Atlanta—For patients undergoing sleeve gastrectomy, different approaches to managing the crura had an impact on short-term complications, but not on the development of a hiatal hernia in the long term, according to new research presented at the 2021 Southeastern Surgical Congress.

Hiatal hernia, which has been reported in up to 50% of obese patients, remains a vexing problem for bariatric surgeons among whom there are no formal consensus on how best to manage the crura at the time of sleeve gastrectomy.

To shed some light on this situation, Edward C. Tobin, MD, a general surgery resident at the University of West Virginia, in Charleston, and his colleagues performed a retrospective review of patients undergoing sleeve gastrectomy at their institution between 2007 and 2014.

“One clarifying point I’d like to make is a distinction between crural management and hiatal hernia repair, which is sometimes used interchangeably,” Dr. Tobin said. “However, it’s important to remember that in patients who have undergone lap sleeve gastrectomy, there is not a formal hiatal repair, as there cannot be any fundoplication.”

The procedures, all performed by the same surgeon, included three strategies for managing the crura: no crural closure, primary closure of the crura and primary closure with mesh reinforcement. The primary end point of the study was the presence of a hiatal hernia within five years of surgery. Secondary end points included dysphagia, reflux, nausea and vomiting.

Based on esophagogastroduodenoscopy and imaging findings, patient symptoms and subsequent hiatal hernia repair, Dr. Tobin and his colleagues determined that hiatal hernias had occurred in 15 of 154 patients with no crural closure (9.7%), 23 of 164 patients with primary crural closure (14%) and seven of 43 patients with mesh-enforced closure (16.3%), differences that did not reach statistical significance (P=0.37).

In regard to the short-term complications, however, while there was no difference across the board for nausea or vomiting, crural management was associated with the presence of dysphagia and reflux. Dysphagia was experienced by 2.2%, 7.4% and 14.3% of patients with no crural closure, primary closure and mesh-enforced closure, respectively; and reflux was seen in 6.5%, 17% and 19%.

“We found the lowest rates of dysphagia, reflux and overall complications in the group that had no crural closure, and the highest rates were seen in the group that had crural closure with mesh reinforcement,” Dr. Tobin said.

He was surprised by the findings. One explanation that he offered for not seeing a difference in hiatal hernia presence despite attempts to reduce it with crural closure with or without mesh reinforcement was that none of the patients could undergo fundoplication.

“Also, our mesh group had only 43 patients and the other two had more than 150; it could be that if we’d had a larger sample size and longer follow-up, we might have found a difference.”