on post-operative reflux symptoms.

Graphical abstract

中文翻译：

在 RYGB 时修复小 I 型食管裂孔疝对于解决反流症状不是必需的

介绍

Roux-en-Y 胃旁路术 (RYGB) 是治疗严重肥胖患者胃食管反流病 (GERD) 的金标准手术，但外科医生对小 I 型食管裂孔疝 (HH) 是否需要同时进行常规修复的意见存在差异RYGB。我们试图检查在 RYGB 期间不修复小型 I 型 HH 是否会影响 GERD 结果。

方法

术前我们的患者都接受内窥镜检查，并根据主治外科医生的实践和偏好选择有反流症状的患者接受食道造影。我们通常与 RYGB 同时修复食管旁疝 (PEH)，但如果在术中胃脂肪垫和贲门位于横隔膜下方且没有回缩到纵隔的证据，则避免修复小 I 型 HH。对 2016 年 1 月至 2021 年 2 月期间接受原发性 RYGB 并完成术前 GERD-HRQL 评估的 268 名连续患者的记录进行了审查，以确定是否存在 I 型 HH 或 PEH。Mann-Whitney U检验检查了在 RYGB 时未修复的 I 型 HH 患者（HH 组）和无疝气患者（NH 组）中 GERD-HRQL 术前至术后的变化。

结果

术前，HH 组（中位数 = 7，平均值 = 8.5，n = 100）和 NH 组（中位数 = 6.5，平均值 = 7.2，n = 141）之间的 GERD-HRQL 评分无统计学差异（p > 0.05）。术后，疝气未修复的患者的 GERD-HRQL 评分没有增加。两组均无临床病理术后 GERD-HRQL 评分，HH 组（n = 68）的 6 个月中位数评分为 1，NH 组（ n = 90）为 1.5 （ p > 0.05），12 个月的中位数评分为HH 组 ( n = 40)为 1.5 ，而 NH 组 ( n = 56) 为 1 ( p > 0.05)。