A hiatal hernia occurs when a portion of the stomach protrudes through the diaphragm, the muscle separating the chest and abdomen, into the chest cavity. This condition is frequently observed in individuals with obesity, and it can contribute to gastroesophageal reflux disease (GERD). This article explores the relationship between hiatal hernias and weight loss surgery, examining the implications of concurrent hiatal hernia repair (HHR) during bariatric procedures.
Understanding Hiatal Hernias
In a hiatal hernia, a gap in the diaphragm allows part of the stomach to migrate into the chest, potentially leading to heartburn and vomiting. There are two main types:
- Sliding Hiatal Hernias: Common in obese patients due to increased intra-abdominal pressure, which can enlarge the hernia and worsen reflux over time.
- Paraesophageal Hiatal Hernias (Type II): These may or may not be associated with obesity and have a higher chance of recurrence.
Diagnosis typically occurs during tests for heartburn or chest/upper abdominal pain, such as X-rays of the upper digestive system, endoscopy, or esophageal manometry.
Symptoms of Hiatal Hernias
Many individuals with hiatal hernias may not experience any symptoms. However, when symptoms do arise, they are often related to chronic acid reflux, including:
- Heartburn (burning sensation in the chest)
- Noncardiac chest pain
- Indigestion
- Burping and regurgitation
- Difficulty swallowing
- Sore throat and hoarseness
Other possible warning signs may include nausea, shortness of breath, and pressure or pain in the upper abdomen or lower chest, particularly with larger paraesophageal hernias.
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Causes and Complications
Hiatal hernias occur when there's a weak spot in the tissues separating body compartments, allowing the hernia to protrude. Factors contributing to increased abdominal pressure can weaken the diaphragm over time, including:
- Chronic coughing or sneezing
- Chronic straining during bowel movements (constipation)
- Obesity
- Frequent vomiting
- Intense exercise or heavy lifting
- Pregnancy and childbirth
While most hiatal hernias aren't serious, larger hernias can lead to complications, primarily chronic acid reflux. This can result in:
- Esophagitis (inflammation of the esophagus)
- Esophageal stricture (narrowing of the esophagus due to scarring)
- Barrett’s esophagus (precancerous tissue changes)
In rare cases, the hernia can become stuck or compressed, leading to gastrointestinal obstruction, gastritis, or ischemia.
The Link Between Obesity and Hiatal Hernias
Hiatal hernias are notably prevalent among bariatric patients, with studies indicating that individuals with a Body Mass Index (BMI) greater than 30 are significantly more likely to have a hiatal hernia. It's estimated that approximately 40% of patients with obesity also have a hiatal hernia. The increased intra-abdominal pressure in individuals with obesity contributes to the development and exacerbation of these hernias.
Treatment Options
Most people don't require treatment unless they experience symptoms. Initial treatment often involves:
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- Lifestyle Modifications: Avoiding trigger foods, elevating the head of the bed, and eating smaller meals.
- Medications:
- Antacids for quick relief.
- H-2-receptor blockers to reduce acid production.
- Proton pump inhibitors to block acid production and heal the esophagus.
Surgical Intervention
Surgery may be necessary when medications and lifestyle changes are insufficient. Surgical options include:
- Pulling the stomach down into the abdomen.
- Making the opening in the diaphragm smaller.
- Reshaping the muscles of the lower esophagus to prevent stomach contents from rising.
Surgery can be performed via thoracotomy (single incision in the chest wall) or laparoscopy (using a tiny camera and special tools through small abdominal incisions).
Hiatal Hernia Repair and Bariatric Surgery
Bariatric surgery is an effective treatment for obesity, leading to weight loss and improvement in obesity-related diseases. While some bariatric procedures, like Roux-en-Y gastric bypass, can improve hiatal hernias, these hernias often recur.
Concurrent Hiatal Hernia Repair (HHR)
Recent research suggests that identifying and repairing hiatal hernias during bariatric surgery (concurrent HHR) is the most effective approach for long-term benefits. Both gastric sleeve and gastric bypass surgeries can be performed with HHR, but Roux-en-Y gastric bypass is particularly effective for GERD and hiatal hernias due to reduced acid reflux.
Considerations for Gastric Sleeve Surgery:
In cases of a gastric sleeve surgery, a foreign body right next to a hiatal hernia could worsen the hernia and the reflux. A better approach is to identify the hernia beforehand so the surgeon can design a better action plan with the patient, educate him/her about his/her surgical options and obtain a pre-operative authorization for the hernia repair, simultaneous to the bariatric surgery.
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Benefits of Combining HHR with Bariatric Surgery
Combining HHR with bariatric surgery reduces GERD and the chances of hernia recurrence, proving safer and more effective than either procedure alone. Hernia recurrence rates are lower with combined HHR and bariatric surgery compared to single hernia repair with fundoplication.
Identifying Hiatal Hernias Before Surgery
Doctors may use upper gastrointestinal contrast studies or endoscopy to identify hiatal hernias before surgery. Discussing the possibility of HHR with your doctor before bariatric surgery is crucial.
Study on Concurrent Hiatal Hernia Repair and Bariatric Outcomes
A retrospective cohort study examined the association between concurrent HHR and bariatric outcomes, utilizing a nationwide health insurance claims data set. The study compared rates of post-bariatric operative and endoscopic interventions among matched cohorts of patients who did and did not undergo contemporaneous HHR.
Methodology
The study identified adults who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) alone or concurrently with HHR. Patients were matched based on factors likely associated with both hiatal hernia and reintervention. Researchers analyzed data for incident abdominal operative interventions, bariatric revisions/conversions, and endoscopy, following patients for up to 3 years.
Key Findings
- Patients undergoing concurrent SG and HHR were more likely to have additional abdominal operations and endoscopies within one year after surgery, a pattern that persisted at 3 years.
- Concurrent SG/HHR was associated with an increased risk of subsequent operative and nonoperative interventions, a pattern not consistently observed for RYGB.
- There was no detectable difference in the risk of additional abdominal operations at 1 year among RYGB patients with and without HHR.
- Bariatric revisions and conversions were rare, with no significant difference based on HHR status.
- SGHHR patients had an increased risk of endoscopy compared to SGonly patients at 1 year.
- RYGB patients with HHR remained more likely to receive endoscopic interventions at 3 years.
Implications
The study suggests that while HHR may offer longer-term benefits in reducing GERD-related complications, combining it with SG may increase the risk of early complications and later complications due to adhesions or other subacute issues.
Specific Observations
- The excess risk of abdominal operations for SGHHR patients appeared early after the index surgery, with omental flaps (indicative of leaks) being a common procedure.
- Operative reintervention codes differed between RYGB and SG patients, with nonspecific laparoscopy and gastropexy being the most common early procedures among RYGB patients.
Existing Research and Comparisons
Several recent studies have compared bariatric outcomes based on concurrent HHR status. Some studies found no difference in 30-day adverse event rates, while others observed higher rates of reoperation, readmission, and overall morbidity among SG patients with HHR. These discrepancies may be due to variations in study design, patient populations, and the comprehensiveness of adverse event capture.
Limitations of the Study
The observational, nonrandomized design of the study precludes causal inference. Potential for unmeasured confounding by provider and patient characteristics exists, and the study lacked data on hernia severity.
Post-operative Weight Management
Weight loss is a common side effect after hiatal hernia surgery due to dietary modifications during recovery. A liquid diet is initially required to minimize pressure and discomfort at the surgical site, gradually progressing to soft foods and a normal diet. Additionally, the procedure may reduce the size of the stomach, leading to a feeling of fullness with less food.
Recommendations for Safe Recovery
To minimize side effects and promote safe recovery:
- Follow the doctor’s instructions for home care.
- Avoid foods and beverages that irritate the stomach (alcohol, acidic foods, fried foods).
- Do not drink with a straw.
- Keep incision sites clean and bandaged.
- Avoid intense activity or heavy lifting.
- Stay mobile to minimize the risk of blood clots.
Weight Loss After Hiatal Hernia Surgery
Weight loss after hiatal hernia surgery is common. The body’s response to surgery, an expected loss of appetite, and dietary restrictions can all lead to weight loss. However, rapid weight loss after surgery is not considered normal and should be evaluated by a doctor.