Efficiency of preoperative esophagogastroduodenoscopy in identifying operable hiatal hernia for bariatric surgery patients.

Background: Gastroesophageal reflux (GERD) is a symptom frequently found in obese patients, and often is related to the presence of a hiatal hernia (HH). Surgeons may evaluate for the presence of HH on esophagogastroduodenoscopy (EGD). However, preoperative endoscopic presence or absence of a significant HH does not always correlate with intraoperative findings.

Objective: To compare the rate of detection of repairable HH between clinical, endoscopic, and intraoperative methods SETTING: Independent, university-affiliated teaching hospital METHODS: A retrospective chart review of all consecutive patients who had undergone a primary bariatric procedure sleeve gastrectomy, gastric bypass, or biliopancreatic diversion/duodenal switch with routine preoperative EGD in a single institution from 2009-2013 was performed. Data points included the diagnosis of GERD/heartburn/proton pump inhibitor or histamine antagonist from history, the diagnosis of HH from preoperative EGD, and the diagnosis of HH intraoperatively that merited repair.

Results: 1570 consecutive patients were included in the study. Eight hundred fifty-seven (55%) had diagnosis of GERD or heartburn, and 713 (45%) were asymptomatic (negative for GERD or heartburn). Hiatal hernia repair was performed in 153 (18%) patients with the diagnosis of GERD or heartburn and in 107 (15%) patients without the diagnosis of GERD and or heartburn. In all, 434 (28%) out of 1570 patients had a finding of HH on EGD; 204 (47%) were repaired. On endoscopy, 326 (75%) were defined as small, 87 (20%) as moderate, and 21(5%) as large HH. Of these, repairs were done on 128 (39%), 60 (70%), and 16 (76%). The sensitivity of detecting repairable HH by clinical indicators such as GERD or heartburn was 55% (P = .123) and sensitivity of EGD findings was 78% (P = .000). Specificity was 46% and 82%, respectively.

Conclusion: Small HH are over-diagnosed with EGD, as most do not require repair. However, moderate and large HH are accurately detected.