Comparison of Upper Gastrointestinal Series and Symptom Questionnaires with Intraoperative Diagnosis of Hiatal Hernia During Sleeve Gastrectomy

• Acid reflux is the number one concern patients have about sleeve gastrectomy. This study found that standard preoperative tests for hiatal hernias miss a significant number that are only discovered during surgery.
• Even if preoperative testing shows no hiatal hernia, one may still be present. Dr. de la Cruz-Muñoz routinely evaluates the hiatus during every sleeve gastrectomy and repairs any hernia found.
• This proactive approach may reduce the risk of developing new or worsening acid reflux after surgery.
• Dr. de la Cruz-Muñoz is the senior author; the research team extended this work into a long-term outcomes study presented at the 2024 ASMBS Annual Meeting.

Why This Study Was Needed

A hiatal hernia is common in people with obesity, and it matters for sleeve gastrectomy: an unrepaired hernia is one of the main reasons patients develop reflux after sleeve gastrectomy. Many programs obtain an upper GI (barium swallow) X-ray before surgery or ask about reflux symptoms, and use the results to decide whether to look for a hernia in the operating room. Whether those tests are actually reliable had never been tested against what the surgeon finds during the operation.

How the Study Was Done

This study was the first phase of a randomized trial at a US university hospital, with Dr. de la Cruz-Muñoz as senior author, testing routine inspection of the hiatus (the opening in the diaphragm) during sleeve gastrectomy. Between November 2019 and June 2020, 100 patients completed two validated questionnaires, the GerdQ for reflux and the BEDQ for dysphagia, and an upper GI series before surgery. In the operating room, any hernia visible from the front was repaired. Patients without a visible hernia were randomized to a standard sleeve or to a posterior dissection of the crura to look for a hidden hernia, repairing any that was found.

What the Study Found

• The upper GI series detected a hiatal hernia in 28% of patients before surgery.
• On first look in the operating room, 35 of 100 patients had a hernia.
• Compared with what the surgeon saw, the upper GI series had a sensitivity of only 35.3% and a specificity of 80.7%: it missed about two of every three hernias.
• Reflux and swallowing questionnaires did not predict who had a hernia.
• Among patients randomized to posterior inspection, a hidden hernia was found in another 34% (10 of 29).
• Hernias were more common in older patients, those with a lower BMI, and Black patients.

What This Means for Patients

A normal barium swallow, or having no heartburn, does not mean you do not have a hiatal hernia. Hernias are present in a large share of sleeve patients, many are only found by actively looking behind the esophagus, and repairing them at the time of the sleeve is one of the best ways to reduce reflux afterward. If you are planning a sleeve, ask your surgeon how they evaluate the hiatus. If you already have reflux after a sleeve, an overlooked or recurrent hernia is a common cause, and hiatal hernia repair after sleeve or sleeve-to-bypass conversion may help. Our Reflux Surgery Guide and article on reflux after bariatric surgery explain the options.

Clinical Pearls

• The upper GI series missed about 65% of hiatal hernias found at surgery.
• GerdQ and BEDQ scores did not correlate with hernia presence.
• Posterior crural dissection uncovered a hernia in one-third of patients whose hiatus looked normal from the front.
• Preoperative testing should not determine whether the hiatus is examined during sleeve gastrectomy.

Strengths and Limitations

Patients were studied prospectively with standardized questionnaires and imaging, and the intraoperative assessment followed a defined protocol within a randomized trial. The sample was 100 patients from one center, and this report focuses on diagnosis; the effect of routine posterior inspection on long-term reflux requires the full trial results.

Expert Commentary

Reflux after sleeve gastrectomy is one of the most common reasons patients come to me for revision, and an unrecognized hiatal hernia is often part of the story. We designed this study because I did not trust a normal barium swallow to rule out a hernia, and the results confirmed it: the X-ray missed most of them.

The practical lesson for surgeons is to look carefully at the hiatus during every sleeve. The lesson for patients is to ask.

— Dr. Nestor de la Cruz-Muñoz