IBC-Ox26 Concomitant hiatal hernia repair during bariatric surgery: is it the reinforcement making the difference?

Abstract Background Concomitant hiatal hernia repair (HHR) in patients who undergo bariatric surgery (BS) is under debate. Aims To evaluate on long-term the safety and efficacy of posterior cruroplasty (PC), simple or reinforced with a biosynthetic, absorbable mesh, performed during BS. Primary endpoint: PC's failure, defined as symptomatic HH recurrence, nonresponding to conservative treatment and requiring revisional surgery. Methods The prospective database of 1948 patients undergoing BS in a center of excellence between 2011-2020 was searched. Intraoperative measurement of the hiatal surface area (HSA) was performed routinely. Results 268 patients undergone BS and concomitant HHR (13.7%). Simple PC (group A, 165 patients) was performed during 137 sleeve gastrectomies LSG, 5 re- sleeves and 23 gastric bypasses LGB; mean BMI 43.4 ± 5.8 kg/m2, HSA mean size 3.4 ± 2 cm2. Reinforced PC (group B) was performed in 102 cases: 64 primary LSG, 23 LGB and 15 revisions of LSG; mean BMI 44.6 ± 7.7 kg/m2, HSA mean size 6.7 ± 2 cm2. PC's failure, with intrathoracic migration (ITM) was encountered in 12 cases (7.5%) of simple vs. only 4 cases (3.9%) of reinforced PC (p=0.23); hence, a repeat, reinforced PC and LGB was performed in all cases. No mesh-related complications were registered perioperatively or after long-term follow-up (mean 61 months), minimum 12 months. Only one case of cardiac metaplasia was detected 4 years postoperatively; conversion to LGB, with reinforced redo of the PC was performed. The Cox hazard analysis showed that the use of more than four stitches for cruroplasty represents a negative factor on recurrence (HR = 8; p < 0.05). Conclusions Our results support the use of bioabsorbable, synthetic mesh as reinforcement of HH > 4 cm2 in obese patients during BS, showing excellent recurrence rate results (4%). Accurate patients’ and technique's selection, combined with PC (simple or reinforced) ensure effectiveness and safety, with a combined rate of failure (HH recurrence) at 4 years of 6.0%.