title: A randomized trial comparing reflux symptoms in sleeve gastrectomy patients with or without hiatal hernia repair.
abstract: BACKGROUND
  The effect of laparoscopic sleeve gastrectomy (SG) on reflux symptoms is unclear. Many surgeons offer SG only to patients with minor or no reflux symptoms, fearing that patients with severe reflux symptoms will experience worsening of their condition after SG. Many also advocate crural repair at the time of SG to prevent de novo or worsening reflux symptoms. These decisions are made without suitable data to form such conclusions.
  
  
  OBJECTIVE
  To determine the effect of SG with or without hiatal hernia repair on reflux symptoms.
  
  
  METHODS
  University of Texas Health Sciences Center in Houston.
  
  
  METHODS
  The Gastrointestinal Symptom Rating Scale (GSRS) was administered to 100 consecutive, preoperative SG patients who were then randomly assigned into a crural repair group or nonrepair group in a parallel design. The patients were subsequently followed-up every 3 months for 1 year. We compared reflux symptoms of the 2 groups on the basis of demographic characteristics, body mass index, weight loss, presence and size of hiatal hernia, and GSRS for 12 months.
  
  
  RESULTS
  At 1 year, with 78% follow-up, the data demonstrated a significant decrease in the GSRS for both groups (P<.001); however, there was no difference between the groups (P = .35). Age, starting body mass index, percent excessive weight loss, and hiatal hernia size did not correlate with change in the GSRS score. The only variable that affected outcome was the preoperative GSRS. At 12 months, 38% of patients with a preoperative GSRS score less than the median score of the study population experienced worsening of their symptoms compared with only 2% of patients who had a preoperative GSRS score greater than the median. Overall, 19% experienced worsening reflux (5% de novo), 14% had no change, and 66% reported an improvement in symptoms.
  
  
  CONCLUSIONS
  These data suggest that a crural repair at the time of SG does not significantly reduce reflux symptoms compared with SG alone. Preoperative patients with significant reflux symptoms experienced a more significant improvement in symptoms after surgery compared with those who did not report significant reflux symptoms before surgery. The high incidence of reflux after SG observed in the current literature may be a result of a specific patient subpopulation who undergoes SG because of surgeon bias rather than an inherent property of SG itself or the presence of a hiatal hernia.
authors.affiliation: Department of Surgery, University of Texas Health Sciences Center, Houston, Texas. Electronic address: brad.snyder@uth.tmc.edu.
authors.forename: Brad
authors.initials: B
authors.lastname: Snyder
authors.affiliation: Department of Surgery, University of Texas Health Sciences Center, Houston, Texas.
authors.forename: Erik
authors.initials: E
authors.lastname: Wilson
authors.affiliation: Department of Surgery, University of Texas Health Sciences Center, Houston, Texas.
authors.forename: Todd
authors.initials: T
authors.lastname: Wilson
authors.affiliation: Department of Surgery, University of Texas Health Sciences Center, Houston, Texas.
authors.forename: Sheilendra
authors.initials: S
authors.lastname: Mehta
authors.affiliation: Department of Surgery, University of Texas Health Sciences Center, Houston, Texas.
authors.forename: Kulvinder
authors.initials: K
authors.lastname: Bajwa
authors.affiliation: Department of Surgery, University of Texas Health Sciences Center, Houston, Texas.
authors.forename: Conniw
authors.initials: C
authors.lastname: Klein
mesh_terms: D000328:Adult; D000368:Aged; D050110:Bariatric Surgery / Q000379:methods; D005743:Gastrectomy / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000209:etiology*; D006551:Hernia, Hiatal / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery; D061646:Operative Time; D011183:Postoperative Complications / Q000209:etiology; D016896:Treatment Outcome; D055815:Young Adult
keywords: Bariatric surgery; Crural repair; Heartburn; Hiatal hernia; Reflux; Sleeve; Sleeve gastrectomy