Concomitant Treatment of the Hiatus

Hiatal (i.e. paraesophageal) hernias are common in patients with obesity, with nearly 40% of bariatric surgery candidates having a co-morbid hiatal hernia. Symptoms of gastroesophageal reflux disease (GERD) are often reported with both obesity and hiatal hernias, however, symptoms do not always correlate with the presence of disease. In considering bariatric surgical options for individual patients, it is important to remember that reflux esophagitis is an independent risk factor for the development of future malignancy. Due to the morbidity associated with GERD, hiatal hernia repair is recommended concomitantly with bariatric surgery, regardless of symptom severity or timing of diagnosis (pre- or intra-operative). Management of a hiatal hernia at the time of bariatric surgery includes reduction of the stomach and esophagus into the abdomen, a high, circumferential mediastinal dissection of the esophagus, and a tension-free, posterior re-approximation of the crural pillars, with or without mesh reinforcement. The addition of an anti-reflux or acid-diverting procedure can be made at the surgeon’s discretion based on individual patient factors. Additionally, diagnosis of a large paraesophageal hernia (type III or IV), uncontrolled GERD despite maximal medical management, Los Angeles (LA) Grade C or D esophagitis, and/or Barrett’s esophagus (BE) should play a role in procedural decision-making. Roux-en-Y gastric bypass (RYGB) is generally preferred over sleeve gastrectomy (SG) due to the benefits of the RYGB as an acid-diverting procedure and the increased risk of GERD and BE following SG. However, in patients with small hiatal hernias (sliding, type I), GERD that is asymptomatic or well-controlled on medications, and most incidentally found hiatal hernias, concomitant SG and hiatal hernia repair is safe and effective.