Gastroesophageal reflux in laparoscopic sleeve gastrectomy: hiatal findings and their management influence outcome.
BACKGROUND
Sleeve gastrectomy (SG) has become a definitive treatment for morbid obesity. There is conflicting evidence on the effects of SG on gastroesophageal reflux disease (GERD).


OBJECTIVE
The objective of this study was to assess whether taking an aggressive approach to managing hiatal weakness in patients undergoing SG results in an alteration in GERD symptoms.


SETTING
Tertiary public hospital and private hospital, Sydney, Australia.


METHODS
Patients undergoing laparoscopic extended (beginning within 2 cm from pylorus) SG were included. If evidence of weakness was present, an anterior hiatal dissection and tight suture repair was performed. If a hiatus hernia was present, formal repair was undertaken. Patients were questioned and scored on preoperative and postoperative reflux symptom frequency and severity, proton pump inhibitor (PPI) usage, current weight, and satisfaction.


RESULTS
A continuous cohort of 262 patients experienced a significant reduction in heartburn frequency (P = .035) and severity (P = .017). Moderate/severe preoperative reflux (Visick score 3 and 4) often improved whether there was a defect requiring repair or not (no repair P = .02, hiatal suture P = .001, hiatus hernia repair P<.001). The severity of symptoms also improved (no repair P = 0.005, hiatal suture P<.001, hiatus hernia repair P< .001).


CONCLUSION
Moderate or severe preexisting gastroesophageal reflux improved for most of our obese patients undergoing an extended SG when hiatal defects were routinely repaired. Moderate to severe preoperative reflux also improved in the average obese patient when there was no hiatal defect to repair.