Background

Hiatal hernias (HH) are common in bariatric surgery patients, but the utility of preoperative upper gastrointestinal series (UGI) for HH detection remains in question.Objectives: This study prospectively compares preoperative and intraoperative HH detection rates in a cohort of patients undergoing laparoscopic sleeve gastrectomy (LSG).

Methods

As part of randomized clinical trial NCT04168060 evaluating the role of routine crural dissection during LSG, we analyzed data for an initial cohort of patients undergoing primary LSG. Preoperatively, patients underwent UGI and completed GerdQ and BEDQ to score symptoms of gastroesophageal reflux (GERD) and dysphagia. Intraoperatively, patients with an anteriorly visible HH underwent hiatal hernia repair (HHR) followed by LSG. All others were randomized to standalone LSG or complete crural dissection with HHR if a HH was identified, followed by LSG.

Results

Between November 2019 and June 2020, 98 patients (71 female) were enrolled. Preoperative UGI identified HH in 25 patients. Intraoperatively, we found 35 HH visible anteriorly and an additional 9 in the 27 patients randomized to crural dissection. Intraoperative HH was associated with older age, lower body mass index, and Black race. Patients with HH had similar preoperative rates of GERD and scores on GerdQ and BEDQ as those without HH. Compared to gold standard intraoperative diagnosis, UGI demonstrated sensitivity 37.2%, specificity 81.3%, positive predictive value 64.0%, and negative predictive value 59.1%.

Conclusions

Hiatal hernias are highly prevalent in this population. Compared to preoperative UGI and symptom questionnaires, complete crural dissection during LSG allows for identification of significantly more HH.