Exploration of esophageal hiatus: does crural repair reduce proximal pouch distension?

Abstract

BackgroundRepair of a hiatal hernia during laparoscopic adjustable gastric banding is advisable; however, the practice of more active esophageal hiatus exploration and repair has been promoted with an expectation of reducing proximal gastric pouch distension (PPD). Our objective was to explore the relationship between crural exploration and repair (CR) and PPD in a private practice in Canada. MethodsThe data from 3000 consecutive patients who underwent primary laparoscopic adjustable banding procedures at a single center from February 2005 to May 2011 were examined. Several analyses were performed, with the PPD cases carefully matched to historic (time-of-placement) and historic-, age-, and gender-matched controls. ResultsThroughout the series, the PPD rates decreased and the CR rates increased. Revision for PPD was performed in 132 patients (4.4%). The patients with PPD were more likely to have undergone CR during primary surgery (odds ratio 1.5, 95% confidence interval 1.2–2.2, P = .001) compared with historic, and historic-, age-, and gender-matched controls (odds ratio 2.3, 95% confidence interval 1.4–3.8, P < .001). The findings were confirmed using adjusted binary logistic regression analysis controlling for age, gender, body mass index, and time-of-placement. This increased risk was most evident early in the series when incident PPD cases were greater. However, at no stage did CR reduce the risk of symmetric or asymmetric PPD. ConclusionThe results of the present analysis do not support the theory that increased exploration and repair of the esophageal hiatus reduces the incidence of PPD. There might be a role for CR at surgery for specific clinical indications. CR increases the complexity and possibly the risk of the procedure.