Hiatal hernias and acid reflux are common occurrences in obese patients. There is an almost linear correlation between BMI and GERD. Indeed, elevated intraabdominal pressure in overweight patients stresses the delicate phreno-esophageal membrane. Weakness in this membrane leads to effacement of the angle of His, laxity in the diaphragmatic crura, and migration of the intraabdominal esophagus into the chest. With time, a hiatal hernia develops, and acid reflux worsens. Most obese patients presenting for gastric sleeve surgery suffer from GERD. The question that frequently arises: what to do with the hiatal hernia if present?

A recent prospectively randomized study by Klein et al, published in SOARD journal, showed no difference in GERD symptoms at one year after sleeve gastrectomy. Morbidly obese patients scheduled for gastric sleeve surgery and found to have a hiatal hernia less than 4 cm in axial displacement were randomly divided into two groups. The first group underwent gastric sleeve surgery with hiatal hernia repair and the second group received a sleeve gastrectomy without hiatal hernia repair. Both groups were closely followed, and statistical analysis showed no significant difference in terms of GERD related symptom resolution or de novo symptom formation between both groups. In other words, according to this group of bariatric surgeons in Houston, there is no need to repair a hiatal hernia measuring less than 4 cm in axial displacement during gastric sleeve surgery.

At Houston Weight Loss Surgery Center, we have learned over the past few years that any size hiatal hernia must be repaired during gastric sleeve surgery to prevent post-operative GERD and bile gastritis. The main purpose of hiatal hernia repair is to restore normal anatomy consisting of at least 3 cm of intra-abdominal esophagus. This allows the lower esophageal sphincter to be exposed to the positive intra-abdominal pressure; this is particularly important in the case of gastric sleeve surgery. An unrepaired hiatal hernia leaves the upper part of gastric sleeve lumen exposed to the negative intra-thoracic pressure. The narrow gastric sleeve lumen has low wall compliance that easily transmits the negative intra-thoracic pressure into the gastric lumen. This results in a pressure gradient across the diaphragmatic opening favoring not only gastro-esophageal reflux but also duodeno-gastric reflux.  Indeed, almost all sleeve gastrectomy patients with GERD and hiatal hernia have evidence of bile gastritis on upper endoscopy. Biliary acids also contribute to reflux esophagitis and Barrett’s esophagus development.

Gastric sleeve surgery and hiatal hernia repair go hand in hand to prevent de novo, persistent or worsening post-operative acid reflux. Meticulous surgical technique is key to achieve proper hiatal hernia repair and a well contoured gastric sleeve. When properly performed, bariatric patients experience a reflux free weight loss journey.