Obesity Surgery

, Volume 24, Issue 3, pp 377–384 | Cite as

Hiatal Hernia Repair in Laparoscopic Adjustable Gastric Banding and Laparoscopic Roux-En-Y Gastric Bypass: A National Database Analysis

  • Benjamin J. S. al-Haddad
  • Robert B. Dorman
  • Nikolaus F. Rasmus
  • Yong Y. Kim
  • Sayeed Ikramuddin
  • Daniel B. Leslie
Original Contributions


Hiatal hernia (HH) repairs are commonly done concomitantly with laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) to decrease gastroesophageal reflux disease (GERD). There is limited evidence about the additional surgical risk these combined procedures engender. We used the United States Nationwide Inpatient Sample 2004–2009 to compare mortality risk, prolonged length of stay (PLOS), and perioperative adverse events using propensity score-matched analysis. We repeated the analysis after removing patients diagnosed with GERD. There were 42,272 weighted patients undergoing LRYGB alone representing 206,559 discharges nationally and an additional 1,945 and 9,060, respectively, undergoing LRYGB + HH repair. For LAGB, there were 10,558 records representing 52,901 LAGB-only discharges and 1,959 representing 9,893 LAGB + HH repair discharges. Thirty-eight percent (95 % CI: 36, 41 %) of the patients in the LRYGB-only group had GERD compared to 55 % (51, 59 %) in the LRYGB + HH repair group. Among the LAGB groups, 31 % (28, 34 %) of LAGB-only patients had GERD compared to 44 % (38, 49 %) in the LAGB + HH repair group. We find that the average treatment effect on the treated (considering the concomitant procedure as treatment and the single procedure as control) for PLOS was −0.12353 (−0.15909, −0.08797) between the LRYGB groups and −0.04353 (−0.07488, −0.01217) for the LAGB groups. We find no evidence of increased risk of perioperative adverse events among patients undergoing concomitant HH repair with LRYGB or LAGB. Patients undergoing the combined procedure appear to be at lower risk of PLOS; this may be due to surgical training norms.


Hiatal hernia repair Laparoscopic adjustable gastric band Laparoscopic Roux-en-Y Gastric bypass 



Gastroesophageal reflux disease


Laparoscopic Roux-en-Y gastric bypass


Laparoscopic adjustable gastric banding


Hiatal hernia


Prolonged length of stay


Nationwide Inpatient Sample


Average treatment effect on the treated


International Classification of Diseases version 9



We would like to thank Mr. Mathew Grabau, Ms. Nikki Voulgaropoulos, Mrs. Bridget Slusarek, Mrs. Elsie Waddick, Mrs. Barbara Sampson, Dr. Nathan Liu, and Dr. Aboude Nowaylati for their helpful contributions. B.J.S. al-Haddad and Y. Kim were supported by NIH MSTP grant T32 GM008244 and the Department of Surgery Research Funds. R.B. Dorman, N.F. Rasmus, S. Ikramuddin, and D.B. Leslie were supported by the Department of Surgery Research Funds.

Conflict of interest

B.J.S. al-Haddad has no conflict of interest. R.B. Dorman has no conflict of interest. N.F. Rasmus has no conflict of interest. Y. Kim has no conflict of interest. S. Ikramuddin has no conflict of interest. D.B. Leslie has no conflict of interest.


  1. 1.
    Delaney BC. Review article: prevalence and epidemiology of gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2004;20:2–4. PMID:15575863.PubMedCrossRefGoogle Scholar
  2. 2.
    Locke III GR, Talley NJ, Fett SL, et al. Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota. Gastroenterology. 1997;112(5):1448–56. PMID:9136821.PubMedCrossRefGoogle Scholar
  3. 3.
    Jones MP, Sloan SS, Rabine JC, et al. Hiatal hernia size is the dominant determinant of esophagitis presence and severity in gastroesophageal reflux disease. Am J Gastroenterol. 2001;96(6):1711–7. PMID:11419819.PubMedCrossRefGoogle Scholar
  4. 4.
    Smith S, Edwards C, Goodman G. Symptomatic and clinical improvement in morbidly obese patients with gastroesophageal reflux disease following Roux-en-Y gastric bypass. Obes Surg. 1997;7:479–84. PMID:9730504.PubMedCrossRefGoogle Scholar
  5. 5.
    Friedenberg FK, Xanthopoulos M, Foster GD, et al. The association between gastroesophageal reflux disease and obesity. Am J Gastroenterol. 2008;103(8):2111–22. PMID:18796104.PubMedCrossRefGoogle Scholar
  6. 6.
    Tolonen P, Victorzon M, Niemi R, et al. Does gastric banding for morbid obesity reduce or increase gastroesophageal reflux? Obes Surg. 2006;16(11):1469–74. LA – English. PMID:17132413.PubMedCrossRefGoogle Scholar
  7. 7.
    Hallerbäck BJ. Laparoscopy in the gastroesophageal junction. Int Surg. 1995;80(4):307–10. PMID:8740674.PubMedGoogle Scholar
  8. 8.
    Näslund E, Granström L, Melcher A, et al. Gastro-oesophageal reflux before and after vertical banded gastroplasty in the treatment of obesity. Eur J Surg. 1996;162(4):303–6. PMID:8739417.PubMedGoogle Scholar
  9. 9.
    Frezza EE, Barton A, Wachtel MS. Crural repair permits morbidly obese patients with not large hiatal hernia to choose laparoscopic adjustable banding as a bariatric surgical treatment. Obes Surg. 2008;18(5):583–8. PMID:18317857.PubMedCrossRefGoogle Scholar
  10. 10.
    Gulkarov I, Wetterau M, Ren CJ, et al. Hiatal hernia repair at the initial laparoscopic adjustable gastric band operation reduces the need for reoperation. Surg Endosc. 2008;22(4):1035–41. PMID:18080712.PubMedCrossRefGoogle Scholar
  11. 11.
    Kasotakis G, Mittal SK, Sudan R. Combined treatment of symptomatic massive paraesophageal hernia in the morbidly obese. JSLS: J Soc Laparoendosc Surg/Soc Laparoendosc Surg. 2011;15(2):188–92. PMID:21902973.CrossRefGoogle Scholar
  12. 12.
    Salvador-Sanchis JL, Martinez-Ramos D, Herfarth A, et al. Treatment of morbid obesity and hiatal paraesophageal hernia by laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2010;20(6):801–3. PMID:18773250.PubMedCrossRefGoogle Scholar
  13. 13.
    Angrisani L, Iovino P, Lorenzo M, et al. Treatment of morbid obesity and gastroesophageal reflux with hiatal hernia by Lap-Band. Obes Surg. 1999;9(4):396–8. PMID:10484300.PubMedCrossRefGoogle Scholar
  14. 14.
    Dolan K, Finch R, Fielding G. Laparoscopic gastric banding and crural repair in the obese patient with a hiatal hernia. Obes Surg. 2003;13(5):772–5. PMID:14627475.PubMedCrossRefGoogle Scholar
  15. 15.
    Healthcare Cost and Utilization Project (HCUP). HCUP Nationwide Inpatient Sample (NIS).Google Scholar
  16. 16.
    StataCorp. Stata Statistical Software: release 12. Release 12. Software SS, editor. 2011.Google Scholar
  17. 17.
    Rosenbaum PR, Rubin DB. Constructing a control group using multivariate matched sampling methods that incorporate the propensity score. Amer Stat. 1985;39(1):33–8.Google Scholar
  18. 18.
    Guo SY, Fraser MW. Propensity score analysis. 2010.Google Scholar
  19. 19.
    Morgan SL, Winship C. Counterfactuals and causal inference: methods and principles for social research. 2007Google Scholar
  20. 20.
    Gordon C, Kang JY, Neild PJ, et al. The role of the hiatus hernia in gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2004;20(7):719–32. PMID:15379832.PubMedCrossRefGoogle Scholar
  21. 21.
    Ethicon Endo Surgery. Realize. [Accessed 2013 Sep 19]. Available from: http://www.realize.com/
  22. 22.
    Allergan Inc. LapBand. 2013 [Accessed 2013 Sep 19]. Available from: http://www.lapband.com/
  23. 23.
    Wilson LJ, Ma W, Hirschowitz BI. Association of obesity with hiatal hernia and esophagitis. Am J Gastroenterol. 1999;94(10):2840–4. doi:10.1111/j.1572-0241.1999.01426.x.PubMedCrossRefGoogle Scholar
  24. 24.
    El-Serag HB, Graham DY, Satia JA, et al. Obesity is an independent risk factor for GERD symptoms and erosive esophagitis. Am J Gastroenterol. 2005;100(6):1243–50. PMID:15929752.PubMedCrossRefGoogle Scholar
  25. 25.
    Khouzam RN, Akhtar A, Minderman D, et al. Echocardiographic aspects of hiatal hernia: a review. J Clin Ultrasound. 2007;35(4):196–203. PMID:17354243.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Benjamin J. S. al-Haddad
    • 1
    • 2
  • Robert B. Dorman
    • 1
  • Nikolaus F. Rasmus
    • 1
  • Yong Y. Kim
    • 1
  • Sayeed Ikramuddin
    • 1
  • Daniel B. Leslie
    • 1
  1. 1.Department of SurgeryMinneapolisUSA
  2. 2.Division of Epidemiology & Community Health, B681 Mayo BuildingUniversity of MinnesotaMinneapolisUSA

Personalised recommendations