Laparoscopic Sleeve Gastrectomy and Hiatoplasty. Three-Year Experience of A Bariatric Center of Excellence
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- Category: Vol. 85, December 2017
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Laparoscopic Sleeve Gastrectomy and Hiatoplasty. Three-Year Experience of A Bariatric Center of Excellence, MOHAMED ABD EL-GAWAD, NABIL GAD EL-HAK, AHMED EL-GEIDIE, EHAB EL-HANAFY and GIANFRANCO SILECCHIA
Abstract
Background: Laparoscopic crural closure in addition to laparoscopic sleeve gastrectomy LSG can represent a valuable option for the synchronous management of morbid obesity and Hiatal Hernia (HH), providing good outcomes in terms of weight loss and Gastro-Esophageal Reflux Symptoms (GERD) control. The prosthetic reinforcement of the hiatal closure can also be performed in selected cases when an increased risk of HH recurrence exists. This study aimed at testing the effect of hiatoplasty with LSG to control sympto-matic and asymptomatic HH. It also aimed at comparing simple hiatoplasty versus mesh reinforced hiatoplasty in morbidly obese patients in terms of GERD symptoms control, maintaining the anatomy in the hiatal area after the procedure and assessment of Biosynthetic Absorbable (BIO-A) mesh related complications at 2 years follow-up.
Methods: The study groups included 96 morbidly obese patients who underwent simultaneous LSG and cruroplasty. Group A: 48 patients with hiatal areal defect/4cm2 and normal pillars (simple posterior cruroplasty); Group B: 48 patients with hiatal areal defect [4 and/8cm2 with weakness of the right pillar (on-lay synthetic absorbable mesh-reinforced cruroplasty). Upper GI symptoms were assessed by Roma III standard questionnaire. Endoscopy, imaging, esophageal 24h pH monitoring and HR manometry were performed in cases of persistent or recurrent symptoms after surgery.
Results: Intra-operative diagnosis of hiatal hernia occured in 41 patients (42.7%). Mesh-related complications were none. Perioperative complications occurred in four patients (4.1%). After 19-to 21-month follow-up, GERD symptom remission occurred in 89% of patients. GERD symptoms were detected postoperatively in eight patients: Six in Group A (five symp-tomatic and radiological recurrences and one persistent) and two in Group B (one persistent and one de novo GERD) (p/0.05).
Conclusions: Synthetic absorbable mesh is a valuable option for crural repair during LSG with low recurrence rates. The midterm results of this prospective comparative study evaluating two different technical options for hiatoplasty carried out during LSG suggest that the simultaneous proce-dures are safe and hiatoplasty is effective in mild-to-moderate GERD control in the majority of the cases.
The complete exposure of the hiatal area guarantee com-plete freeing of the posterior gastric wall and facilitates complete resection of the fundus. This in turn is highly important for the success of LSG in terms of weight loss and avoiding de novo GERD caused by acid secretion and regur-gitation of the persistent gastric fundus content into the esophagus, without affecting leak rates.