“Concomitant hiatal hernia repair with laparoscopic sleeve gastrectomy is safe: analysis of the ACS-NSQIP database” by Safadi et al is a retrospective review 32581 patients who underwent sleeve gastrectomy between 2010 and 2014. This database is part of NSQIP, the American College of Surgeons National Surgical Quality Improvement Program. 14.4% of those patients underwent a concomitant hiatal hernia repair. There was no difference in the 30-day mortality and morbidity rates between those who underwent a gastric sleeve procedure with hiatal hernia repair and those who only had a sleeve gastrectomy.

Hiatal hernia repair, when performed by expert acid reflux and weight loss surgeons is safe. It may be more technically challenging in the morbidly obese patient especially in the presence of an enlarged liver due to steatohepatitis. Bariatric surgeons, however, continue to debate the need to repair hiatal hernias during gastric sleeve surgery. Should all hiatal hernias be addressed irrespective of size? Does sleeve gastrectomy improve, worsens or causes GERD postoperatively irrespective of hiatal hernia repair?

It is our experience at Houston Weight Loss Surgery Center, that a well performed gastric sleeve procedure is associated with improvement of existing GERD. The components of a well performed sleeve gastrectomy are:
1- Any size hiatal hernia must be repaired
2- Gastric fundus must be completely resected
3- Incisura angularis must not be narrowed
4- Sleeve lumen must be straight and free of any kinking or narrowing

Indeed, sleeve gastrectomy that follows these guidelines is as good as Nissen fundoplication in curing and preventing GERD. The most commonly accepted explanation for GERD is related to increased transient lower esophageal sphincter relaxation, TLESR, events. Gastric fundus greatly affects the frequency of TLESR events. Resecting the gastric fundus and wrapping it around the distal esophagus may have the same effect on reducing TLESR and improving GERD.

Additional studies are needed to prove the long-term effect of sleeve gastrectomy on GERD. However, it remains a fact that preventing both mechanical and functional gastric sleeve lumen narrowing while completely resecting the gastric fundus are crucial steps in alleviating GERD related symptoms. Concomitant repair of a hiatal hernia furthers reinforces the anti-reflux barrier. It prevents the herniation of the gastric sleeve into the chest which exposes the intra-gastric and non-compliant lumen to negative intrathoracic pressure. This in turns transforms the sleeve lumen into a suction pump causing bile and acid reflux into the esophagus. From this perspective, we advocate the safe and concomitant hiatal hernia repair with sleeve gastrectomy.