I read with great interest the commentary on evaluating the feasibility of phrenoesophagopexy during hiatal hernia repair in sleeve gastrectomy patients. The commentary was recently published in SOARD by Dr. Jose Ferrer from the Bariatric and Metabolic Surgery Center in Valencia, Spain. The author reports his concern about the development of GERD, severe reflux esophagitis, and Barrett’s esophagus following gastric sleeve surgery. Ferrer recommends hiatal hernia repair during gastric sleeve surgery. However, herniorrhaphy alone is not enough sometimes. Additional techniques have been developed such as phrenoesophagopexy, Hill gastropexy, Teres ligament pexy, and different forms of fundoplications to augment the anti-reflux barrier.

Ferrer recommends leaving 2 cm of gastric tissue around the angle of His to preserve the phrenoesophageal angle. If a hernia is present, he recommends posterior hiatal repair and if the hernia is greater than 4 cm he favors gastric bypass surgery over sleeve gastrectomy.

I continue to be amazed by these studies and opinions regarding the effect of gastric sleeve surgery on GERD. As an acid reflux specialist and bariatric surgeon, I have found the gastric sleeve, when properly performed, to be a great anti-reflux procedure. Indeed, I offer hiatal hernia repair with sleeve gastrectomy to obese patients presenting for GERD management. I fully agree with Dr. Ferrer that a formal hiatal hernia repair must be performed concomitant with gastric sleeve surgery. Hiatal hernia repair technique varies greatly, however, among surgeons. Some bariatric surgeons perform an anterior repair which in my mind is completely useless. Other bariatric surgeons perform a posterior repair without esophageal mobilization which is equally useless. Based on these two commonly performed techniques, most sleeve gastrectomy patients are not receiving proper hiatal hernia repair. When the upper part of the gastric sleeve lumen is subjected to the negative intra-thoracic pressure, reflux (mainly bile reflux) is inevitable. The sleeve lumen is narrow and with low wall compliance. Consequently, it transmits the negative thoracic pressure effectively favoring not only acid reflux but also bile reflux from the duodenum across the pylorus. For this reason, hiatal hernia repair is of utmost importance in sleeve gastrectomy cases. Equally important is the sleeve resection. A narrowed or twisted sleeve lumen causes reflux. The most common mistake performed in gastric sleeve surgery is narrowing the natural angle of the stomach at the incisura angularis. The majority of bariatric surgeon place a bougie across the incisura angularis and start the resection hugging the bougie and obliterating the angle. Obliterating the incisura angularis creates a functional obstruction that favors acid reflux.

A properly performed hiatal hernia repair and a well contoured gastric sleeve are effective anti-reflux solutions. Persistent or new onset GERD following gastric sleeve surgery is not inherent to the nature of the procedure but rather a good indication of poor surgical technique.