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

Abstract

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. 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. 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. 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.