Do Hiatal Hernias Fail After Gastric Sleeve Surgery?

Sasha from Kingwood, North Houston, sent us this question: “I had a Bariatric sleeve/hiatal hernia repair in October 2015. I lost 100 lbs. I had severe acid reflux before surgery. It was gone completely after surgery. I had some regain last year but lost 50 lbs. However, my reflux has returned. Medications and a change in eating habits have had no effect. I’m having surgery in May. Drs tell me that 65% of these repairs fail. My question is why did it fail after I lost the weight? It does not make sense. Thank you.”

Dear Sasha,

Properly performed hiatal hernia and sleeve gastrectomy are associated with high acid reflux resolution rate and low failure/recurrence rate. Proper hiatal hernia repair is technically demanding especially in the obese patient with an enlarged liver. Incomplete esophageal mobilization during hiatal hernia invariably results in hiatal hernia recurrence. A second reason for hiatal hernia development leading to acid reflux development is a narrowed gastric sleeve. Narrowing the sleeve lumen at the junction between gastric antrum and gastric body results in functional obstruction. Functional obstruction favors reflux of gastric content into esophagus. Initially, reflux is minimal especially if the hiatal hernia was repaired. Consequently, patients, like yourself, do not experience acid reflux symptoms in the early post-operative period. However, with time constant acid reflux forces the esophagus to retract into the chest leading to hiatal hernia development. Hiatal hernia formation exacerbates acid reflux and acid reflux further contributes to hiatal hernia development. At this point, patients start to experience acid reflux symptoms which tend to worsen with time.

Luckily, gastric sleeve narrowing resulting in functional obstruction resolves with time as the stomach dilates in that area. Hence, Redo hiatal hernia repair is an effective and durable solution to stop acid reflux and alleviate symptoms. If stomach narrowing is still present, unlikely to be your case, then conversion of gastric sleeve to gastric bypass is needed to stop acid reflux.