Paraesophageal hernia repair combined with Roux-en-Y gastric bypass reduces short-term hernia recurrence with added metabolic benefit in patients with BMI ≥ 35: A 15-year experience.

introductionObesity is a risk factor for paraesophageal hernias (PEH), with reported higher prevalence in patients with obesity. Similarly, higher body mass index (BMI) levels adversely affect PEH repair outcomes, with well-documented hernia recurrence rates in patients with obesity. We sought to investigate PEH recurrence in combined laparoscopic PEH repair with laparoscopic Roux-en-Y gastric bypass (LPEHr/LRYGB) vs laparoscopic PEH repair alone (LPEHr) in patients with obesity. We hypothesized that LPEHr/LRYGB is associated with reduced PEH recurrence and improved metabolic outcomes compared to LPEHr.

methodsA retrospective review of a prospectively maintained database from a single academic institution was conducted. We included patients with BMI ≥ 35, with type II, III, and IV large PEH (defined as ≥ 35% of intrathoracic stomach) operated from 1/1/2009 to 1/1/2024. Patients with previous foregut surgery or concomitant weight loss surgery other than LRYGB were excluded. The primary outcome was overall PEH recurrence. Secondary outcomes were defined by metabolic benefit, measured by reduction in BMI between the two groups, and acid reflux symptoms at time of recurrence, measured by proton pump inhibitor (PPI) use. Additionally, we looked at procedural variability in the surgeries. Statistical analysis was performed by comparing propensity-matched groups using Kaplan-Meier estimates and a Log-rank test.

resultsA total of 397 patients underwent index LPEHr/LRYGB (n = 223) or LPEHr (n = 174). After propensity matching, there were a total of 180 patients with 90 patients in each group. Median follow-up after propensity matching for LPEHr/LRYGB was 57 months vs 53 months for LPEHr. There was a significant reduction of PEH recurrence rate for the first 36 months of follow-up in patients who underwent LPEHr/LRYGB compared to LPEHr (p = 0.015); however, the recurrence rates converged subsequently and at 72 months of follow-up, the difference was no longer significant (p = 0.6). Time until reoperation between the groups was not significantly different (p = 0.447). Patients who underwent LPEHr/LRYGB had a significant reduction in BMI compared to LPEHr at follow-up (- 10.2 kg/m2 vs - 2.2 kg/m2; p < 0.001). Use of PPI at time of PEH recurrence was not significantly different between the groups (p = 0.065). While use of mesh was significantly higher in the LPEHr group (59% vs 7%; p < 0.001), use of mesh was not associated with lower PEH recurrence (p = 0.273).

conclusionPatients with obesity with a BMI ≥ 35 who underwent LPEHr/LRYGB had a significant reduction in early PEH recurrence rate for the first 36 months compared to LPEHr, in addition to significant added metabolic benefit measured by long-term reduction in BMI. The long-term PEH recurrence rate between these groups showed no difference at 72 months of follow-up and beyond.