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In the eye of the beholder: surgeon variation in intra-operative perceptions of hiatal hernia and reflux outcomes after sleeve gastrectomy

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Abstract

Background

Hiatal hernia repair performed at the time of laparoscopic sleeve gastrectomy (LSG) may reduce post-operative reflux symptoms. It is unclear whether intra-operative diagnosis of hiatal hernia varies among surgeons or if it affects outcomes.

Study design

Surgeons (n = 38) participating in a statewide bariatric surgery quality improvement collaborative reviewed 33 videos of LSG in which no hiatal hernia repair was performed. Reviewers were blinded to patient information and were asked whether they perceived a hiatal hernia. Surgeon characteristics and surgeon-specific patient outcomes for LSG were compared between surgeons who identified at least one hiatal hernia during video review and those who did not.

Results

Ten surgeons (26%) identified at least one hiatal hernia after reviewing the videos. There were no significant differences in operative experience or practice type between surgeons who did and did not identify hiatal hernias. Surgeons who identified a hiatal hernia more often performed concurrent hiatal hernia repair in their practice when compared to those who did not (43.0% versus 36.5%, p < 0.001). Although complication rates were similar between surgeon groups, there were higher rates of de novo reflux symptoms (13.6% versus 11.1%, p = 0.032) and lower rates of antacid discontinuation at one-year (71.0% versus 77.2%, p = 0.043) among surgeons who identified hiatal hernias.

Conclusion

Surgeons who identified hiatal hernias during video review had a higher rate of concurrent hiatal hernia repairs in their practice. This was not associated with improved patient-reported reflux symptoms after LSG. Standardizing identification and management of hiatal hernias during bariatric surgery may help improve reflux outcomes post-operatively.

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Abbreviations

LSG:

Laparoscopic sleeve gastrectomy

GERD:

Gastroesophageal reflux disease

UGI:

Upper gastrointestinal series

EGD:

Esophagogastroduodenoscopy

MBSC:

Michigan Bariatric Surgery Collaborative

GERD-HRQL:

Gastroesophageal Reflux Disease-Health Related Quality of Life

BMI:

Body mass index

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Authors and Affiliations

  1. Department of Surgery, University of Michigan, 1500 E Medical Center Drive, SPC 5343, 2210 Taubman Center, Ann Arbor, MI, 48109, USA

    Anne P. Ehlers, Justin B. Dimick & Oliver Varban

  2. Center for Healthcare Outcomes & Policy, Ann Abor, MI, USA

    Anne P. Ehlers, Karan Chhabra, Jyothi R. Thumma & Justin B. Dimick

  3. National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, Ann Arbor, USA

    Karan Chhabra

  4. Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Karan Chhabra

Authors
  1. Anne P. Ehlers
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  2. Karan Chhabra
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  3. Jyothi R. Thumma
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  4. Justin B. Dimick
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  5. Oliver Varban
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Corresponding author

Correspondence to Anne P. Ehlers.

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Disclosures

This study received support from AHRQ 1R01HS023597-01 (Video Analysis for Ensuring Safer Diffusion of New Procedures) and the Michigan Bariatric Surgery Collaborative (Blue Cross Blue Shield of Michigan). Dr. Justin Dimick is a consultant & equity owner at ArborMetrix, Inc, which had no role in the work herein. Dr. Oliver Varban receives salary support from Blue Cross Blue Shield of Michigan for his role as co-director of the Michigan Bariatric Surgery Collaborative. Dr. Karan Chhabra is a participant in the IHPI National Clinician Scholars Program. Dr. Anne Ehlers and Dr. Jyothi Thumma have no additional conflicts of interest or financial ties to disclose.

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Ehlers, A.P., Chhabra, K., Thumma, J.R. et al. In the eye of the beholder: surgeon variation in intra-operative perceptions of hiatal hernia and reflux outcomes after sleeve gastrectomy. Surg Endosc 35, 2537–2542 (2021). https://doi.org/10.1007/s00464-020-07668-4

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  • DOI: https://doi.org/10.1007/s00464-020-07668-4

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