title: The Effect of Laparoscopic Sleeve Gastrectomy with Concomitant Hiatal Hernia Repair on Gastroesophageal Reflux Disease in the Morbidly Obese.
abstract: BACKGROUND
  The effect of laparoscopic sleeve gastrectomy (LSG) on gastroesophageal reflux disease (GERD) is controversial. Although concomitant hiatal hernia repair (HHR) at the time of LSG is common and advocated by many, there are few data on the outcomes of GERD symptoms in these patients. The aim of this study was to evaluate the effect of concomitant HHR on GERD symptoms in morbidly obese patients undergoing LSG.
  
  
  METHODS
  A single institution, multi-surgeon, prospectively maintained database was examined to identify patients who underwent LSG and concomitant HHR from December 2010 to October 2013. Patient characteristics, operative details, and postoperative outcomes were analyzed. Standardized patient questionnaires administered both pre- and postoperatively were utilized. Primary endpoints included subjective reflux symptoms and the need for antisecretory therapy. Weight loss was considered a secondary endpoint.
  
  
  RESULTS
  Fifty-eight patients were identified meeting inclusion criteria (LSG + HHR), with a mean follow-up of 97.5 weeks (range 44-172 weeks). The mean age of the cohort was 49.5 ± 11.2 years, with 74.1 % being female. Mean preoperative BMI was 44.2 ± 6.6 kg/m(2). Preoperative upper gastrointestinal contrast series was performed in all patients and demonstrated a hiatal hernia in 34.5 % of patients and reflux in 15.5 % of patients. Preoperatively, 44.8 % (n = 26) of patients reported subjective symptoms of reflux and/or required daily antisecretory therapy [Corrected]. After LSG + HHR, 34.6 % of symptomatic patients had resolution of their symptoms off therapy while the rest remained symptomatic and required daily antisecretory therapy; 84.4 % of patients that were asymptomatic preoperatively remained asymptomatic after surgery. New onset reflux symptoms requiring daily antisecretory therapy was seen in 15.6 % of patients who were previously asymptomatic. Post surgical weight loss did not correlate with the presence or resolution of reflux symptoms.
  
  
  CONCLUSIONS
  Based on our data, LSG with concomitant HHR improved GERD symptoms or the need for daily antisecretory therapy only in a third of symptomatic patients. Furthermore, 15.6 % of asymptomatic patients developed de novo GERD symptoms despite a HHR. In patients with a documented hiatal hernia, HHR does not lead to GERD resolution or prevention after LSG, indicating the need for appropriate patient counseling and further study.
authors.affiliation: Department of General Surgery, Loma Linda University Medical Center, Coleman Pavilion 21111, 11175 Campus Street, Loma Linda, CA, 92350, USA. kamransamakar@gmail.com.
authors.forename: Kamran
authors.initials: K
authors.lastname: Samakar
authors.affiliation: Department of General Surgery, Mayo Clinic, Rochester, MN, USA. mckenzie.travis@mayo.edu.
authors.forename: Travis J
authors.initials: TJ
authors.lastname: McKenzie
authors.affiliation: Department of General and GI Surgery, Brigham and Women's Hospital, Boston, MA, USA. atavakkoli@partners.org.
authors.forename: Ali
authors.initials: A
authors.lastname: Tavakkoli
authors.affiliation: Department of General and GI Surgery, Brigham and Women's Hospital, Boston, MA, USA. avernon@partners.org.
authors.forename: Ashley H
authors.initials: AH
authors.lastname: Vernon
authors.affiliation: Department of General and GI Surgery, Brigham and Women's Hospital, Boston, MA, USA. mkrobinson@partners.org.
authors.forename: Malcolm K
authors.initials: MK
authors.lastname: Robinson
authors.affiliation: Department of General and GI Surgery, Brigham and Women's Hospital, Boston, MA, USA. sshikora@partners.org.
authors.forename: Scott A
authors.initials: SA
authors.lastname: Shikora
mesh_terms: D000328:Adult; D000368:Aged; D000863:Antacids / Q000008:administration & dosage; D004334:Drug Administration Schedule; D005260:Female; D005743:Gastrectomy / Q000009:adverse effects* / Q000379:methods; D005764:Gastroesophageal Reflux / Q000188:drug therapy / Q000209:etiology* / Q000601:surgery; D006551:Hernia, Hiatal / Q000150:complications / Q000601:surgery*; D059685:Herniorrhaphy; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000150:complications / Q000601:surgery*; D012189:Retrospective Studies; D016896:Treatment Outcome; D015431:Weight Loss; D055815:Young Adult
chemical_list: D000863:Antacids
keywords: Gastroesophageal reflux; Hiatal hernia; Laparoscopic sleeve gastrectomy; Morbid obesity